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• CASE REPORT •
Brunner’s gland adenoma of duodenum: A case report and literature
Yu-Ping Gao, Jian-Shan Zhu, Wen-Jun Zheng
Yu-Ping Gao, Jian-Shan Zhu, Wen-Jun Zheng, Department of
Pathology, Affiliated Renji Hospital, Shanghai Second Medical
University, Shanghai 200001, China
Correspondence to: Dr Yu-Ping Gao, Department of Pathology,
Affiliated Renji Hospital, Shanghai Second Medical University, 145
Shandong (c) Road, Shanghai 200001, China. email@example.com
Telephone: +86-21-58752345 Ext. 3349
Fax: +86-21-58752345 Ext. 3349
Received: 2003-11-21 Accepted: 2004-01-15
AIM: To analyze the clinicopathological features of Brunner’s
gland adenoma of the duodenum.
METHODS: A rare case of Brunner’s gland adenoma of the
duodenum was described and related literature was reviewed.
RESULTS: Brunner’s gland adenoma of the duodenum
appeared to be nodular hyperplasia of the normal Brunner’s
gland with an unusual admixture of normal tissues, including
ducts, adipose tissue and lymphoid tissue. We suggested
that it might be designated as a duodenal hamartoma rather
than a true neoplasm.
CONCLUSION: The most common location of the lesion is
the posterior wall of the duodenum near the junction of its
first and second portions. It can result in gastrointestinal
hemorrhage and duodenal obstruction. Endoscopic polypectomy
is a worthy treatment for benign Brunner’s gland adenomas,
as malignant changes in these tumors have never been proven.
Gao YP, Zhu JS, Zheng WJ. Brunner’s gland adenoma of
duodenum: A case report and literature review. World J
Gastroenterol 2004; 10(17): 2616-2617
Brunner’s gland adenoma, also known as Brunneroma or
polypoid hamartoma, is a rare, benign, proliferative lesion arising
from the Brunner’s glands of the duodenum, accounting for
10.6% of benign tumors of the duodenum. The time patients
are usually asymptomatic and lesions are discovered incidentally.
These lesions manifest occasionally as a rare cause of duodenal
obstruction or upper gastrointestinal hemorrhage, and require
surgical excision. This article reports a case of Brunner’s gland
adenoma, and reviews briefly its clinical presentations, pathological
features and therapy.
A 32-year-old Chinese man complained of two episodes of
melenas and a two-month history of vague epigastric discomfort.
The patient had in October 2001 his first tarry stool episode
without nausea, vomiting and epigastralgia. Endoscopic
examination revealed a mild ulcer in the duodenal bulb. The
symptoms were relieved by antacids and H2 blockers. He reported
however another tarry stool in September 2002 and complained
about epigastric pain without nausea and vomiting during the
preceding 2 mo. Antacids were taken and the pain was relieved.
Vital signs were normal and no anemia was reported when he was
admitted. The physical examination had no unremarkable finding.
The abdomen was soft without palpating pain and jumping pain.
However, X-rays barium radiological examination of the
upper gastrointestinal in October 2002 revealed a nodular,
polypoid-filling defect mass measuring 3 cm×2.5 cm with a
smooth surface and no ulceration in the duodenal bulb. A
tumor was suspected. Follow-up endoscopy disclosed a
lobulated, red-color tumor, occupying the anterior wall of the
bulb. The surface of the tumor was smooth with mild depression
at the top. The mucosa had no erosions and ulcers. Multiple
biopsy specimens were taken and interpreted as “mucosal mild-
medium atypia.” CT scan was negative. A preoperative diagnosis
of malignant tumor was made and the patient prepared for
operation. On October 25, 2002, at the time of operation, a
pedunculated polyp on a short broad-based stalk, 3.5 cm×3 cm×2 cm
in size, was found in the anterior wall of the duodenal bulb. The
common bile duct was normal. The lesion was amputated at the
base of the stalk.
The resected specimen showed a lobulated, polypoid mass
measuring 3.3 cm×2.5 cm×2.5 cm projecting into the duodenum.
The stalk was measured 1.8 cm in diameter and 0.5 cm in length.
The tumor was completely enveloped by the intact thin duodenal
mucosa. The surface of the tumor was smooth without erosions
and ulcers. The cut surface of tumor had a gray-red or gray-
yellow color, revealing lobules. The consistency was moderate.
On microscopic examination, the tumor was composed of
hyperplasia of Brunner’s glands. The hyperplasia formed lobules
that were separated by intervening bands of fibrous tissue,
adipose tissue, ducts and well developed aggregated lymphoid.
No sign of malignancy was found in the hyperplasia, Brunner’s
glands as well as the surrounded duodenal mucosa. The frozen
sections and the final pathologic diagnosis were assessed as
Brunner’s gland adenoma. The patient had an uneventful
postoperative course and was discharged on the tenth postoperative
day. He has remained symptom free ever since and no episode
of recurrent melenas has been reported.
Besides the duodenal gland, the duodenum has Brunner’s
glands under the mucin. Its structure and function are similar
to glands of the pylorus. Brunner’s glands secrete an alkaline
fluid composed of viscous mucin, whose function appears to
protect the duodenal epithelium from acid chyme of the stomach.
