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The Turkish Journal of Gastroenterology
Turk J Gastroenterol 2011; 22 (4): 419-421
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Brunnerís gland hyperplasia: An unusual cause of gastrointestinal bleeding
Ajaz Ahmad MALIK, Mohd Lateef WANI, Rais Ahmad MALIK, Ifat IRSHAD
Department of Surgery, Sher-i-Kashmir Institute Of Medical Sciences Srinagar Kashmir, Srinagar, India
Keywords: Brunnerís gland, polyp, gastrointestinal bleeding.
Summary
A case of Brunnerís gland hyperplasia presenting as gastrointestinal bleeding is reported herein. A 40-year-old male presented to our hospital with features of upper gastrointestinal bleeding. The patient had a history of passing black tarry stools for the last two days. Upper gastrointestinal endoscopy was done, which showed a pedunculated polypoid lesion in the second part of the duodenum with active bleeding at the base of the polyp. Adrenaline was injected around the bleeding site; however, the patient continued to bleed. He was taken for surgery. A laparotomy was done, and the duodenum was mobilized and opened. A large pedunculated polyp measuring approximately 2 cm was found with bleeding at the base. Polypectomy was done. Histopathological examination of the specimen showed mature Brunnerís gland with normal duodenal mucosa at the surface. Diagnosis of Brunnerís gland hyperplasia was made. The patient is under follow-up and is symptom-free.
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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • Introduction
    Brunnerís gland hyperplasia is a very rare cause of upper gastrointestinal bleeding. The patient can present with symptoms of gastric outlet obstruction or upper gastrointestinal bleeding requiring prompt surgical or endoscopic intervention. Brunnerís gland hyperplasia is an infrequently encountered polypoid lesion in the proximal duodenum. We report this case of Brunnerís gland hyperplasia causing upper gastrointestinal bleeding and requiring surgical intervention.
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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • Case Presentation
    A 40-year-old male patient presented to our Accident and Emergency Department with a complaint of black tarry stools for the last two days. There was no history of smoking or drug intake and no family history. On examination, the patient was grossly pale, ill in appearance, with a pulse of 120/minute and blood pressure of 80/40. Laboratory examination revealed hemoglobin of 5 g/dl, total leukocyte count of 8400/mm3 and platelet count of 70000/mm3. The patient was subjected to upper gastrointestinal endoscopy, which revealed a pedunculated polypoid lesion in the second part of the duodenum with active bleeding at the base of the polyp. Adrenaline was injected around the bleeding site; however, the patient continued to bleed and had progression of symptoms. The patient was taken to surgery. Laparotomy was done, and the duodenum was mobilized and opened. A large pedunculated polyp measuring about 2 cm was found. There was a small ulcer at the base, which was bleeding. Polypectomy was done (Figure 1). The duodenum was closed primarily. Histopathological examination of the specimen showed mature Brunnerís gland with normal duodenal mucosa at the surface. There was no evidence of malignancy (Figure 2). Diagnosis of Brunnerís gland hyperplasia (adenoma) was made. The patient is still under follow-up and is symptom-free.
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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • Discussion
    The etiology of Brunnerís gland hyperplasia, which is usually found in middle age, without any gender preponderance, is unknown (1). The most common location is the posterior wall of the duodenum near the junction of the first and second sections. The size of Brunnerís gland hyperplasia ranges from 0.5-12 cm (2,3-5). In a series of 27 patients, Levine et al. (1) reported that 70% of them are found in the duodenal bulb, 26% in the second section and 4% in the third section of the duodenum.

    Brunnerís gland hyperplasia should be distinguished from other duodenal lesions such as leiomyoma, polypoid adenoma of the superficial mucosal glands, aberrant pancreatic tissue, and malignant tumors (3,6-8). They are usually asymptomatic and often diagnosed incidentally on barium meal or endoscopy (3,5).

    Diagnosis is rarely conclusive on endoscopic biopsies because the lesion locates mainly in the submucosal layer, and the biopsy is often not deep enough to reach the submucosal tumor tissue (3,5,7).

