Department of Upper GI and Bariatric Surgery, University Hospital of North Midlands, United Kingdom
Brunner's gland adenoma is a rare benign tumour of the duodenum. Less than 200 cases have been reported in the literature. Usually asymptomatic, these lesions rarely manifest as upper gastrointestinal haemorrhage or duodenal obstruction. We report a 40-year-old gentleman who presented with melaena and iron deficiency anaemia. Duodenoscopy revealed a large pedunculated tumour in the duodenal bulb. Due to the huge size, the patient underwent surgical polypectomy through laparotomy and duodenotomy. Histological examination confirmed it to be Brunner's gland adenoma. Endoscopic and radiological features are illustrated along with a literature review of this rare, yet important and easily overlooked cause of gastrointestinal haemorrhage.
Brunner's gland adenoma, Gastrointestinal haemorrhage, Brunneroma
Brunner's gland adenoma also known as Brunneroma, is a harmartoma of the brunner's glands-branched acinotubular glands situated in the submucosa of the first part of duodenum which neutralizes acid chyme by its alkaline secretion. They are usually asymptomatic, found incidentally at endoscopy. Occasionally, they cause gastrointestinal haemorrhage or duodenal obstruction necessitating surgical excision. Endoscopic polypectomy is the treatment of choice, though large size, as in our case may require open surgical polypectomy.
A forty-year-old male presented with 2-3 episodes of malaena of few days duration. There was no associated significant past medical history. Clinical examination was normal, apart from pallor. Routine blood investigations revealed Hb of 8.0 gm/dl and ferritin level of 2.0. Upper gastrointestinal endoscopy revealed a smooth polypoidal tumour arising in the duodenal bulb (Figure 1), biopsies of which was reported as normal. Small bowel meal revealed a smooth polypoidal filling defect in the first part of duodenum (Figure 2).
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Figure 1: Upper gastrointestinal endoscopy revealing smooth polypoidal tumour arising in the duodenal bulb. View Figure 1
Figure 2: Small bowel meal showing a smooth polypoidal filling defect in the first part of duodenum. View Figure 2
At laparotomy, a soft mobile swelling was palpable within the first part of duodenum. Duodenotomy revealed a 5 × 3 cm sized pedunculated polypoidal growth arising from the mucosa (Figure 3). It was excised and the patient made an uneventful recovery. At 1 year follow up, the patient was completely asymptomatic with no further episodes of malaena.
Figure 3: 5 × 3 cm polypoidal growth at duodenotomy. View Figure 3
The cut surface of the tumor had a grayish color, revealing multiple cystic spaces and histopathology examination revealed submucosa with numerous Brunner's glands in a lobular architecture surrounded by bundles of fibromuscular and connective tissue, confirming the diagnosis of Brunner's gland adenoma.
Brunner's gland adenomas (BGA) are rare benign tumours arising from the Brunner's glands of the duodenum and account for about 10.6% of benign duodenal tumors [1]. Since the first reported cases by Curveilhier in 1835 and Salvioli in 1876, less than 200 cases of BGA have been reported in the literature [2]. The first case of a Brunner's gland adenoma was described in 1835 by Cruveilhier [1,3] who presented a woman who died from intussusception secondary to obstruction.
Histologically, Brunner's glands are branched acinotubular glands located in the submucosa. They produce alkaline secretion which empty into the Crypts of Lieberkuhn in the duodenum and protect the duodenal mucosa from the damaging action of acid chyme [4]. They also secrete an enteric hormone - enterogastrone, which is an inhibitor of gastric acid secretion. Thus, it is thought to play an important role in duodenal resistance to ulcer formation.
The distribution of these glands is mostly proximal to the ampulla of Vater, with most of them being just distal to the pylorus. Brunner's gland adenomas are most commonly located in the duodenal bulb, with the second and third portions of the duodenum being much less affected. Usually small in size (1-2 cm), only a few cases more than 4 to 5 cm in size have been reported in the literature [5]. Lesions less than 1 cm represent hyperplasia, whereas those more than 1 cm are called adenoma.
The exact pathogenesis of BGA still remains unclear. Some have suggested that the Brunner's glands are stimulated to undergo hyperplasia by increased acid secretion [6]. Studies suggest that concurrent H. pylori infection is very common in patients with BGA, but it's role remains unclear [7]. The present view is that BGA represent hamartomas in the duodenum. They may be sessile or pedunculated. Benign, proliferative changes of the brunner's gland are very rare and account for about 10% of duodenal bulb neoplasias. They are occasionally associated with gastric hyperchlorhydria or chronic pancreatitis. Malignancy seems to occur only very rarely, with only 14 cases reported in the literature [8].
