Endosonographic features of Brunner's gland hamartomas which were subsequently resected endoscopically

Brunner Gland Hamartomas-Uncommon Presentations and Endoscopic Management

Brunner gland hamartoma (BGH) is a rare condition that requires a high clinical suspicion to diagnose. Large hamartomas may initially present with iron deficiency anemia (IDA) or symptoms suggesting intestinal obstruction. Barium swallow may demonstrate the lesion, but endoscopic evaluation is the acceptable first line management unless a concern for underlying malignancy. The present case report and literature review highlight the uncommon presentations and endoscopic role in large BGHs management. Internists should consider BGH in their differential, especially in patient with occult bleeding, IDA, or obstruction, which can be treated with endoscopic resection of large sized tumors by trained experts.

A 10 cm pedunculated duodenal Brunner gland hamartoma, case report and literature review

INTRODUCTION

Brunner gland hamartoma is rare duodenal neoplasm. These benign lesions are usually presented by upper gastrointestinal bleeding and sometimes extend to cause intestinal obstruction.

PRESENTATION OF THE CASE

We report a case of a 43-year-old male patient manifested with iron deficiency anemia. Upon investigations, computed topography (CT) scan found a dilated first part of the duodenum with presence of large pedunculated polyp. The histopathological examination revealed a submucosal lobular proliferation of duodenal Brunner's gland separated by a fine fibrous septum. No dysplastic signs were observed. Immunohistochemical studies confirmed the nature of the glands and reveled absence of Helicobacter pylori gastritis. Diagnosis was confirmed.

DISCUSSION

Brunner glands hamartomas are rare tumors. They are commonly presented by upper GI bleeding and intestinal obstruction. The pathogenesis remains unclear. They are usually located in the first part (bulb) of the duodenum. Mucosal irritation and Helicobacter pylori infection are suggested causes. Different surgical and endoscopical modalities are applied in the management depending on the size and location of the mass. In our case, the tumor was removed by Endoscopic submucosal dissection.

CONCLUSION

Brunner gland hamartoma is a rare usually benign tumor. Presented clinically by upper GI bleeding and obstruction. Histopathologically Brunner gland Hamartoma characterized by lobular proliferation of Brunner gland associated with presence of other mature tissues. Although these tumors are benign it carries a minor risk of malignant transformation.

Giant Brunner's gland hamartoma diagnosed via endoscopic mucosal resection: A case report

We report the case of a patient with a giant Brunner's gland hamartoma that was pathologically diagnosed by endoscopic mucosal resection. A 69‐year‐old woman presented with intermittent abdominal pain, and imaging revealed a smooth saccular submucosal tumor, 40 mm in diameter, on the anterior wall of the duodenal bulb. Brunner's gland and smooth muscle tissue were observed on endoscopic ultrasound‐guided fine‐needle aspiration biopsy, which resulted in the preoperative diagnosis of a duplication cyst. However, subsequent endoscopic mucosal resection established a final histopathological diagnosis of Brunner's gland hamartoma.

Brunner's Gland Hamartoma of the Duodenum: A Literature Review

Brunner's gland hamartoma is a benign tumor of the duodenum, but has malignant potential with a very low risk of progression into adenocarcinoma. It is uncommon with a frequency of less than 1.0% among the primary tumors of the small intestine. In addition, its clinical manifestations are nonspecific, etiology remains unclear, and treatment strategy needs to be further refined. This literature review mainly discusses the epidemiology, clinical features, possible etiology and pathogenesis, diagnostic methods, malignant potential, treatment, and prognosis of Brunner's gland hamartoma.

A case report of endoscopic resection for the treatment of duodenal Brunner's gland adenoma with upper gastrointestinal bleeding

RATIONALE

Gastrointestinal bleeding as the first sign of Brunner's gland adenoma (BGA) is an extremely rare, and its clinical features and treatment methods have not been well described.

PATIENT CONCERNS

We described a 81-year-old female patient with coronary artery disease and chronic atrial fibrillation presenting with presenting with gastrointestinal bleeding requiring blood transfusion.

