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Shmais M, Mousawi A, Mourad F, Sharara AI. Brunner's gland hamartomas: Not always benign. Arab J Gastroenterol 2024; 25:70-73. [PMID: 38296695 DOI: 10.1016/j.ajg.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 12/14/2023] [Accepted: 12/23/2023] [Indexed: 02/02/2024]
Abstract
Brunner's gland hamartoma (BGH) is a rare, benign tumor of the duodenum. It is mostly asymptomatic and usually found incidentally on routine esophagogastroduodenoscopy (EGD). However, some BGHs present with major complications including anemia, bleeding, obstruction, or dysplasia, requiring management and resection of these lesions. Herein, we present two cases of large BGHs of the duodenum, one presenting as severe gastrointestinal bleeding and the other, noted on EGD for iron deficiency anemia, found to have high grade dysplasia. This literature review discusses the rare serious complications of BGH, including iron deficiency anemia, overt gastrointestinal bleeding, and malignant potential.
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Affiliation(s)
- Manar Shmais
- Division of Gastroenterology and Hepatology, Saint Louis University Hospital, MO, USA.
| | - Ahmad Mousawi
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon.
| | - Fadi Mourad
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon.
| | - Ala I Sharara
- Division of Gastroenterology and Hepatology, American University of Beirut, Beirut, Lebanon.
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2
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Dhali A, Ray S, Mandal TS, Das S, Ghosh R, Khamrui S, Dhali GK, Sarkar A. Surgical Outcome of Brunner's Gland Hamartoma: A Single-Centre Experience. Surg J (N Y) 2022; 8:e14-e18. [PMID: 35059497 PMCID: PMC8763466 DOI: 10.1055/s-0041-1741510] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/02/2021] [Indexed: 01/04/2023] Open
Abstract
Introduction
Brunner's gland hamartomas (BGH) are rare benign lesions with an incidence of <0.01%, accounting for 5 to 10% of all benign tumors of the duodenum. It requires expeditious management by a multidisciplinary team. The aim of the study is to report our experience with surgery for BGH.
Methodology
Data of all patients who underwent surgical intervention for duodenal polypoidal mass between August 2007 and March 2020 were retrieved from our prospectively maintained gastrointestinal (GI) surgery database. All patients whose histopathology report of the resected specimen confirmed BGH (
n
= 9) were included in the present study. Other pathological diagnosis like duodenal lipoma (
n
= 2), ganglioneuroma (
n
= 1), adenoma (
n
= 10), and adenocarcinoma (
n
= 4) were excluded.
Results
Nine patients had confirmatory histopathological diagnosis of BGH and met our inclusion criteria. Three (33.3%) of them were men with a median age of 45 (range: 24–61) years. The median interval between onset of symptoms and diagnosis of duodenal polyp was 14 (range: 4–180) days. Five patients (55.5%) presented with upper GI hemorrhage. Three (33.3%) patients presented with abdominal pain, and one (11.1%) patient presented with episodes of bilious vomiting. Diagnostic endoscopy could detect the lesion in all (100%) patients. Contrast-enhanced computed tomography detected duodenal polypoidal lesion in five (55.5%) patients. The mean size of tumor was 4.78 ± 1.36 cm. These lesions were symptomatic in all the patients and warranted intervention. In view of failed endoscopic intervention (
n
= 7, 77.7%), or extramural extension of the tumor (
n
= 2, 22.2%), surgical intervention was considered. Most commonly performed operation was duodenal polypectomy (
n
= 6, 66.6%). Three postoperative complications developed in two (22.2%) patients. There was no surgery-related mortality. After a median follow-up of 60 (12 -78) months, no patient developed GI bleed or intestinal obstruction.
Conclusion
In this study, the clinical profile of BGH was explored from the surgeon's point of view. Although endoscopic management is the first-line treatment, surgery plays an important role, particularly, if this fails or is not feasible. In experienced hand, surgery can be performed with acceptable perioperative morbidity and mortality and long-term satisfactory outcomes.
