Rutgers Medical School of Robert Wood Johnson - Saint Peter's University Hospital New Brunswick, New Jersey
Introduction: Brunner gland hamartoma (BGH) is rare benign tumor of the duodenum that requires a high clinical suspicion to diagnose. Although it may be discovered incidentally, it can be the etiology of the underlying gastrointestinal bleeding (GIB) or intestinal obstruction. Here, we present a case of anemia and vomiting due to BGH followed by a literature review of the current practice of the diagnosis and management of large BGH.
Case Description/Methods: A 66-year-old man was referred to the gastroenterology clinic for iron deficiency anemia (IDA), vomiting, and abdominal discomfort. He reported no early satiety, unintentional weight loss, or change in bowel habits. Physical exam was significant for pallor and abdominal exam was soft and non-tender. Laboratory work up was significant for normocytic anemia with hemoglobin of 9.6 g/dL and iron deficiency with iron level of 7mcg/dL, ferritin of 3.5 ng/mL, transferrin saturation of 7%, and total iron binding capacity 411 mcg/dL. Intrinsic factor antibody, folate, TSH, and comprehensive metabolic profile were normal. Patient underwent an EGD that revealed a 2cm hiatal hernia, grade B esophagitis, and a large 50mm partially obstructing pedunculated duodenal polyp extending from the duodenal sweep to the 2nd portion of the duodenum (Figure 1A). Multiple attempts at endoscopic hot snare removal with endoloop were made without success. Biopsies of the polyp showed benign Brunner’s gland hyperplasia (Figure 1B). Patient was then referred to an advanced endoscopist for resection of the large pedunculated duodenal polyp. The patient’s IDA and abdominal symptoms have significantly improved following resection of the duodenal polyp with no further vomiting or intermittent abdominal discomfort. The IDA was deemed to be second to the duodenal BGH.
Discussion: Brunner gland hamartomas are extremely rare benign hyperplastic lesions of the GI tract. Small BGHs have an average size of 1.6cm and are commonly asymptomatic. Large hamartomas ( >2cm) are likely to present with GI bleeding, anemia, or obstructive symptoms. Management of BGH is either endoscopic or surgical and is usually based on the tumor size (typically 0.5-5 cm) and malignancy potential. On the other hand, surgery is reserved for lesions that are large, endoscopically unresectable, or have a suspicion for malignancy. In summary, we suggest that clinicians should be cognizant of considering BGH in their differential, especially in case of obstruction, occult GI bleeding, and IDA.
