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CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 9  |  Page : 1298-1300

Giant brunneroma originating from pylorus imitating duodenopancreatic malignancy


Division of Gastroenterology, Department of Internal Medicine, Sanko University, Faculty of Medicine, Sehitkamil, Gaziantep, Turkey

Date of Acceptance18-Mar-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Dr. N Yilmaz
SANKO University, Faculty of Medicine, Department of Internal Medicine, Division of Gastroenterology, Sehitkamil, Gaziantep 27310
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_274_18

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   Abstract 


Brunner's gland adenoma is usually asymptomatic and sometimes accompanied by nausea, vomiting and swelling. İt is often confused with duodenal malignancy, which may mislead and the physician about its treatment. We want to present a case of a 40-year-old female with a history of weight loss, vomiting and nausea since six months. İnitial imaging studies that revealed a large mass in the duodenum and endoscopic findings that suggested duodenal invagination. Whipple operation had been recommended to the patient by two different general surgery departments. The patient reported to our clinic for gastroenterological evaluation before the operation. At our exmination, a giant polyp, 5 to 6 cm in size, was observed in the second part of the duodenum; it was 9 to 10 cm long and originated from the pylorus. Duodenotomy was performed, and only the giant polyp was removed. Pathological examination revealed hyperplastic Brunner's glands mixed with fibromuscular tissue and mature fat tissue.

Keywords: Brunneroma, duodenal malignancy, giant polyp


How to cite this article:
Yilmaz N. Giant brunneroma originating from pylorus imitating duodenopancreatic malignancy. Niger J Clin Pract 2019;22:1298-300

How to cite this URL:
Yilmaz N. Giant brunneroma originating from pylorus imitating duodenopancreatic malignancy. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 21];22:1298-300. Available from: http://www.njcponline.com/text.asp?2019/22/9/1298/266160




   Introduction Top


Brunner's glands are submucosal glands that secrete bicarbonate and mucus, thereby aiding in the neutralization of the acidic chyme and facilitating the intestinal digestion. They were first described in 1688 by a Swiss anatomist, Johann Conrad Brunner.[1] Brunner's gland adenoma is a rare benign proliferative lesion, which is also known as Brunneroma or polypoid hamartoma, which was first described by Cruveilhier in 1835.[2] In endoscopic examination, these lesions are displayed as pedunculated polyps with a long stem and large diameter. Although the lesions firstly appear in the bulbus, they gradually decrease in number and size towards distal duodenum. When they reach giant dimensions, they may obstruct the gastric outlet or duodenum, consequently leading to intussusception. Brunner's gland adenoma is usually asymptomatic and sometimes accompanied by nausea, vomiting, and swelling. Preoperative diagnosis with endoscopic biopsy is usually difficult in large adenomas owing to the mostly submucosal location. Also, it is often confused with duodenal malignancy and this may lead to incorrect treatment.[3],[4]


   Case Report Top


A 40-year-old female patient had admitted to the hospital with complaints of nausea, vomiting, and weight loss for 6 months. Duodenal invagination was detected in the diagnostic endoscopy. A mass lesion about 5--6 cm in size that filled the second part of the duodenum and led to the thickening of the bulbus wall had been detected with abdominal computed tomography (CT) [Figure 1]. The patient had referred to general surgery clinic due to detecting the lesion endoscopically. Whipple operation had suggested to the patient by two different general surgery departments. Finally, the patient was referred to our hospital for the operation. The patient reported to our polyclinic for gastroenterological evaluation before the operation. There was no history of drug use other than the proton pump inhibitor, which she had received for 1 to 2 years to reduce dyspeptic symptoms. Physical examination revealed mild pallor on the skin and conjunctiva and no organomegaly. Laboratory tests showed hemoglobin of 8.2 g/dL and iron of 31 mg/dL. No pathology observed in other laboratory tests. A giant polyp, 5--6 cm in size was observed in the second part of the duodenum; it was 9--10 cm long and originated from the pylorus [Figure 2]a, [Figure 2]b. The surface of the polyp was irregular and erosive with a malignant appearance. It was difficult to see the whole lesion due to its large size and moving stem. Biopsies were taken from polyp which indicated nonspecific duodenitis. Endoscopic polypectomy was planned but it could not be done due to large polypectomy stem. We referred the patient to the general surgery clinic due to a very wide polyp stem that originated from the large part of pylorus. Surgical duodenotomy and a small incision was done from bulbus, excision of polyp from duodenum site of pylorus was achieved. Excised polyp was removed from bulbus by the surgeon [Figure 3]. In the pathological examination, hyperplastic Brunner's glands mixed with fibromuscular tissue and mature fat tissue were observed [Figure 4]. In addition, hyperplastic Brunner's glands and epithelial type of gastroduodenal junction separated by thick fibrous bands in the submucosa were seen in microscopy. The resection sites around the duodenum were clean because the lesion was originating from the pylorus.
Figure 1: Mass appearance in the second part of Duodenum in CT

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Figure 2: In the second part of the duodenum, thick and long stem polyps with erosions on the normal duodenal mucosa were observed (a) and (b)

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Figure 3: Macroscopic appearance of polyp after duodenotomy

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Figure 4: Microscopic appearance of hyperplasic Brunner glands mixed with fibromuscular and mature fat tissue

