The pentagastrin test in the diagnosis of the carcinoid syndrome: Blockade of gastrointestinal symptoms by ketanserin

The levels of 5-hydroxytryptamine (serotonin, 5-HT) and substance P (SP) were assayed (using high performance liquid chromatography-electron capture and radioimmunoassay methods) in the peripheral blood of 17 patients with known mid-gut carcinoids, 16 of whom had hepatic metastases. All patients had supranormal basal levels of 5-HT and SP. The clinical and hormonal changes induced by two provocation tests, intravenous pentagastrin (PG and calcium infusion, were compared. Pentagastrin caused flushing in all the patients, induced gastrointestinal symptoms in all but one of the patients and hepatic involvement, and universally elevated circulating 5-HT levels. Pretreatment with a 5-HT₂-receptor blocking agent, ketanserin, abolished the gastrointestinal effects but had virtually no influence on either 5-HT levels or flushing induced by intravenous pentagastrin. In contrast, calcium infusion induced carcinoid symptoms in only two of six patients, and this was consistently associated with stimulation of circulating serotonin levels. The authors conclude that (1) 5-HT may be responsible for the fastrointestinal symptoms in carcinoid patients, but it does not seem to play any role in fluhsing; (2) ketanserin may be a useful therapeutic agent in alleviating gastrointestinal symptoms in carcinoid patients; (3) differential responses to PG suggests that SP is released from a site different from that of 5-HT; (4) it is possible that SP may contribute to the mediation of flushing, but it cannot be the sole agent causing this symptom; and (5) the pentagastrin test with measurements of 5-HT levels in peripheral blood seems to be superior to calcium infusion as a provocative test in documenting the diagnosis of carcinoid disease.