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Affiliation(s)
- Arkadeep Dhali
- Department of Gastrointestinal Surgery, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sukanta Ray
- Department of Gastrointestinal Surgery, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Tuhin S. Mandal
- Department of Gastrointestinal Surgery, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Somak Das
- Department of Gastrointestinal Surgery, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Ranajoy Ghosh
- Department of Gastrointestinal Pathology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sujan Khamrui
- Department of Gastrointestinal Surgery, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Gopal K. Dhali
- Department of Gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Avik Sarkar
- Department of Gastrointestinal Radiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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Desai G, Yadav K, Pande P, Sali P, Tampi C, Wagle P. BRUNNER GLAND ADENOMA MASQUERADING AS DUODENAL GASTROINTESTINAL STROMAL TUMOR WITH INTUSSUSCEPTION: CASE REPORT. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2019; 30:71-72. [PMID: 28489176 PMCID: PMC5424694 DOI: 10.1590/0102-6720201700010020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 11/17/2016] [Indexed: 12/15/2022]
Affiliation(s)
| | | | | | | | - Chandralekha Tampi
- Pathology, Lilavati Hospital and Research Center, Bandra Reclamation, Bandra West, Mumbai 400050, Maharashtra, India
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Pasetti A, Capoferro E, Querzoli G, Montanari R, Bocus P. En Bloc Endoscopic Resection of Large Pedunculated Brunner's Gland Hamartoma: A Case Report. Case Rep Gastroenterol 2018; 12:344-351. [PMID: 30022927 PMCID: PMC6047568 DOI: 10.1159/000490098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/07/2018] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Annalisa Pasetti
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Elvira Capoferro
- Gastroenterology and Digestive Endoscopy Unit, Sacro Cuore Don Calabria Hospital of Negrar, Negrar, Italy
| | - Giulia Querzoli
- Pathology Unit, Sacro Cuore Don Calabria Hospital of Negrar, Negrar, Italy
| | - Renzo Montanari
- Gastroenterology and Digestive Endoscopy Unit, Sacro Cuore Don Calabria Hospital of Negrar, Negrar, Italy
| | - Paolo Bocus
- Gastroenterology and Digestive Endoscopy Unit, Sacro Cuore Don Calabria Hospital of Negrar, Negrar, Italy
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Peloso A, Viganò J, Vanoli A, Dominioni T, Zonta S, Bugada D, Bianchi CM, Calabrese F, Benzoni I, Maestri M, Dionigi P, Cobianchi L. Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review. Ann Med Surg (Lond) 2017; 17:43-49. [PMID: 28408987 PMCID: PMC5382022 DOI: 10.1016/j.amsu.2017.03.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/24/2017] [Accepted: 03/25/2017] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Andrea Peloso
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Jacopo Viganò
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Alessandro Vanoli
- IRCCS Policlinico San Matteo Foundation, University of Pavia, Department of Molecular Medicine, Piazzale Golgi, 27100, Pavia, Italy
| | - Tommaso Dominioni
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Sandro Zonta
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Dario Bugada
- Department of Surgical Science, University of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Carlo Maria Bianchi
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Francesco Calabrese
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Ilaria Benzoni
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Marcello Maestri
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Paolo Dionigi
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
| | - Lorenzo Cobianchi
- Department of Clinical Surgical Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- IRCCS Policlinico San Matteo Foundation, General Surgery 1, Piazzale Golgi, 27100, Pavia, Italy
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6
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A Giant Brunneroma Causing Gastrointestinal Bleeding and Severe Anemia Requiring Transfusion and Surgery. Case Rep Surg 2017; 2017:6940649. [PMID: 28299229 PMCID: PMC5337360 DOI: 10.1155/2017/6940649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/26/2017] [Accepted: 01/29/2017] [Indexed: 12/29/2022] Open
Abstract
Brunner's gland hamartoma, also called hyperplasia, adenoma, and Brunneroma, is an extremely rare benign proliferative lesion of Brunner's glands in the duodenum. While being mostly small and asymptomatic, they can result in gastrointestinal bleeding and obstruction. We report the case of a 54-year-old man presenting with melena and severe anemia requiring blood transfusion. CT scans showed a large mass of 8 cm in diameter, presumably arising in the duodenum. Endoscopic biopsies were not conclusive. As we were unable to determine the nature of the mass preoperatively and due to the severe symptoms, its size, and the uncertain malignant potential, a classic Whipple procedure was performed. The resected specimen showed extensive proliferation of Brunner's glands without signs of malignancy.
