Zollinger-Ellison syndrome (ZES) is a rare condition, characterized by acid hypersecretion, due to a gastrin-secreting neuroendocrine tumour (NET) – gastrinoma, linked to multiple endocrine neoplasia type 1 (MEN-1) syndrome in 25% of the cases. Surgical resection is the standard treatment for localized gastrinomas, but Endoscopic Ultrasound–Guided Radiofrequency Ablation (EUS-RFA) is emerging as a minimally invasive alternative for selected pancreatic NETs, supported mainly by experience with insulinomas.

We report a 33-year-old male with end-stage kidney disease and history of Wilms and parathyroid tumors, who presented with gastrointestinal bleeding from erosive esophagitis, esophageal ulcer, complicated by stricture, and peptic ulcers. Computed tomography showed a 1,2cm solid nodule between the distal duodenum and the pancreatic uncinate process. Serum gastrin level was 4982 pg/ml (normal: <115 pg/ml). EUS revealed a 14-mm homogeneous, hypoechoic, round peripancreatic nodule adjacent to the uncinate process and close to the superior mesenteric vein. Fine-needle biopsy (22G-FNB) confirmed a well-differentiated NET (CD56+, chromogranin+, synaptophysin+, Ki-67 <2%), establishing the diagnosis of ZES and MEN1.

Given his comorbidities and high-surgical risk, after a multidisciplinary team reunion, it was opted for EUS-RFA. After esophageal balloon dilation (12 mm), EUS-RFA was successfully performed (30 W for 25 seconds, impedance >500 Ohms) without adverse events. The patient was discharged after 48 hours. Serum gastrin decreased to 311 pg/ml within six days. Upon follow-up, the patient remained asymptomatic.

            This case highlights the potential role of EUS-RFA as a therapeutic option for gastrinomas, particularly in patients who are poor surgical candidates. Further studies are warranted to better define its role, long-term outcomes, and ideal clinical indications.