A giant Brunner's gland hamartoma being treated as a pedunculated polyp: a case report

Giant Brunner's gland hyperplasia of the duodenum successfully resected en bloc by endoscopic mucosal resection: A case report

BACKGROUND

Duodenal Brunner's gland hyperplasia (BGH) is a therapeutic target when complications such as bleeding or gastrointestinal obstruction occur or when malignancy cannot be ruled out. Herein, we present a case of large BGH treated with endoscopic mucosal resection (EMR).

CASE SUMMARY

An 83-year-old woman presented at our hospital with dizziness. Blood tests revealed severe anemia, esophagogastroduodenoscopy showed a 6.5 cm lesion protruding from the anterior wall of the duodenal bulb, and biopsy revealed the presence of glandular epithelium. Endoscopic ultrasonography (EUS) demonstrated relatively high echogenicity with a cystic component. The muscularis propria was slightly elevated at the base of the lesion. EMR was performed without complications. The formalin-fixed lesion size was 6 cm × 3.5 cm × 3 cm, showing nodular proliferation of non-dysplastic Brunner's glands compartmentalized by fibrous septa, confirming the diagnosis of BGH. Reports of EMR or hot snare polypectomy are rare for duodenal BGH > 6 cm. In this case, the choice of EMR was made by obtaining information on the base of the lesion as well as on the internal characteristics through EUS.

CONCLUSION

Large duodenal lesions with good endoscopic maneuverability and no evident muscular layer involvement on EUS may be resectable via EMR.

A giant Brunner's gland hamartoma: a rare cause of upper gastrointestinal bleeding

A 78-year-old man was admitted with melena, anemia and hypotension. Upper endoscopy revealed a giant lobulated and pedunculated lesion of the duodenal bulb with an ulcerated area (Fig.1A-C). Biopsies performed during upper endoscopy revealed foveolar epithelium with no dysplasia. Abdominal CT showed a nodular lesion protruding to the duodenal lumen with a diameter of approximately 40mm (Fig.2A). Giving the anemia, with recurrent transfusion need, endoscopic resection was proposed. During the intervention an endoloop was deployed at the base of the pedicle and a hot snare polypectomy was successfully performed without complications (Fig.1D). The patient was discharged after the procedure, asymptomatic, with no evidence of bleeding recurrence. Histology (Fig.2B) was consistent with Brunner’s gland hamartoma (BGH).

Feasibility of endoscopic resection for large pedunculated duodenal lesions (with video)

BACKGROUND

A standard treatment method for pedunculated duodenal lesions has not yet been established. This study aimed to evaluate the feasibility of endoscopic resection (ER) for pedunculated duodenal lesions, especially for large lesions.

METHODS

This study retrospectively reviewed cases of pedunculated duodenal lesions treated with ER at our institute between July 2010 and January 2021. We collected data on the clinical characteristics and treatment outcomes. In addition, the cases were divided based on the treatment provided for the lesion, i.e., the ESD and snare resection groups, and we compared the data between the two groups.

RESULTS

Thirty-eight cases were included in this study. The overall en bloc resection rate was 95%. No perforation occurred in any of the cases. There were 10 cases treated with ESD, which were considered difficult to achieve en bloc resection using snare forceps, and 28 cases treated with snare resection. Although the median lesion size was significantly larger in the ESD group than in the snare resection group (27 [range 23-66] vs. 19 [range 6-55] mm, P = 0.0052), treatment outcomes were not significantly different between the two groups. Among the 10 cases treated using ESD, en bloc resection was achieved in all cases, along with specimen retrieval without any perforations, despite the large size of the lesions.

CONCLUSION

ER could be performed to achieve a high en bloc resection rate without any perforations in pedunculated duodenal lesions, even in extremely large (e.g., ≧ 60 mm) lesions, suggesting that ER is feasible and may be an alternative to surgical resection for large pedunculated duodenal lesions.

A giant Brunner gland hamartoma successfully treated by endoscopic excision followed by transanal retrieval: A case report

RATIONALE

Brunner gland hamartoma (BGH) is a rare tumor of the duodenum. Although BGH is a benign tumor, larger lesion with gastrointestinal symptoms requires tumor removal. We report a giant BGH, successfully treated by endoscopic excision followed by transanal retrieval.

PATIENT CONCERNS

A 38-year-old woman complained of severe anemia, tarry stool, and vomiting.

DIAGNOSES

Esophagogastroduodenoscopy (EGD) showed a pedunculated giant submucosal mass at the duodenal bulb.

INTERVENTIONS

We attempted to remove it because the lesion seemed to be responsible for patient's anemia and vomiting. The lesion had clear but bulky stalk. We carefully cut the stalk using needle-knife and IT knife2. We tried to retrieve specimen, but the mass could not pass through the pyloric ring because of its size. Then we tried to obtain the specimen from anus. Polyethylene glycol solution was administered to accelerate rapid excretion.

OUTCOMES

The mass was successfully removed and was histologically confirmed as a giant BGH, measuring 55 mm in size.

LESSONS

Reports about endoscopic resection of giant BGH are rare. Moreover, our case is the first report of transanal retrieval of resected specimen using polyethylene glycol solution. Endoscopic resection of BGH is less-invasive but can be more challenging if the mass is large. Our case provides useful option for endoscopic treatment of giant BGH.

Brunner's glands hamartoma with pylorus obstruction: a case report and review of literature

Proliferative lesions of the Brunner’s glands are uncommonly encountered lesions of the small intestine, originating from the deeply seated mucosal and submucosal Brunner’s glands, mainly in the duodenum. The vast majorities of these lesions are benign and include Brunner’s glands hyperplasia (adenomas/nodules) and hamartomas. The etiology and pathogenesis of these lesions are not fully understood, and the diagnosis can sometimes be challenging. We report a case of Brunner’s gland hamartoma in a 57-year-old man who presented with chronic dyspepsia, hematemesis and weight loss. Endoscopic and radiological investigations show a submucosal polypoid lesion at the first part of the duodenum. Routine endoscopic biopsies demonstrated normal duodenal mucosa. The lesion considered endoscopically unresectable and was surgically resected. Frozen section examination and intraoperative consultation showed unremarkable duodenal mucosa and histologically bland Brunner’s glands.