A 55 year old woman presents with mild epigastric pain, and intermittent heartburn and regurgitation for the past 2 years. She has also experienced intermittent watery diarrhea for the last 6 months. She underwent an endoscopy 4 months ago, which revealed a duodenal ulcer. Tests for Helicobacter pylori were negative. Subsequently, she was started on a course of Pantoprazole for 4 weeks. When her symptoms did not resolve, the drug was increased to the maximum permissible dose, which has been continued until now. She is not on any other medications and maintains that she has not used any over-the-counter formulations during the past year. Her surgical and family histories are unremarkable. She has never smoked, and only drinks socially.
There is a large ulcer in the first part of the duodenum, with no evidence of perforation or hemorrhage, or physical features suggestive of malignancy. Multiple biopsies are obtained; these are negative for malignant transformation and Helicobacter pylori.
Fasting serum gastrin levels are 1,400 pg/mL (normal: <100)
111In-pentetreotide SPECT imaging shows duodenal wall localization, with no distant metastases.
You realize that diagnostic laparoscopy is probably not indicated right now.