Brunner's gland adenoma of the duodenum

Endosonographic Appearances of a Rare Duodenal Tumour, Brunner's Gland Hamartoma

Brunner's gland hamartoma (BGH) is a rare sub-epithelial tumour of the duodenum, which may cause haemorrhagic or obstructive gastrointestinal symptoms. Their accurate histological diagnosis often remains elusive before resection. Although endoscopic ultrasonography (EUS) is considered an excellent modality to study lesions within the gastrointestinal wall, only a few reports have described endosonographic characteristics of BGHs. A reliable pre-resection diagnosis with EUS may not only allay fear of malignancy but may as well avert a major surgery for the patients. In this report, we present a rare case of a large BGH in a young female who presented with acute gastrointestinal bleeding. Here, the endosonographic features assuaged the concern for malignancy while aiding in complete and uneventful surgical resection of the tumour via a submucosal plane.

Clinicopathologic characteristics and mucin expression in Brunner's gland proliferating lesions

BACKGROUND

Brunner's gland proliferating lesions, termed Brunner's gland hamartoma, hyperplasia, or adenoma, is regarded as a benign condition. However, cancerous changes have been reported in Brunner's gland proliferating lesions.

AIMS

The purpose of this study was to define the characteristic features of Brunner's gland proliferating lesions and evaluate any observed cancerous changes.

METHODS

We analysed clinicopathologic features and mucin expression in 25 Brunner's gland proliferating lesions.

RESULTS

Brunner's gland proliferating lesions were categorized as Brunner's gland hamartoma or hyperplasia according to their tissue components. Brunner's gland hamartoma commonly occurred in the duodenal bulb and exhibited a polypoid appearance, while Brunner's gland hyperplasia was primarily observed in the second portion of duodenum as a submucosal mass and was accompanied by symptoms more frequently than Brunner's gland hamartoma. The Brunner's glands in Brunner's gland proliferating lesions exhibited various morphologic characteristics, from normal-appearing glands to sclerotic glandular foci with atypia. Changes in MUC5 expression observed in both sclerotic glandular foci and dilated Brunner's glands suggest that they might share a common mechanism and are associated with gastric foveolar metaplasia.

CONCLUSIONS

These findings indicate that most Brunner's gland proliferating lesions are either hamartoma or hyperplasia, and that true neoplastic Brunner's gland proliferating lesions are very rare. Thus, Brunner's gland adenomas or carcinomas arising in Brunner's gland proliferating lesions should be confirmed by ancillary tests, including immunostaining or molecular analysis, in addition to morphological criteria.

Endoscopic management of nonampullary duodenal polyps

Duodenal polyps are a rare finding in patients presenting for gastroscopy, being found in 0.3-4.6% of cases. The majority of patients are asymptomatic. The most common lesions necessitating removal are duodenal adenomas which should be differentiated from other mucosal lesions such as ectopic gastric mucosa, and submucosal lesions such as carcinoids and gastrointestinal stromal tumours (GISTs). Adenomas can occur sporadically or as part of a polyposis syndrome. Both groups carry malignant potential but this is higher in patients with a polyposis syndrome. The majority of sporadic duodenal adenomas are flat or sessile and occur in the second part of the duodenum. Historically duodenal adenomas have been managed by radical surgery, which carried significant mortality and morbidity, or more conservative local surgical excision which resulted in high local recurrence rates. There is growing evidence for the use of endoscopic mucosal resection (EMR) techniques for treatment of sporadic nonampullary duodenal adenomas, with good outcomes and low complication rates. Endoscopic submucosal dissection (ESD) carries greater risk of complications and should be reserved for experts in this technique. Patients with sporadic duodenal adenomas carry an increased risk of colonic neoplasia and should be offered colonoscopy. The impact of endoscopic resection on the course of polyposis syndromes such as familial adenomatous polyposis (FAP) needs further study.

Endoscopic removal of a brunneroma with EUS guidance

Brunner glands are compound tubular submucosal glands typically found in the duodenal bulb. The most common benign tumors of the small intestine are adenoma, and 25% of these occur in the duodenum. Among the benign tumors of the duodenum, 30-50% arise from the Brunner glands. Most of the literature describes their presentations as ranging from benign, nonspecific, epigastric discomfort to obstruction and intestinal bleeding. A good percentage of them are surgically resected; however, there has been an advancement to remove them endoscopically. We present one of the first cases of an endoscopic ultrasound (EUS) approach to the diagnosis and therapeutic removal of a brunneroma.

Inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum

Benign neoplasia of the duodenum are very rare. Moreover, duodenal tubulovillous adenomas are more uncommon lesions. The microscopic structure of tubulovillous adenoma has frond-like projection of mucosa with branching papillary structure and generally upward growth into the lumen. We describe a 72-year-old man who showed aduodenal tubulovillous adenoma with unusual inverted cystic growth pattern. Interestingly, this tubulovillous adenomatous lesion was interrupted by gastric metaplasia in the deep portion of the cyst and was closely surrounded by Brunner’s glands. Although histogenesis of gastric metaplasia of duodenum is not fully understood, Brunner’s glands has been suggested as a precursor for gastric metaplasia. Therefore, these findings argued that this adenoma arises from Brunner’s glands through gastric metaplasia. This is the first case of inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum with gastric metaplasia.

