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Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 113-114
Brunner's gland hamartoma


Department of Histopathology, Armed Forces Hospital, Muscat, Sultanate of Oman

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Date of Web Publication11-Apr-2012
 

How to cite this article:
Ramachandra S, Kuruvila S. Brunner's gland hamartoma. Indian J Pathol Microbiol 2012;55:113-4

How to cite this URL:
Ramachandra S, Kuruvila S. Brunner's gland hamartoma. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Dec 9];55:113-4. Available from: http://www.ijpmonline.org/text.asp?2012/55/1/113/94879



   Introduction Top


Brunner's gland hamartoma (BGH) is a rare benign tumor of the duodenum found in the 5 th or 6 th decade of life. Curveilhier, described the first case of BGH in 1835, as cited by Chatelain et al. [1] in their report. BGH has an estimated incidence of <0.01% and fewer than 200 cases have been reported in the literature. [2] They are detected incidentally and are usually asymptomatic. The symptomatic patients can present with a variety of clinical manifestations and occasionally present with obstruction or intussusception. They present as nodular, polypoid, sessile/pedunculated masses in the duodenum almost always single.


   Case Report Top


Our case was a 71-year-old male patient, who presented with two- to three-months history of weight loss and recurrent vomiting, after intake of solid foods. Tolerance to liquid food was good. He had diabetes mellitus and hypertension, and had been taking oral hypoglycemic agents for 20 years. The patient was subjected to upper gastrointestinal endoscopy which showed a large duodenal cap mass protruding from the anterior wall. With the differential diagnoses of gastrointestinal stromal tumor (GIST) and neuroendocrine tumor, the patient was subjected to the computed tomography (CT) of the chest and the abdomen. CT abdomen showed an intraluminal mass like lesion and endoscopic correlation was recommended. The patient was booked for elective surgery. However, the patient was readmitted as he could not tolerate oral intake of fluids. The mass was surgically resected and the specimen was sent for histopathological examination. The specimen was a grey brown nodular mass measuring 3.0 × 2.5 × 2.5 cm with a smooth congested surface. Cut surface had a nodular, grey white fleshy appearance. No necrosis or cystic changes were seen. Microscopy showed a polypoid tumor covered by small intestinal mucosa. The tumor was composed of lobules of Brunner's glands with a few dilated glands. These lobules were separated by fibrous septae and lymphoid aggregates were seen. A few foci showed smooth muscle. There was no evidence of dysplasia or malignancy.


   Discussion Top


Brunner's glands were first described by Brunner in 1688. [3] They are branched acinotubular alkaline secreting glands located in the submucosa of the duodenum. Ectopic locations include pylorus and jejunum. Fifty seven percent of BGHs are seen in duodenal bulb, 27% in the second, and 5% in the third part of the duodenum, corresponding to the anatomic distribution of the glands. In the past, there has been significant debate regarding the nomenclature of Brunner gland proliferation. Brunner's gland hyperplasia can be seen as diffuse glandular proliferation imparting coarse nodularity to the duodenum or as polypoid excrescences. [4] They may be seen in association with peptic duodenitis. Differentiating hyperplasia from normal Brunner's glands is difficult. Occasionally these hyperplastic excrescences coalesce to form sessile polyps of less than 1 cm. They are clinically insignificant and are referred to as Brunner's gland nodules or Brunner's gland adenomas. Because of their non-neoplastic nature, the term Brunner's gland hyperplasia is preferred. [4] The diagnostic criteria for hyperplasia in endoscopically obtained specimens require the presence of lobules of Brunner's glands within the mucosa in at least 50% of the length of the biopsy specimen. [4] Rarely, Brunner's glands may grow into a large pedunculated polyp and can produce symptoms of obstruction, intussusception, or melena. These lesions are composed of lobules of Brunner's glands with a few cystically dilated glands and admixture of fibromuscular and adipose tissue [Figure 1]. Many authors refer these lesions as Brunner's gland hamartoma because of their large size (>2 cm) and the presence of combination of both mesenchymal and epithelial elements. [4] In our case, the polyp measured 3.0 cm and patient presented with obstructive symptoms. Histologically, Brunner gland proliferation suggests a hamartoma when they consist of increased numbers of normal appearing Brunner glands accompanied by smooth muscle and adipose tissue. Endoscopically, these lesions have a higher chance of being diagnosed as GIST, lymphoma, carcinoid, Peutz Jeghers polyp, prolapsed pyloric mucosa or aberrant pancreatic tissue. [5] Possibility of BGH as a preoperative diagnosis is rare. The aetiology remains unclear. Hyperchlorhydria has been thought to stimulate the proliferation of Brunner's glands. [3] Associated Helicobacter pylori infection is commonly seen in patients with BGH. But their exact role is not clear. Another theory suggests that these glands are hyperplastic reactive proliferation to inflammation. [5] This is not well supported as lymphocytes are present in the sub-mucosa of the entire gastrointestinal tract. Other conditions associated with BGH are chronic pancreatitis, end stage renal failure, and uremia. [3],[4] In our case, the patient is a known case of DM and has been on medication for more than 20 years. Serum amylase was elevated, suggesting chronic pancreatitis. Follow-up investigations have shown that the patient has chronic renal failure. Diagnoses of BGH are made by various imaging studies including endoscopy, barium evaluation, ultrasonography, CT and magnetic resonance imaging (MRI).
Figure 1: Duodenal congested mucosa and the submucosal location of Brunner's gland hamartoma. (H and E stain, x4) Inset showing glands and smooth muscle fibres in the septa (H and E stain, x10)

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BGHs are rare benign lesions of the duodenum, usually found incidentally. They can rarely cause outlet obstruction. Endoscopic removal or surgical resection is the treatment of choice.

 
   References Top

1.Chatelain D, Maillet E, Boyer L, Checkouri G, Mourra N, Flejou JF. Brunner gland hamartoma with predominant adipose tissue and ciliated cysts. Arch Pathol Lab Med 2002;126:734-5.  Back to cited text no. 1
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2.Stewart ZA, Hruban RH, Fishman EF, Wolfgang CL. Surgical management of giant Brunner's gland hamartoma: Case report and literature review. World J Surg Oncol 2009;7:68.  Back to cited text no. 2
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3.Abbass R, Al-Kawas FH. Review Brunner gland hamartoma. Gastroenterol Hepatol 2008;4:473-8.  Back to cited text no. 3
    
4.Yantis RK, Antonioli DA. Polyps of the small intestine. In: Odze RD, Goldblum JR, Crawford JM. Surgical pathology of GItract, liver, biliary tract and pancreas. 1 st ed. Pennysylvania: Saunders Press; 2004. p. 295-6.  Back to cited text no. 4
    
5.Gokhale U, Pillai RG. Large Brunner's gland hamartoma: A case report. Oman Med J 2009;24:41-3.  Back to cited text no. 5
    

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Correspondence Address:
Sunitha Ramachandra
W/O Dr. Manjunath S, ROP Hospital, Qurum, Mina Al Fahal, PO Box 325, PC 116, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.94879

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This article has been cited by
1 A Duodenal Tumor With Intermittent Obstruction
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[Pubmed] | [DOI]



 

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   Introduction
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