2636 Brunner's Gland Hyperplasia: A Massive Duodenal Lesion

Abstract

INTRODUCTION: Brunner’s glands are alkaline-fluid secreting duodenal glands in the proximal duodenum submucosa. Brunner’s gland hyperplasia is a rare entity that accounts for 10% of all benign duodenal tumors, with an estimated incidence of 0.008%. Underlying etiology is postulated to be secondary to excessive acid secretion, H. pylori infection or inflammation. CASE DESCRIPTION/METHODS: A 57-year-old male with PMH of Myasthenia Gravis, GERD and esophageal strictures with prior dilations, presented with melena and intermittent abdominal pain for a few weeks and labs notable for iron deficiency anemia. EGD showed a large 5 cm polypoid mass in the proximal duodenal bulb with shallow surface ulcerations and a thick stalk causing ball-valve like obstruction of the pyloric channel. CT abdomen showed an elongated tubular mass arising from the proximal duodenum projecting antegrade within the duodenal lumen, measuring 5.3 × 1.7 × 1.5 cm, with no evidence of metastasis. Endoscopic ultrasound (EUS) showed the lesion appeared to be arising from the submucosal layer, with a large blood vessel feeding the lesion. A fine needle biopsy revealed benign histology. Due to its large size, the lesion was not amenable to endoscopic removal. He underwent laparotomy with pyloroplasty, duodenotomy and partial duodenal resection due to concern for premalignant potential. Surgical pathology showed Brunner’s gland hyperplasia and hamartoma that was negative for malignancy. The patient is doing well with resolution of abdominal pain. DISCUSSION: Brunner’s gland hyperplasia is usually an incidental finding during endoscopy. Symptomatic presentations include gastrointestinal bleeding and intestinal obstruction. Literature search shows reports of Brunner’s hyperplasia usually 1–2 cm in size, there are few reported that are larger than 5 cm. Diagnosis requires histological examination of the mass, usually by endoscopy with excision or biopsy. CT scan and EUS can demonstrate the submucosal origin of the mass. Mode of excision depends on the size, location and presentation of the lesion. Upper gastrointestinal endoscopy with polypectomy is preferred. Laparoscopic polypectomy is also an option. Laparotomy is reserved for large, sessile tumors, failure of endoscopic approach or unstable bleeding patients. Few cases reported in literature have been managed with laparotomy. The potential cause of our patient’s large Brunner’s gland mass could be gastric acid hypersecretion as he had severe GERD with peptic esophageal strictures.