[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.

A Brunner's gland adenoma as a cause of anemia

Benign tumors of the small bowel are rare. They present with many different manifestations depending on the size and location, and also cause a variety of symptoms that are often nonspecific. These include abdominal pain, dyspepsia, nausea, vomiting, and gastrointestinal bleeding that may be melena or hematemesis. Most of the time patients are asymptomatic and the lesions are discovered as an incidental finding. When bleeding occurs, and it may be severe in certain situations, the patient may develop signs of anemia, such as dyspnea, fatigue, and even high-output cardiac failure. The authors present a patient who was evaluated for melena and who was found to have a duodenal polyp that proved to be a Brunner's gland adenoma on pathology.

Extreme diffuse adenomatous hyperplasia of Brunner's glands: case report

A case of extreme diffuse adenomatous hyperplasia of Brunner's glands was clinically manifested by melena and anemia. Diagnosis was established by barium studies, endoscopy, ultrasonography, computerized tomography, and histology. The radiologic, clinical, pathologic, and differential diagnostic features are reviewed.

Tumors of the small intestine with little or no malignant predisposition: a review of the literature and report of 56 cases

Benign small bowel tumors are rare. If those with malignant potential are excluded, a small group of truly benign lesions remains. Fifty-six cases of these small bowel tumors were analyzed for clinical data, pathologic diagnosis, number, size, location, and radiologic appearance. Lesions included lipoma, myoepithelial hamartoma, Peutz-Jeghers hamartoma, neurogenic tumors (including gangliocytic paraganglioma), Brunner's gland abnormalities, and inflammatory fibroid polyp. Location, number, and radiographic morphology can be helpful in reaching a more specific diagnosis. Age of patient and size of tumor may be helpful in the differential diagnosis; however, sex of the patient and clinical symptoms are not.

"Brunneroma": hamartoma or tumor?

Clinically relevant "tumors" of duodenal glands (Brunner's glands) are uncommon. We present a patient suffering from an exceptionally large tumor of the pars descendens of the duodenum. The tumor remained undetected at endoscopy and is of interest because of its localization, size and its presumable production of urogastrone (human epidermal growth factor). "Brunneromas" are probably hamartomas rather than true neoplasias.

A great Brunner's gland adenoma of the duodenal bulb

The occurrence of Brunner's gland adenoma in the duodenum is infrequent. The authors report a case of great Brunner's gland adenoma of the duodenal bulb, which is of interest because of its great size (8.5 X 4.5 cm) and the negative result of the endoscopic biopsy. Endoscopy has improved the diagnosis of the duodenal tumors; however, traditional endoscopic pinching biopsy does not always make a histological diagnosis. In our case, the endoscopic biopsy was negative because the tumor was located completely in the submucosa and the biopsy forceps was unable to reach to the tumor tissue.

Non-vaterian duodenal adenomas: report of 24 cases and review of the literature

Twenty-four cases of duodenal adenomas which did not originate at the ampulla of Vater are discussed. The radiographic and clinical features of these lesions are presented together with a review of 120 cases previously reported in the literature. The role of barium studies and endoscopy in the evaluation of these adenomas is emphasized. A diameter of more than 5 cm represents a criterion favoring malignant degeneration of such non-Vaterian adenomas.

Duplication cyst of the duodenum in the adult

A duodenal duplication cyst in a 45-year-old male is reported. A hypotonic duodenography showed a smooth spherical defect in the descending portion of the duodenum. A fiberoptic duodenoscopy disclosed a smooth well-defined tumor which was located orally from the ampulla of Vater. A retrograde pancreatocholangiography indicated the tumor was not in communication with the pancreatic duct or biliary tract. At operation, a cystic spherical mass, 3 cm in diameter, was located in the posterior wall of the duodenum corresponding to the above described diagnosis. The combination of a greater awareness of this condition as well as improved X-ray and endoscopic techniques has made preoperative diagnosis more accurate.

An ultrastructural study of the Brunner's cyst

A Brunner's cyst, removed from a 54-year-old woman, was studied by light and electron microscopy. The cyst was spherical, measured 1.5 cm in diameter and was located in the duodenal bulb. Histologically, the cyst, confined in the submucosa, consisted of a single layer of epithelial cells and connective tissue. The epithelial cells were composed of an orderly array of tall columnar cells containing basal round nuclei and fine granular cytoplasm. Ultrastructurally, the epithelial cells contained many secretory granules in the cytoplasm. Each secretory granule was membrane-bound and appeared electron-lucid with a dense core. They were small and sparse around the Golgi apparatus but large and numerous in the apical region. Multinucleated cells were intermingled with cells of the epithelial lining.