DIAGNOSES

The diagnosis of our case mainly refered to radiologic imaging and endoscopic examination. Histological result was compatible with BGA.

INTERVENTIONS

This mass lesion (6 × 7 cm diameter) was successfully totally removed by endoscopic submucosal dissection (ESD) for more than three hours.

OUTCOMES

The patient was followed up for 6 months to date without recurrence.

LESSONS

Endoscopic removal is considered as a safe and low-risk treatment for elderly patients with severe underlying diseases presenting with gastrointestinal bleeding.

Brunner's gland hyperplasia: A rare cause of gastrointestinal bleeding

Brunner’s gland hyperplasia (BGH) is an unusual entity that presents with large duodenal polyp or mass and rarely causes gastrointestinal bleeding. It is usually asymptomatic and often an incidental finding during the esophagoduodenoscopy (EGD). However, most of the cases are benign. We encounter a 40 years old man who presented in Emergency Room with melena. EGD revealed solitary, large duodenal polyp in second part of duodenum and later histopathological findings were consistent with BGH.

Brunner's gland adenoma is a rare cause of upper gastrointestinal bleeding: A case report and literature review

Brunner's gland adenoma is a rare benign tumour that arises from Brunner's glands in the duodenum. Lesions are usually incidentally discovered during oesophagogastroduodenoscopy. However, in some cases, they may present clinically with vague abdominal symptoms or bleeding. We present the case of a 54-year-old male who complained of progressive fatigue and intermittent melena for 3 months. Clinical examination findings were unremarkable. Routine blood tests showed microcytic hypochromic anaemia. Oesophagogastroduodenoscopy showed normal oesophageal and gastric mucosa as well as a pedunculated polyp on the anterior wall of the duodenal bulb. Endoscopic ultrasound (EUS) revealed a duodenal hyperechoic mass arising from the submucosal layer of the anterior wall of the duodenal bulb with central cystic degeneration. Both endoscopic- and EUS-guided biopsies were non-diagnostic. Endoscopic mucosal resection was performed after the patient provided consent. Histopathological examination revealed hyperplastic mucosal lobules containing Brunner's glands and smooth muscle cells; malignant cells or Helicobacter pylori infection were not evident. Brunner's gland adenoma is a rare lesion of the duodenum and should be considered in the differential diagnosis of upper gastrointestinal bleeding. EUS is helpful in the diagnosis and detection of the layer of origin. However, the final diagnosis is usually made after lesion removal.

En Bloc Endoscopic Resection of Large Pedunculated Brunner's Gland Hamartoma: A Case Report

Brunner's gland hamartoma (BGH) is an uncommon benign tumor arising from alkaline-based mucin-secreting glands of the duodenum. These lesions are typically discovered incidentally during upper gastrointestinal endoscopy or radiological diagnostics, even though they can eventually lead (in the case of increasing size) to obstructive or hemorrhagic symptoms. We report the case of a 67-year-old Caucasian man with two episodes of melena and epigastric pain during the last month. Esophagogastroduodenoscopy revealed a large pedunculated and eroded polyp inside the antrum with a 2-cm-long stalk arising from the anterior wall of the duodenal bulb. Endoscopic ultrasonography showed a submucosal lesion with homogeneous hyperechoic parietal thickening and some central gaps. The muscularis was undamaged. No lymphadenopathy was observed. We performed an en bloc endoscopic resection of the polyp. The size of the whole piece was approximately 6 × 3 × 2 cm, pseudocapsulated and tough in consistency. In the case presented, the en bloc endoscopic removal was successful despite the size of the tumor.

Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review

INTRODUCTION

Brunner's gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunner's glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion.

CASE PRESENTATION

A 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunner's glands correspondent to a Brunner's gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure.

CONCLUSION

BGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.

Endoscopic Resection of a Pedunculated Brunner's Gland Hamartoma of the Duodenum

A 68-year-old Japanese woman presented with a solitary pedunculated polyp in the duodenum. Endoscopic ultrasonography showed multiple cystic structures in the polyp. The polyp was successfully resected by endoscopic snare polypectomy and pathologically diagnosed as Brunner's gland hamartoma. Because hamartomatous components were not identified in the stalk of the polyp, we speculate that the stalk developed from traction of the normal duodenal mucosa. When a solitary, pedunculated polyp with cystic structure within the submucosa is found in the duodenum, Brunner's gland hamartoma should be considered in the differential diagnosis, despite the rarity of the disease. This case underscores the usefulness of endoscopic ultrasonography for the diagnosis of duodenal subepithelial tumors.

Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors

Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors

Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

Giant Brunner's gland adenoma as an unusual cause of anaemia: report of a case

BACKGROUND

Brunner's gland adenoma (BGA) is a rare benign duodenal tumour proliferating from Brunner's glands. Here, we present a giant BGA leading to anaemia, with its clinical, endoscopic, radiological, surgical and pathological findings.

CASE REPORT

A 48-year-old Turkish man complained of a six months history of vague epigastric discomfort, loss of appetite and nausea after meals without vomiting. The physical examination had no unremarkable finding. Laboratory findings, including liver function tests, were within normal limits except a hypochromic, microcytic anaemia. The upper gastrointestinal endoscopic examination revealed a lobulated, red, polypoid tumour with a smooth surface covered with normal mucosa. The tumour was located on the anterior surface of duodenal bulb and had a wide base measuring 3.5 × 4 cm in size. Endoscopic ultrasonography revealed a submucosal polypoid mass located at the anterior surface of duodenal bulb. The endoscopic excision was tried but was not successful. The patient was operated and transduodenal polypectomy was done. The postoperative period was uneventful and the pathologic diagnosis was assessed as Brunner's gland adenoma. During the follow-up period, the endoscopic examination was normal at 12th month postoperatively.

CONCLUSIONS

BGA is a rare benign cause of anaemia that can be treated with excellent results.

Giant Brunner's gland adenoma as an unusual cause of anaemia: report of a case

BACKGROUND

Brunner's gland adenoma (BGA) is a rare benign duodenal tumour proliferating from Brunner's glands. Here, we present a giant BGA leading to anaemia, with its clinical, endoscopic, radiological, surgical and pathological findings.

CASE REPORT

A 48-year-old Turkish man complained of a six months history of vague epigastric discomfort, loss of appetite and nausea after meals without vomiting. The physical examination had no unremarkable finding. Laboratory findings, including liver function tests, were within normal limits except a hypochromic, microcytic anaemia. The upper gastrointestinal endoscopic examination revealed a lobulated, red, polypoid tumour with a smooth surface covered with normal mucosa. The tumour was located on the anterior surface of duodenal bulb and had a wide base measuring 3.5 × 4 cm in size. Endoscopic ultrasonography revealed a submucosal polypoid mass located at the anterior surface of duodenal bulb. The endoscopic excision was tried but was not successful. The patient was operated and transduodenal polypectomy was done. The postoperative period was uneventful and the pathologic diagnosis was assessed as Brunner's gland adenoma. During the follow-up period, the endoscopic examination was normal at 12th month postoperatively.

CONCLUSIONS

BGA is a rare benign cause of anaemia that can be treated with excellent results.

[Giant Brunner's gland hamartoma: diagnosis and endoscopic treatment]

Brunner's gland hamartoma is a polypoid lesion typically composed of an increased quantity of normal-appearing Brunner's glands, accompanied by a variable proportion of smooth muscle. Most of these masses are asymptomatic and behave as benign tumors. Occasionally tumoral growth can provoke gastrointestinal problems which, together with the possibility of malignant transformation, will require resection after a broad differential diagnosis has been made with solitary duodenal mass. Both clinical and radiographic studies are nonspecific and often do not allow diagnosis of these tumors. Basic endoscopic studies (upper endoscopy) with adequate characterization of the lesion by endoscopic ultrasound (EUS) can establish a high diagnostic suspicion and determine the best therapeutic option (endoscopy or surgery). We present a case of giant Brunner's gland hamartoma. The initial manifestation was iron-deficiency anemia with no evidence of bleeding. After adequate characterization of the lesion, EUS allowed complete and safe endoscopic resection, avoiding more invasive surgical treatment.