Brunner’s glands consist of submucosal mucin-secreting glands
located exclusively in the duodenum. They extend from the
pylorus distally for a variable distance, usually stopping at the
first and second portions of the duodenum, and less often
stopping at the third and fourth portions.
In 1688 Brunner gave a precise anatomic description of the
duodenal submucosal glands and coined the term “pancreas
secundarium.” In 1846 Middeldorpf correctly identified these
glands as a separate entity, which he proposed be named Brunner’s
glands. Salvioli reported the first adenoma of Brunner’s gland Download full-text
in 1876. Since then, 150 cases or so have been reported in
literature of English language.
The etiology of Brunner’s gland adenoma remains obscure.
It tends to present predominantly in the fifth and sixth decades
of man’s life with no sex predominance. It has been found although
the size of adenoma might extend from 1-12 cm, it is generally 1-
2 cm in diameter. The most common location for the lesion is
the posterior wall of the duodenum near the junction of its first
and second portions. Brunner’s gland adenoma was rarely
found extending to the proximal jejunum.
Brunner’s gland adenoma has fallen into two categories:
symptomatic tumors and asymptomatic ones that are only found
incidentally. Symptomatic tumors can further be divided into
hemorrhagic and obstructive tumors. The clinical manifestations
of the former are gastrointestinal hemorrhage, due to ulceration
or erosion of the tumor. Obstructive tumors occur when hyperplasia
diffuses or a single adenoma grows too large, causing epigastric
bloating, discomfort, vomiting or weight loss. Duodenal
intussusception has been reported only in two patients,
probably because of the fixation of duodenum to the posterior
abdominal wall. There are also reports about patients who
complained of diarrhea owing to duodenal motor disturbances.
Preoperative histological diagnosis at present is not always
easy. In X-rays barium examination, the findings are often
nonspecific because there is usually a sessile or pedunculated
polypoid-filling defect in the duodenal bulb. Some doctors hold
that hypotonic duodenography should play a vital role in
establishing the diagnosis and should be treated as the best
method to check the surface of the lesion. Endoscopy has an
additional function in diagnosing and treating Brunner’s gland
adenoma, since it can verify the histological diagnosis and
remove the tumor simultaneously. Endoscopic pinching biopsy
however usually gave a negative result because the tumor was
almost covered entirely with thick intact duodenal mucosa in
the biopsy sites and the biopsy was often not deep enough to
reach the submucosal tumor tissue. In our case, the endoscopic
biopsy was negative, and the condition was diagnosed as chronic
gastritis, although the final pathologic diagnosis indicated that
the patient suffered from Brunner’s gland adenoma. CT examination
appeared to be unrevealing.
Pathomorphological features of Brunner’s gland are
characterized by the presence of nondysplastic, lobulated
Brunner’s glands. Its hyperplasia is divided into diffuse hyperplasia,
nodular hyperplasia and adenomatous hyperplasia with or
without erosion or ulcer. In our opinion, the unusually admixture
of normal tissues, including Brunner’s glands, ducts, adipose
tissue, and lymphoid tissue, supports the designation of these
lesions as a hamartoma or nodular hyperplasia rather than a
true neoplasm. It is a tumor without malignant predisposition.
The malignant type is rare. Fujimaki et al. reported recently one
patient with a focus atypical gland.
It is still controversial whether asymptomatic Brunner’s gland
adenoma found incidentally needs surgical removal. Some
people think that it needs no treatment, whereas others hold
that it should undergo endoscopic excision in order to prevent
complications. There have been several reports[2,4] that Brunner’s
gland adenoma could give rise to acute profuse bleeding, which
results in shock of patients. Symptomatic Brunner’s gland
adenoma, in our point of view, usually needs surgical treatment.
When the tumor is small or pedunculated, endoscopic polypectomy
is the first choice. Open surgical excision is reserved for cases
where snaring has failed or when tumor is too large. The outcome
of operation is usually excellent and there is no recurrent ever
1 Matsumoto T, Iida M, Matsui T, Yao T, Fujishima M. A large
Brunner’s gland adenoma removed by endoscopic polypectomy.
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Peetz ME, Moseley HS. Brunner’s gland hyperplasia. Am Surg
1989; 55: 474-477
Nakanishi T, Takeuchi T, Hara K, Sugimoto A. A great Brunner’s
gland adenoma of the duodenal bulb. Dig Dis Sci 1984; 29: 81-85
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: 290-294
Spellberg MA, Vucelic B. A case of Brunner’s glands hyper-
plasia with diarrhea responsive to cimetidine. Am J Gastroenterol
1980; 73: 519-522
Gourtsoyiannis NC, Zarifi M, Gallis P, Mouchtouris A, Livaditou
A. Radiologic appearances of Brunner’s gland adenoma: a case
report. Eur J Radiol 1990; 11: 188-190
Fujimaki E, Nakamura S, Sugai T, Takeda Y. Brunner’s gland
adenoma with a focus of p53-positive atypical glands. J
Gastroenterol 2000; 35: 155-158
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