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Delvecchio K, Seman S. Successful surgical excision of a massive symptomatic partially obstructing Brunner's gland hamartoma: a case report. J Surg Case Rep 2016; 2016:rjw206. [PMID: 27994010 PMCID: PMC5165059 DOI: 10.1093/jscr/rjw206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Brunner gland function within the duodenal epithelium is secretion of alkaline mucin to counteract acidic chyme. These glands may grow beyond the duodenal wall to become hamartomas. Rarely, they become large enough to cause obstructive symptoms in the upper gastrointestinal tract. We report a case of one of the largest lesions identified in the literature causing obstruction symptoms. A previously asymptomatic 65-year-old gentleman presented to the emergency department with a single-day history of colicky abdominal pain, cramping and vomiting. After initial imaging with computed tomography was inconclusive, a subsequent esophagogastroduodenoscopy with biopsy and small bowel series was performed indicating a pedunculated polypoid mass. Our patient underwent an uncomplicated exploratory laparotomy with duodenotomy and Heineke-Mikulicz pyloroplasty for resection of a massive Brunner's gland hamartoma. For similar presentations, we recommend this technique.
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Affiliation(s)
| | - Susan Seman
- Department of Surgery (Room M5H02), Sinai Grace Hospital, Detroit, MI, USA
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8
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Gombač M, Dolenšek T, Jaušovec D, Kvapil P, Švara T, Pogačnik M. Simultaneous Occurrence of Pancreatic Adenocarcinoma and Brunner's Gland Adenoma in a Siberian Tiger (Panthera tigris altaica). J Comp Pathol 2015; 153:363-7. [DOI: 10.1016/j.jcpa.2015.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/17/2015] [Accepted: 08/22/2015] [Indexed: 11/30/2022]
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9
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Abstract
Brunner gland hyperplasia, a rare duodenal tumor, usually presents with benign features. A 68-year-old man with a history of anemia presented with a polypoid duodenal mass that was detected by CT and esophagogastroduodenoscopy. This mass showed high F-FDG avidity on PET/CT and was histopathologically confirmed as Brunner gland hyperplasia. We suggest that Brunner gland hyperplasia should be considered in the differential diagnosis of F-FDG-avid duodenal tumors.
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10
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Costa-Pinho A, Pinto-de-Sousa J, Baptista M, Rios E, Moura C, Barbosa J, Costa-Maia J. Brunner's gland hyperplasia: an unusual cause of hemorrhagic shock. J Surg Case Rep 2011; 2011:2. [PMID: 24950582 PMCID: PMC3649241 DOI: 10.1093/jscr/2011.5.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Brunner's gland hyperplasia is a very rare lesion of the duodenum, which is usually asymptomatic and diagnosed incidentally during upper gastrointestinal endoscopy. It can cause gastrointestinal bleeding but hemorrhagic shock is a rare clinical presentation of Brunner's gland hyperplasia. The authors present a case of a patient with hemorrhagic shock due to a bleeding Brunner's gland hyperplasia, treated by urgent laparotomy and polypectomy.