Endoscopic ultrasound in combination with pathological examination for diagnosis of duodenal Brunner's gland hyperplasia and selection of appropriate endoscopic treatment

AIM: To explore the value of endoscopic ultrasound (EUS) in combination with pathological examination in the diagnosis of duodenal Brunner's gland hyperplasia and to examine the role of EUS in guiding the selection of appropriate endoscopic treatment.

METHODS: Nine patients diagnosed with duodenal elevated lesions by gastroscopy were examined by EUS, and different endoscopic treatments were chosen base on the findings from EUS. Biopsies obtained before and after treatment were subjected to pathological examination to confirm the diagnosis of Brunner's gland hyperplasia. Gastroscopy was performed again one month after therapy.

RESULTS: (1) Gastroscopy: Of all nine patients, 3 had polyps and 6 had cysts; 3 had pedunculated lesions, 5 had non-pedunculated lesions, and 1 had a flat elevation lesion; (2) EUS diagnosis: Seven patients had duodenal submucosal cystic lesions - Brunner's gland hyperplasia, and 2 patients had duodenal polyps; (3) Endoscopic treatment: Five non-pedunculated cystic lesions underwent wall removal using rat tooth forceps, 3 pedunculated lesions were resected by snare electrocoagulation, and 1 small flat lesion was resected with argon ion beam. No massive bleeding or perforation occurred.

CONCLUSION: It is difficult to distinguish Brunner's gland hyperplasia, polyp and cyst by gastroscopy. EUS has higher value in differentially diagnosing these diseases and guiding the selection of appropriate endoscopic treatment.

Surgical management of giant Brunner's gland hamartoma: case report and literature review

Brunner's gland hamartomas (BGH) are uncommon benign tumors of the duodenum forming mature Brunner's glands. We report here an unusual case of a giant BGH that was not amenable to endoscopic or surgical local resection thus requiring a pancreaticoduodenectomy for extirpation. The relevant literature is discussed.

Endoscopic diagnosis and therapy for cystic tumors in duodenum

AIM: To investigate the endoscopic diagnosis and therapy for cystic tumors in duodenum.

METHODS: Three cases of cystic tumors in duodenum were diagnosed through routine gastroscopy and endoscopic ultrasonography. Cystic tumors were treated with cystoscopy therapy.

RESULTS: Three cases of cystic tumors confirmed by endoscopic ultrasonography were endoscopically treated with rat-like teeth biopsy forceps. One month later, endoscopy review showed that cystic tumors completely disappeared. The desired therapeutic effect was achieved.

CONCLUSION: The endoscopic ultrasonography is of important value to the diagnosis of cystic tumors in the duodenum. The treatment method with rat-like teeth biopsy forceps is a simple, safe and effective therapy for the cystic tumors in the duodenum.

Endoscopic resection of a large Brunner's gland hamartoma

Brunner's Gland Hamartoma (BGH) is a benign tumor of the duodenum that can lead to gastrointestinal bleeding and intestinal obstruction. Endoscopic resection has seldom been reported. We describe the case of a duodenal obstruction caused by a large BGH (6 cm x 4 cm). We report a 57-year-old woman hospitalized for tarry stools, weight loss and anorexia. Endoscopy revealed a large BGH (6 cm x 4 cm). Endoscopic ultrasound (EUS) revealed a submucosal duodenal tumor. In this paper, we report a case of large hyperplasia of BGH, successfully treated by endoscopic technique.

Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.

[Gastrointestinal bleeding after endoscopic treatment of polypoid hamartoma (adenoma of Brunner's glands)]

The incidence of polypoidal tumors in the duodenum is scarce and Brunner's gland tumors represent 11% of these proliferations. Brunner's gland polypoid hamartoma or adenoma is a highly infrequent benign polypoid proliferation of Brunner's glands that is usually asymptomatic, although gastrointestinal bleeding or intestinal obstruction may sometimes occur. We present the case of a woman with an incidental diagnosis of duodenal polypoid hamartoma. The lesion was resected with polypectomy loop and at 48 h, the patient presented gastrointestinal bleeding as a complication. We describe the endoscopic treatment of the lesion and this complication.