A Large Brunnerʼs Gland Adenoma Resected Endoscopically

Abstract

55-year-old male with a history of NSAID use was admitted with three days of multiple episodes of melena and a near-syncopal episode. He denied symptoms of anemia such as shortness of breath, weakness, or fatigue. Unintentional weight loss of four pounds over past month was reported. Family history was negative for gastrointestinal malignancies. Physical exam was remarkable for general pallor and pale conjunctiva. Laboratory: WBC 12.1, hemoglobin 7.8, platelets 117. After fluid resuscitation, hemoglobin was 4.7. Transfusion of 2 units of blood corrected hemoglobin to 7.0. Endoscopy revealed a 3 × 4 cm pedunculated polyp with an ulcerated stalk. Using standard snare polypectomy technique, the polyp was resected (Figure 1). The ulcer site was treated endoscopically with good hemostasis. Pathology identified a 3.4cm Brunner's gland adenoma with no evidence of malignancy (Figure 2). H Pylori IgG antibody titer was positive. On follow up several months later, he was asymptomatic with resolution of anemia. Brunner's glands are submucosal tubular mucous glands located in the duodenum that provide abundant alkaline mucus to neutralize the acidity from stomach contents. Hypotheses on Brunner's gland adenoma pathogenesis include gland hyperplasia by increased acid secretion, inflammatory foci, and H pylori infection. However, it is currently believed that these adenomas are hamartomas with predominance of Brunner's glands plus mixed elements. There are less than 200 reported cases in the literature with the majority being pedunculated and less than 2 cm in size. Although a rare cause of gastrointestinal bleeding, 40–50% of Brunner's gland adenomas present with symptomatic anemia and melena. The case presented stands amongst few cases demonstrating the feasibility of endoscopic resection for symptomatic, large Brunner's gland adenomas thereby obviating the need for surgical intervention. [figure 1][figure 2]Figure 1Figure 2