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   Discussion Top


Duodenal tumors are rare entity. Brunner's gland adenomas or Brunneroma constitutes 10.6% of all benign duodenal tumors. Although these are most frequently observed in the bulbus (57%), they can be present in the second (27%) and third parts (5%) of the duodenum. The frequency of occurrence of Brunneroma in the pyloric canal, jejunum, and proximal ileum is approximately 5%. Brunner's gland adenomas are mostly smaller than 2 cm, asymptomatic, and usually detected incidentally. Symptoms are obstruction, compression, or hemorrhage that starts appearing due to increase in the diameter of the lesion.[4] The literature reports polyps with stems reaching a size of 12--13 cm and extending to second and third parts of the duodenum. Kumar et al. reported a 13 cm Brunner's adenoma in a 62-year-old patient who presented with weight loss and vomiting. This lesion was reported as the largest one in the literature.[5] The most common symptoms in symptomatic patients are gastrointestinal bleeding, anemia, nausea, vomiting, and weight loss. It may resemble duodenum and periampullary region tumors because of the frequent occurrence of alarm symptoms. In addition, benign-malignant differentiation by endoscopic or radiological imaging cannot be performed clearly. Although abdominal CT and endoscopy are useful in the diagnosis of Brunner's adenoma, the sensitivity of endoscopy is 72--89%, and endoscopic biopsy may give false results due to submucosal position of the lesion.[6],[7] In our case, the lesion could not be observed during the first endoscopy due to the invagination. Biopsy could not be done for this reason. The lesion was seen on the second endoscopy, and the biopsy reported nonspecific duodenitis. In a recent case report, Franke et al. detected a giant mass that completely filled the lumen at the distal of the pylorus and it was visible partially due to its large size. The biopsy did not yield any results, and a giant mass originating from the second part of the duodenum was seen in the abdominal CT. As a result of multidisciplinary discussions, the 8 cm mass originating from the proximal duodenum of the patient who underwent Whipple operation was pathologically diagnosed as Brunner's gland adenoma. The patient was discharged on the 17th postoperative day.[8] Similarly, in our case, firstly Whipple operation was planned; however, after the second endoscopy, a less invasive procedure was planned and Whipple operation was not performed. The etiology of Brunner's gland adenoma is still uncertain. It exerts an antacid effect due to mucus and bicarbonate content of its secretion. A recent study that found duodenal mucosal injury to be associated with Brunner's gland proliferation emphasized that increased acidity and peptic duodenitis may cause this condition.[9] In our case, the hyperacidity could not be the etiological factor because of receiving proton pump inhibitor of patient for 1 to 2 years due to the dyspeptic complaints. The recommended treatment approach is primarily endoscopic polypectomy or submucosal resection for small lesions; these are less invasive and cost-effective. However, duodenotomy is recommended for larger and more difficult lesions that cannot be removed endoscopically.[10] When deciding on the type of surgery, consideration should be given to possible risks and complications. In the present case, we preferred duodenotomy because of the large lesion, and the patient was discharged on the third day after the operation.


   Conclusion Top


We presented a case report of Brunner's gland adenoma that originated from the pylorus and extended into the second part of the duodenum and resembled the duodenopancreatic malignancy. We believe that our case, with its rare properties, will contribute to the literature. The avoidance of Whipple operation in our patient demonstrated that the endoscopy results should be carefully interpreted by an experienced physician.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wong C, Matin A, Syed MA, Levi GS, Carr-Locke DL. When Brunner Glands Are Not So Innocent -Medscape-Dec 17, 2012. [Internet]. Available form: https://www.medscape.com/viewarticle/775988. [Last Cited on 2018 Feb 26].  Back to cited text no. 1
    
2.
Abbas R, Al-Kawas FH. Brunner gland hamartoma: Review article. Gastroenterol Hepatol 2008;4:473-5.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
Bayan K, Tüzün Y, Yilmaz S, Bilici A. Pyloric giant Brunner's gland hamartoma as a cause of both duodenojejunal intussusception and obscure gastrointestinal bleeding. Turk J Gastroenterol 2009;20:52-6.  Back to cited text no. 4
    
5.
Kumar SA, Ajesh S, Prabhudesai S. Pyloric giant Brunner's gland adenoma mimicking duodenal carcinoma. J Med Diagn Meth 2013;4:2.  Back to cited text no. 5
    
6.
So CS, Jang HJ, Choi YS, Koh DH, Choi MH, Kae SH, et al. Giant Brunner's gland adenoma of the proximal jejunum presenting as iron deficiency anemia and mimicking intussusceptions. Clin Endosc 2013;46:102-5.  Back to cited text no. 6
    
7.
Kume K, Yamasaki M, Narita R, Yoshikawa I. A case of Brunner's gland hyperplasia with features of duodenal cancer. Gastroenterology 2009;1:e8.  Back to cited text no. 7
    
8.
Frenkel NC, Laclé MM, Rinkes IHMB, Molenaar IQ, Hagendoorn J. A giant brunneroma causing gastrointestinal bleeding and severe anemia requiring transfusion and surgery. Case Rep Surg 2017:6940649. doi: 10.1155/2017/6940649.  Back to cited text no. 8
    
9.
Akaki M, Taniguchi S, Hatakeyama K, Kushima R, Kataoka H. Duodenal mucosal damage is associated with proliferative activity of Brunner's gland hamartoma: A case report. BMC Gastroenterol 2014;14:14.  Back to cited text no. 9
    
10.
Khan Z. Brunner's gland adenoma: A case report with review of literature. Pak J Surg 2007;23:302-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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