Brunnerʼs Gland Adenoma: A Rare Cause of Upper Gastrointestinal Bleeding

Abstract

Case Description: A 81-year-old Caucasian woman presented to the emergency department with acute onset of hematemesis and hematochezia. Patient was on warfarin for atrial fibrillation. At the time of presentation, hemoglobin was 6.1g/dL and INR 3.8. Esophagogastroduodenoscopy (EGD) was performed which showed a large sub-epithelial pedunculated polypoid lesion at the junction of 1st and 2nd portion of the duodenum (Figure 1). There appeared to be superficial ulceration on this lesion indicating most likely source of her bleeding (Figure 2). Patient subsequently underwent endoscopic ultrasound which revealed that this lesion arose from the submucosal layer of the duodenum. Underlying muscularis propria and adventitia was intact and there was no evidence of peri-duodenal lymphadenopathy. This lesion was removed by endoscopic mucosal resection in an en-bloc manner and the mucosectomy defect was closed by using hemostat clips. Histological examination of this lesion revealed packed Brunner's glands and ducts admixed with smooth muscle suggestive of Brunner's adenoma (Figure 3). No signs of malignancy or dysplasia was seen. Warfarin was restarted a week later and patient remained symptom free ever since with no further episodes of gastrointestinal bleeding.Figure: Esophagogastroduodenoscopy: Pendunculated polyp on the anterior wall of the duodenum.Figure: Endoscopic Image: Duodenal polyp with superficial ulceration.Figure: Hyperplastic Brunner's glands (BG) with lymphoid aggregates consistent with BG adenoma (H and E).Discussion: Brunner glands are branched acinotubular submucosal glands, predominantly localized in the duodenal bulb and proximal duodenum. On the other hand, Brunner's gland adenoma is a rare tumor-like lesion, mostly seen in middle aged individuals without sex predominance. It is generally seen as a single pedunculated polyp, with an average size of 2 cm and rarely larger than 5 cm. The most common location is the posterior wall of the duodenum near the junction of its first and second portions. Etiology of this lesion is not known. Brunner's gland adenoma is often asymptomatic or on occasion can present with gastrointestinal bleeding or duodenal obstruction (especially larger lesions). Differential diagnoses include gastrointestinal stromal tumor, lymphoma, carcinoid tumors or aberrant pancreatic tissue. Resection, preferably endoscopic is recommended for Brunner gland adenomas larger than 2.0 cm, even if they are asymptomatic. Data regarding recurrence of these lesions after resection is not known. In conclusion, Brunner's gland adenoma should be recognized as a rare cause of gastrointestinal bleeding. Symptomatic lesions can be safely managed by endoscopic resection.