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This 35-year-old man presented with a history of abdominal pain and weight loss. For the last 5 years he has suffered intermittent abdominal pains. He has recently been treated with lansoprazole for some weeks but with no response.
Hb 112 g/dl MCV 99 fl WCC 12.9 x 109 Platelets 395 x 109 Basal gastrin level: 180 pg/ml (normal <75) This is the patients gastric antrum. WHAT IS THE MOST LIKELY DIAGNOSIS?
explanation
Quite a nasty looking gastritis. All of the options seem to be on the table but what about the raised gastrin level? Could this be a case of ZE? Of course you can explain the elevated basal gastrin level! The patient is taking a PPI and low gastric acid levels will induce a positive feedback loop to raise the gastrin levels ! The second clue is the macrocytic anaemia... How do you explain this?
Of course the combination of abdominal pain and macrocytic is usually found in patients addicted to alcohol with recurrent attacks of pancreatitis. However, there is another possibility! The macrocytosis is due to vitamin B12 deficiency from terminal ileal Crohn's disease. The antral gastritis was also due to Crohn's! Courtesy ofWikipedia, there is a diagram below to remind you of the hormones involved in gastric acid secretion ! 
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