    The final diagnosis of Brunnerís gland hyperplasia depends on the pathological findings of resected specimens obtained by endoscopic mucosal resection, polypectomy or surgical treatment. Only 0.34.6% of benign tumors originating from the duodenum can be found with endoscope (9).

    Brunnerís gland hyperplasia of the duodenum can best be removed endoscopically, because it is thought to be clinically and histologically benign. However, endoscopists should be aware that there have been rare case reports of malignancy arising from Brunnerís gland (3,6,10,11).

    Brunnerís gland hyperplasia is not fatal and patients remain asymptomatic, except for gastrointestinal bleeding or bowel obstruction. Treatment is necessary if gastrointestinal bleeding occurs (68,12-14), as in the present case. Gastrointestinal bleeding can occasionally be massive and rarely fatal, typically manifested by hematemesis or melena, from ulceration or erosion of the mucosa stretched over the submucosal lesion (1,13). In the present case, bleeding was from the base of the polypoid lesion as a result of a small ulcer. The mechanism underlying gastrointestinal bleeding in the present case was atypical, as it is the apex of the polyp that usually bleeds. Brunnerís gland hyperplasia should be considered in the differential diagnosis of duodenal masses.

    In conclusion, we report a case of pedunculated Brunnerís gland hyperplasia of the duodenum causing upper gastrointestinal hemorrhages.
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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • References
    1. Levine JA, Burgart LJ, Batts KP, Wang KK. Brunner's gland hamartomas: clinical presentation and pathological features of 27 cases. Am J Gastroenterol 1995; 90: 290-4.
    2. Patel ND, Levy AD, Mehrotra AK, Sobin LH. Brunner's gland hyperplasia and hamartoma: imaging features with clinicopathologic correlation. AJR Am J Roentgenol 2006; 187: 715-22.
    3. Chattopadhyay P, Kundu AK, Bhattacharyya S, Bandyopadhyay A. Diffuse nodular hyperplasia of Brunner's gland presenting as upper gastrointestinal hemorrhage. Singapore Med J 2008; 49: 81-3.
    4. Nakanishi T, Takeuchi T, Hara K, Sugimoto A. A great Brunner's gland adenoma of the duodenal bulb. Dig Dis Sci 1984; 29: 81-5.
    5. Gao YP, Zhu JS, Zheng WJ. Brunner's gland adenoma of the duodenum: a case report and literature review. World J Gastroenterol 2004; 10: 2616-7.
    6. Patel ND, Levy AD, Mehrotra AK, Sobin LH. Brunner's gland hyperplasia and hamartoma: imaging features with clinicopathologic correlation. AJR Am J Roentgenol 2006; 187: 715-22.
    7. Schluger LK, Rotterdam H, Lebwohl O. Gastrointestinal hemorrhage from a Brunner's gland hamartoma. Am J Gastroenterol 1994; 89: 2088-9.
    8. Walden DT, Marcon NE. Endoscopic injection and polypectomy for bleeding Brunner's gland hamartoma: case report and expanded literature review. Gastrointest Endosc 1998; 47: 403-7.
    9. Perez A, Saltzman JR, Carr-Locke DL, et al. Benign nonampullary duodenal neoplasms. J Gastrointest Surg 2003; 7: 536-41.
    10. Christie AC. Duodenal carcinoma with neoplastic transformation of the underlying Brunner's glands. Br J Cancer 1953; 7: 65-7.
    11. Fujimaki E, Nakamura S, Sugai T, Takeda Y. Brunner's gland adenoma with a focus of p53-positive atypical glands. J Gastroenterol 2000; 35: 155-8.
    12. de Nes LC, Ouwehand F, Peters SH, Boom MJ. A large Brunner's gland hamartoma causing gastrointestinal bleeding and obstruction. Dig Surg 2007; 24: 450-2.
    13. Kehl O, Buhler H, Stamm B, Amman RW. Endoscopic removal of a large, obstructing and bleeding duodenal Brunner's gland adenoma. Endoscopy 1985; 17: 231-2.
    14. Block KP, Frick TJ, Warner TF. Gastrointestinal bleeding from a Brunner's gland hamartoma: characterization by endoscopy, computed tomography, and endoscopic ultrasound. Am J Gastroenterol 2000; 95: 1581-3.
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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
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