HSHS St. Mary's Hospital Medical Center Augusta, GA, United States
Kwabena Adu-Gyamfi, MD1, Michael Maitar, MD2, Rami Matar, 3, Dominic Amakye, MBBCh4 1HSHS St. Mary's Hospital Medical Center, Green Bay, WI; 2Southern Illinois University School of Medicine, Springfield, IL; 3St. George's University School of Medicine, University Center, Grenada, Saint George, Grenada; 4Piedmont Athens Regional Medical Center, Athens, GA
Introduction: Brunner’s Gland Hamartoma (BGH) is a rare duodenal lesion which may cause diagnostic dilemma at upper endoscopy and lead to inadvertent extensive surgery. We describe a case of a large BGH presenting as gastrointestinal bleeding and symptomatic anemia. Initial esophagogastroduodenoscopy (EGD) with biopsies was non-diagnostic. At repeat endoscopy, it was successfully excised and diagnosis was clinched. This case illustrates how with the right skill-set and perseverance, even large BGH can be endoscopically treated with excellent outcomes.
Case Description/Methods: A 67-year-old Caucasian man with multiple comorbidities presented to the Emergency Department with 1 week history of melena, weakness and dizziness. He was pale with hemoglobin of 7.2g/dl. The rest of his examination, vital signs and lab results were unremarkable. 1 unit of blood was given. EGD revealed a large pedunculated polypoid mass with ulceration and oozing in the duodenal bulb (Fig 1a). This was biopsied and injected with 5cc of epinephrine to secure hemostasis. Pathology results were non-diagnostic, favoring areas of duodenitis only. At repeat EGD 3 days later by another provider, an Endoloop ligature was deployed to the base of the polyp (Fig 1b), and resected using a 4cm snare and electrocautery (Fig 1c, 1d). The hard 4x3cm mass (Fig 1e) was eventually retrieved utilizing a pediatric colonoscope, snares and Roth nets. Histopathology was diagnostic for a giant Brunner’s gland hamartoma. The patient tolerated procedure well and was discharged home the next day. He remained asymptomatic with no evidence of recurrence at 1-year follow up.
Discussion: BGH with incidence of 0.008%, is a rare benign polypoid mass which arises from the alkaline-secreting submucosal Brunner’s glands located in the duodenum. It may present with gastrointestinal bleeding or gastric outlet obstruction and also easily mimics other benign and malignant small bowel lesions. BGH are usually covered by normal duodenal mucosa and this typically leads to non-diagnostic biopsies at EGD. Endoscopic resection for BGH tends to be very arduous for larger lesions. Many affected patients therefore require surgery and this may involve partial gastrectomy or duodenectomy before a diagnosis is established. As seen in our patient, individuals with multiple comorbidities who are poor surgical candidates can have excellent outcomes following endoscopic resection. BGH needs to be considered when duodenal masses are encountered on EGD to guide treatment decision-making.
Figure: Figure 1
Kwabena Adu-Gyamfi indicated no relevant financial relationships.
Michael Maitar indicated no relevant financial relationships.
Rami Matar indicated no relevant financial relationships.
Dominic Amakye indicated no relevant financial relationships.
Kwabena Adu-Gyamfi, MD1, Michael Maitar, MD2, Rami Matar, 3, Dominic Amakye, MBBCh4. P2529 - The Elusive Giant Duodenal Mass - Brunner’s Gland Hamartoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.