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LETTERS TO EDITOR  
Year : 2020  |  Volume : 63  |  Issue : 2  |  Page : 334-335
Brunner's gland hamartoma presenting as large duodenal polyp


1 Department of Medicine, Maulana Azad Medical College, India
2 Department of Pathology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, India

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Date of Web Publication18-Apr-2020
 

How to cite this article:
Nath S, Panda G, Karna R, Kumar N, Saran RK, Kar P. Brunner's gland hamartoma presenting as large duodenal polyp. Indian J Pathol Microbiol 2020;63:334-5

How to cite this URL:
Nath S, Panda G, Karna R, Kumar N, Saran RK, Kar P. Brunner's gland hamartoma presenting as large duodenal polyp. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Aug 10];63:334-5. Available from: http://www.ijpmonline.org/text.asp?2020/63/2/334/282706




Dear Editor,

Brunner's gland hamartoma (BGH) are infrequently encountered polypoid nodules in the proximal duodenum.[1] Most of the lesions are small, asymptomatic, and are detected incidentally. It is a very rare cause of upper gastrointestinal (GI) bleed. Clinically, patients may present with symptoms of duodenal obstruction or upper GI bleed and require endoscopic or surgical excision.[2] Here, we describe a case of pedunculated Brunner's gland hamartoma of the duodenum causing upper GI bleed.

A 47-year-old male presented to the OPD with history of black tarry stool for 20 days. He was in good physical health with no relevant family or medical history. On examination, he was afebrile with blood pressure of 130/70 mm Hg and pulse 90/min and there was no postural hypotension. Laboratory results showed Hb- 10 gm%, TLC -6800/μl, platelet count-1,70,000/μl, total bilirubin -1 mg/dl, SGOT -37 u/ml, SGPT-35 u/ml ALP-87 iu/ml, blood urea-33 mg/dl, and serum creatinine-1.1 mg/dl. Endoscopic examination of the upper digestive tract revealed a large pedunculated, lobular polyp, about 30 mm in diameter, arising from the wall of the first part of the duodenum. GI bleeding was occurring from the base of stalk of the polyp. Contrast Enhanced Computed Tomography (CECT) abdomen was done to rule out extraluminal extension. It revealed a large pedunculated polyp in D1 region without any necrosis. Endomucosal resection was performed. The resected specimen was approximately 3-cm whitish soft mass. Histopathological examination of the specimen revealed that the main body of the polyp contained several lobules of mature Brunner's gland [Figure 1] and [Figure 2]. The surface epithelium consisted of normal duodenal mucosa with areas of focal ulceration. There was no evidence of malignancy. The lesion was diagnosed as a Brunner's gland hamartoma of the duodenum. After endoscopic polypectomy, melena resolved in the patient.
Figure 1: X 10 HE. Large area of normal Brunner's glands seen below the muscularis mucosae

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Figure 2: X 20 HE section showing Brunner's glands

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Brunner's glands are branched acinotubular glands located in the submucosa and lined with cuboidal-to-columnar clear cells in the glands, and cuboidal cells in the duct.[3] They are predominantly seen in the duodenal bulb and proximal duodenum and progressively decrease in size and number in the distal portion.[4] In infants, Brunner's glands occupy 55% of the total area of the duodenum and by 50 years of age it drops to 35%.[5] Functionally, they secrete an alkaline fluid composed of mucin, which exerts a physiologic anti-acid function by coating the duodenal epithelium, protecting it from the acid of the stomach. Furthermore, in response to the presence of acid in the duodenum, they also secrete pepsinogen and urogastrone which inhibit gastric acid secretion.[6] Thus, they play a significant role in duodenal resistance to ulcer formation. Brunner's gland hamartoma is a rare benign tumor of the duodenum accounting for about 10.6% of benign duodenal tumor.[7] Most Brunner's gland hamartomas are located in the duodenal bulb (57%) but may also be found in the second (27%) and third (7%) parts of the duodenum and rarely detected in the pyloric canal (5%), jejunum (2%), and proximal ileum (2%).[7] Usually they are pedunculated lesions (89%)[8] with size ranging from 1 to 2 cm. They are usually asymptomatic and often detected incidentally on barium meal or endoscopy.[1],[2] Patients with Brunner's gland hamartoma usually present with GI bleeding or bowel obstruction.[1],[5],[9] The diagnosis of Brunner's gland hamartoma is usually made by a combination of radiographic and endoscopic findings. The diagnosis of Brunner's gland hamartoma can only be confirmed by the pathological findings of resected specimens obtained after endoscopic mucosal resection, polypectomy, or surgical treatment.[1],[3],[4] As to therapy, Brunner's gland hamartoma of the duodenum can best be removed endoscopically, because it is thought to be clinically and histologically benign.[1],[9],[10],[11]

Here, we reported a case of Brunner's gland hamartoma of the duodenum causing upper GI bleed. Although rare, it should be taken into consideration as a differential diagnosis of duodenal masses.

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.
Patel ND, Levy AD, Mehrotra AK, Sobin LH. Brunner's gland clinicopathologic correlation. AJR Am J Roentgenol 2006;187:715-22.  Back to cited text no. 1
    
2.
Matsumoto T, Iida M, Matsui T, Yao T, Fujishima M. A large Brunner's gland adenoma removed by endoscopic polypectomy. Endoscopy 1990;22:192-3.  Back to cited text no. 2
    
3.
Gao YP, Zhu JS, Zheng WJ. Brunner's gland adenoma of duodenum: A case report and literature review. World J Gastroenterol 2004;10:2616-7.  Back to cited text no. 3
    
4.
Rocco A, Borriello P, De Colibus P, Pica L, Iacono A, Nardone G. Large Brunner's gland adenoma: Case report and literature review. World J Gastroenterol 2006;12:1966-8.  Back to cited text no. 4
    
5.
Chattopadhyay P, Kundu AK, Bhattacharya S, Bandyopadhyay A. Diffuse nodular hyperplasia of Brunner's gland presenting as upper gastrointestinal haemorrhage. Singapore Med J 2008;49:81-3.  Back to cited text no. 5
    
6.
Abbas R, Al Kawas FH. Brunner gland hamartoma. Gastroenterol Hepatol 2008;4:473-5.  Back to cited text no. 6
    
7.
Al Khurry LE, Al Khafaji KR, Rakhem SA, Al Rubaie AL, Al Sahili SA. Brunner's gland adenoma at the gastroduodenal junction: A case report. Arab J Gastroenterol 2006;7:127-9.  Back to cited text no. 7
    
8.
Nes LCF, Ouwehand F, Peters SHA, Boom MJ. A large Brunner's gland hamartoma causing gastrointestinal bleeding and obstruction. Dig Surg 2007;24:450-2.  Back to cited text no. 8
    
9.
Kitagawa Y, Osumi H, Kawachi H, Yoshio T, Yoshimizu S, Horiuchi Y, et al. Giant duodenal Brunner's gland hamartoma successfully treated via endoscopic mucosal resection. Arab J Gastroenterol 2018;19:125-9.  Back to cited text no. 9
    
10.
Tornambe A, Tornambe G. A case of peduncolated Brunner's gland Hamartoma. G Chir 2018;39:111-3.  Back to cited text no. 10
    
11.
Woharndee P, Sornmayura P, Bunyaratvej S. Brunner's gland adenoma: A report of two cases. J Med Assoc Thai 2005;88:841-4.  Back to cited text no. 11
    

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Correspondence Address:
Premashis Kar
E23 Nivedeta Kunj, Sector 10 R.K. Puram, New Delhi - 110 022
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_650_18

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