Joint Program in Nuclear Medicine

Low Back Pain with Elevated Gastrin

Presentation

A 62 year-old white male underwent a cholecystectomy 7 years ago. At that time, the liver was normal but an enlarged pancreatic head was noted. Three years ago, he was admitted for upper GI bleeding. Endoscopy revealed multiple ulcers in the duodenum and stomach. The serum gastrin level was 1000 pg/cc (nl 0-100 pg/cc). An abdominal CT scan revealed two masses in the pancreas and multiple liver metastases. The liver biopsy confirmed the presence of non-beta islet cell, gastrin-producing, tumor tissue. LFT's were normal.

A work-up for multiple endocrine adenomatosis type I was negative with normal serum Ca., PTH, T4 and calcitonin levels. The patient was treated with Cimetidine and Probanthin and was doing relatively well for one year. Two years prior to the current admission, ascites and left pleural effusion developed and he was started on chemotherapy including Streptozocin, Adriamycin and 5FU.

Three months prior to presentation, an epidural injection of steroids was performed because of lumbar radiculopathy.

The familial history revealed that the father and one brother died of prostate carcinoma. The acid phosphatase was 7.8 IU/L (nl 0-5.4 IU/L) and the prostatic fraction 0.7 (0-1.2 IU/L). The alkaline phosphatase was 561 IU/L (nl 21-130 IU/L) and the serum gastrin level greater than 1,000 pg/ml (nl 0-100 pg/ml).

The patient presented with persisting low back pain and irradiation to the left calf.

Images

Bone scintigraphy

AP lumbar spine

Lateral lumbar spine

Lumbar spine spot

Description of Findings

Full case report

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J. Anthony Parker, MD PhD, Tony_Parker@bidmc.harvard.edu