Patients with BGA usually present in the 4th to 6th decade of life. Most are asymptomatic or present with nonspecific, vague abdominal pain or discomfort, nausea, or bloating. These patients are diagnosed incidentally in the form of small polypoid lesions at barium examination or at endoscopy. Atypical presentations include jaundice, obstruction, and gastrointestinal bleeding. Anemia results from intermittent chronic blood loss secondary to ulceration from the mucosa overlying the mass. Uncommon manifestations include palpation of an abdominal mass, obstructive jaundice, biliary fistula, recurrent pancreatitis and intussusception [5,9].
The diagnosis is usually made by radiological studies followed by upper gastrointestinal endoscopy, which can also provide definitive treatment. Barium studies may reveal a duodenal filling defect, seen as a “vacuole sign” - smooth-walled, polypoid-filling defects, sessile or pedunculated, in the bulb or corresponding portion of the duodenum [2]. Endoscopy demonstrates the tumor in the duodenal lumen and facilitates biopsy from the lesion, which is usually negative owing to the submucosal location of the tumor. Endoscopic ultrasound helps to establish a preliminary diagnosis depending on the layer from which the lesion arises and also from the characteristic appearance of the lesion. It can also detect involvement of the surrounding structures [10]. Computed tomography can be used to delineate the extraluminal extent of large adenomas. Differential diagnosis includes leiomyoma, lipoma, carcinoid tumor, lymphoma, aberrant pancreatic tissue, prolapsed pyloric mucosa, and foreign body. Since bleeding associated with this condition is not of high volume, a contrast enhanced CT is usually not helpful in pinpointing the source of bleed and these lesions are best described as heterogeneous with variable echogenicity [11].
Endoscopic or surgical removal of the adenoma has been suggested in symptomatic patients to prevent development of complications. Local excision of the lesion is the main treatment and may be done by either endoscopic snare-cautery technique or excision of the mass via duodenotomy. As the majority of BGA are quite small, endoscopic polypectomy will confirm the diagnosis and cure the condition in most cases [12]. However, if the size and the anatomic location makes endoscopic removal more difficult or impossible, excision via duodenotomy must be performed. Diffuse involvement may require partial resection of the duodenum.
BGAs are rare benign tumours and usually asymptomatic. Symptoms are often due to obstruction or ulceration of the lesion within the duodenum. Total removal of the lesion leads to minimal morbidity and eliminates the risks of complications.
Nil.
- Peison B, Benisch B (1982) Brunner's gland adenoma of the duodenal bulb. Am J Gastroenterol 77: 276-278.
- Cruveilhier J (1844) Anatomy of the Human Body. Harper and Bros, New York.
- Fuller JW, Maj MC, Cruse CW (1997) Hyperplasia of Brunner's glands of the duodenum. Am Surg 43: 246-250.
- Grossman MI (1958) Glands of Brunner. Physiol Rev 38: 675-690.
- Desilva S, Chandrasoma P (1977) Giant duodenal hamartoma consisting mainly of Brunner's glands. Am J Surg 133: 240-243.
- Peetz ME, Moseley HS (1989) Brunner's gland hyperplasia. Am Surg 55: 474-477.
- Kovacevi I, Ljubici N, Cupi H, Doko M, Zovak M, et al. (2001) Helicobacter pylori infection in patients with Brunner's gland adenoma. Acta Medica Croatica 55: 157-160.
- Chrwastie AC (1953) Duodenal carcinoma with neoplastic transformation of the underlying Brunner's glands. Br J Cancer 7: 65-67.
- Skellenger ME, Kinner BM, Jordan Jr PH (1983) Brunner's gland hamartomas can mimic carcinoma of the head of the pancreas. Surg Gynaecol Obstet 156: 774-776.
- Weisselberg B, Melzer E, Liokumovich P, Kurnik D, Koller M, et al. (1997) The endoscopic ultrasonographic appearance of Brunner's gland hamartoma. Gastrointestinal Endoscopy 46: 176-178.
- Walden DT, Marcon NE (1998) Endoscopic injection and polypectomy for bleeding Brunner's gland hamartoma: case report and expanded literature review. Gastrointestinal Endoscopy 47: 403-407.
- Block KP, Frick TJ, Warner TF (2000) Gastrointestinal bleeding from a Brunner's gland hamartoma characterization by endoscopy, computed tomography, and endoscopic ultrasound. Am J Gastroenterol 95: 1581-1583.
Mahmood F, Ahmed A, Shen C, Cabezon S, Rao V (2018) Giant Brunner's Gland Adenoma - An Unusual Cause of Gastrointestinal Haemorrhage. Int J Surg Res Pract 5:085. doi.org/10.23937/2378-3397/1410085
FAQs
Giant Brunner's Gland Adenoma - An Unusual Cause of Gastrointestinal Haemorrhage? ›
Brunner's gland adenoma is an extremely rare benign small bowel neoplasm, often discovered incidentally during upper gastrointestinal endoscopy or radiological diagnostics. In few cases, it tends to cause gastrointestinal hemorrhage or intestinal obstruction.
