Hemoclip Assisted Polypectomy Following Epinephrine Volume Reduction of a Massive Bleeding Brunnerʼs Gland Hamartoma

Abstract

Purpose: Brunner's gland hamartomas (BGH) are rare tumors of the duodenum caused by hyperplasia of exocrine glands within the duodenal mucosa. They are usually asymptomatic, but may cause occult or massive gastrointestinal bleeding or intestinal obstruction. We present a case of BGH in a high-risk patient where polyp volume reduction techniques facilitated polypectomy. A 60-year-old man with a history of schizophrenia and coronary artery disease was admitted with 4-days of melena. He denied abdominal pain, nausea, or vomiting. He had no prior history of GI bleeding or endoscopy. He had a bare metal coronary stent placed 3 months prior to presentation and was being treated with aspirin and clopidogrel by his cardiologist, who recommended against discontinuing the clopidogrel. On admission, his vitals were stable, and rectal exam was positive for occult blood. His hemoglobin was 8.7 gm/dL, which later decreased to 6.6 gm/dL, and was transfused. The EGD revealed a 6 cm pedunculated polyp with a thick stalk in the duodenal bulb. The head of the polyp was bleeding. The polyp was injected with epinephrine, but could not initially be resected with the snare due to its size. Biopsies revealed hyperplastic mucosa. Two days later, the patient continued to bleed and underwent repeat EGD in attempt to avoid surgery. The EGD revealed a large, lobulated, polyp with a thick stalk in the duodenal bulb with the polyp head invaginating into the second portion of the duodenum. A total of 13 cc of epinephrine was injected into the polyp head, decreasing its size, and 3 hemoclips were placed on the stalk, which reduced the polyp volume. A standard snare was now able to be placed around the head immediately above the hemoclips. Using pure coagulation current, the polyp was resected. On histology, the polyp was composed of lobules of benign tubuloalveolar glands separated by fibromuscular connective tissue consistent with a BGH. Following the procedure the patient had no further bleeding. BGHs account for 5-11% of duodenal tumors. They are an extremely rare cause of gastrointestinal bleeding. They are generally benign, but malignant transformation has been described. Intervention is required in cases of bleeding or obstruction. Endoscopic biopsies are rarely sufficient for diagnosis since these lesions often have normal superficial mucosa. Surgical or endoscopic resection is often required to obtain a diagnosis. There are limited data on endoscopic resection of BGHs. Epinephrine volume reduction has been described for removal of giant colon polyps. To our knowledge, this is the only case in which epinephrine injection for volume reduction of a polyp was used to allow successful snare polypectomy of a BGH.