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Affiliation(s)
| | | | | | - E Rios
- Hospital S. João, Porto, Portugal
| | - Cs Moura
- Hospital S. João, Porto, Portugal
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11
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Surgical management of giant Brunner's gland hamartoma: case report and literature review. World J Surg Oncol 2009; 7:68. [PMID: 19725968 PMCID: PMC2749032 DOI: 10.1186/1477-7819-7-68] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Accepted: 09/02/2009] [Indexed: 11/10/2022] Open
Abstract
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.
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12
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Hirasaki S, Kubo M, Inoue A, Miyake Y, Oshiro H. Pedunculated Brunner’s gland hamartoma of the duodenum causing upper gastrointestinal hemorrhage. World J Gastroenterol 2009; 15:373-5. [PMID: 19140240 PMCID: PMC2653337 DOI: 10.3748/wjg.15.373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A case of pedunculated Brunner’s gland hamartoma (BGH) of the duodenum causing upper gastrointestinal (GI) hemorrhage is reported. The patient was a 47-year-old man who visited our hospital for further evaluation of tarry stools and shortness of breath. Endoscopic examination of the upper digestive tract revealed a large peduncular polyp with bleeding, about 30 mm in diameter, arising from the wall of the second portion of the duodenum. GI bleeding occurred from the base of the stalk of the polyp. Endoscopic polypectomy was performed. Histological examination of the specimen revealed that the main body of the polyp contained several lobules of mature Brunner’s gland with areas of cystic dilatation. The surface epithelium consisted of normal duodenal mucosa with areas of focal ulceration. This polyp was diagnosed as a BGH. The symptom of tarry stools resolved after endoscopic resection. Our case shows that treatment is necessary for duodenal BGH if GI bleeding occurs.
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13
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Stermer E, Elias N, Keren D, Rainis T, Goldstein O, Lavy A. Acute pancreatitis and upper gastrointestinal bleeding as presenting symptoms of duodenal Brunner's gland hamartoma. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:541-2. [PMID: 16955152 PMCID: PMC2659938 DOI: 10.1155/2006/806926] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Brunner's gland hamartomas are rare, benign small bowel tumours. There were fewer than 150 cases reported in the English literature until the end of the last century. These hamartomas may be discovered incidentally during an upper gastrointestinal tract endoscopy. Otherwise, they may be diagnosed in patients presenting with acute upper gastrointestinal bleeding, anemia or symptoms of intestinal obstruction. The case of a young woman admitted for acute upper gastrointestinal bleeding along with acute pancreatitis is presented. The investigation revealed a giant Brunner's gland hamartoma in the second part of the duodenum. After total endoscopic resection of the tumour, the patient has remained completely asymptomatic for a follow-up period of seven months.
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Affiliation(s)
- Edy Stermer
- Deaprtment of Gastroenterology, Bruce Rappaport School of Medicine, Technion, Haifa, Israel.
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14
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Alvarez-Uría G, Pallero M, de Torres I, Majó J, Ordi J, Saperas E. [Massive hemorrhage due to nodular hyperplasia of Brunner's glands in antiphospholipid syndrome]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:635-8. [PMID: 14670237 DOI: 10.1016/s0210-5705(03)70423-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Gastrointestinal hemorrhage is an exceptional complication of antiphospholipid syndrome and most reported cases are secondary to ischemic lesions. Brunner's gland hyperplasia is an infrequent and usually asymptomatic condition that has been associated with chronic renal failure. We report a patient with primary antiphospholipid syndrome who, after mechanic heart valve replacement and while in a state of drug-induced anticoagulation, experienced a life-threatening upper gastrointestinal hemorrhage due to nodular hyperplasia of Brunner's glands. This entity may be considered in the differential diagnosis of upper gastrointestinal bleeding in patients with antiphospholipid syndrome, most of whom are treated with oral anticoagulatory drugs, and particularly in patients with chronic renal failure.
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Affiliation(s)
- G Alvarez-Uría
- Servicio de Aparato Digestivo. Hospital General Universitario Vall d'Hebron. Barcelona. Spain
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