What is the role of the Brunner's gland in the digestive system? ›Brunner's glands are located in the submucosa of the duodenum. They secrete an alkaline fluid containing mucin, which protects the mucosa from the acidic stomach contents entering the duodenum.
What are the symptoms of the Brunner's gland? ›The clinical manifestations of Brunner's gland hyperplasia are nonspecific, such as epigastric discomfort, abdominal distension, or dyspepsia etc. Occasionally, it can lead to hemorrhages, acceleration of peristalsis, diarrhea, transient and partial bowel obstruction and duodenal intussusception due to the mass (3).
What is the treatment for Brunner's gland hyperplasia? ›Brunner's gland hyperplasia is usually an incidental finding during endoscopy or imaging studies, and endoscopy is the mainstay of management [8]. We present a case of Brunner's gland hyperplasia leading to a 5-cm symptomatic mass that required surgical resection due to its size.
What is a Brunner's adenoma of the duodenum? ›Brunner's gland adenoma, also known as Brunneroma or polypoid hamartoma, is a rare, benign, proliferative lesion arising from the Brunner's glands of the duodenum, accounting for 10.6% of benign tumors of the duodenum. The time patients are usually asymptomatic and lesions are discovered incidentally.
Is intestinal juice secreted by Brunner's gland? ›Paneth cells are found in mucosal layer of crypts of Lieberkuhn of jejunum. They are unicellular glands. They synthesize and secretes enzymes of intestinal juices. The secretory substances of Brunner's glands and Paneth cells are combinedly called intestinal juice or succus entericus.
Which gland is responsible for digestive system? ›Glands in your stomach lining make stomach acid and enzymes that break down food. Muscles of your stomach mix the food with these digestive juices. Pancreas. Your pancreas makes a digestive juice that has enzymes that break down carbohydrates, fats, and proteins.
What is another name for the Brunner's gland? ›Brunner's glands (or duodenal glands) are compound tubular submucosal glands found in that portion of the duodenum which is above the hepatopancreatic sphincter (i.e sphincter of Oddi).
What hormone is in the brunners gland? ›Brunner's glands are compound racemose glands in the submucous layer of the duodenum. Secretin is a hormone released into the bloodstream by the duodenum (especially in response to acidity) to stimulate secretion by the liver and pancreas.
Which hormones are secreted by Brunner's gland? ›Secretin and cholecystokinin(CCK) are hormones secreted by the Brunner's gland present in the submucosal layer of the duodenum.
What is the difference between Brunner gland adenoma and hyperplasia? ›
The disease spectrum of Brunner's glands includes diffuse nodular hyperplasia, circumscribed nodular hyperplasia (most common type), and adenomatous hyperplasia. Hyperplasia refers to multiple lesions less than one centimeter and adenoma refers to a single lesion larger than one centimeter.
How many people have Brunner gland hyperplasia? ›Brunner's gland hyperplasia (BGH) is a rare, benign condition of the duodenum that was first described in 1835. It is also known as Brunner's gland hamartoma, adenoma or Brunneroma. It has been rarely described in the literature, with less than 200 cases reported [1].
Can hyperplasia be removed? ›Atypical hyperplasia is generally treated with surgery to remove the abnormal cells and to make sure no in situ or invasive cancer also is present in the area. Doctors often recommend more-intensive screening for breast cancer and medications to reduce your breast cancer risk.
How do you get rid of adenoma in the duodenum? ›The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps.
How do they remove a tumor from the duodenum? ›During small bowel resection, a surgeon removes the part of the small intestine that contains cancer cells. The surgeon then connects the two healthy ends of intestine tissue together to enable normal digestion. A surgeon may also remove nearby lymph nodes to check for cancer spread.
What causes an adenoma in the duodenum? ›Duodenal adenomas occur in up to 90% of patients with FAP, most commonly at the ampulla, peri-ampullary region or distal duodenum, which is thought to be in part due to the exposure of the duodenal mucosa to bile in a predisposed patient [Bulow et al. 2004; Gallagher et al.
What digestive juice is in the duodenum? ›After foods mix with stomach acid, they move into the duodenum, where they mix with bile from the gallbladder and digestive juices from the pancreas. The absorption of vitamins, minerals, and other nutrients begins in the duodenum.
What happens when intestinal glands secrete intestinal juice? ›Intestinal juice neutralizes hydrochloric acid coming from the stomach; releases gastrointestinal hormones into the bloodstream; and contains digestive enzymes that facilitate the digestion and absorption of food.
What stimulates intestinal glands to secrete intestinal juice? ›Enterocrinin secreted by small intestine to stimulates the crypts of Liberkuhn to release enzyme into the intestinal juice.
What is the largest digestive gland in the body? ›Largest digestive gland in the body is liver. Its most important function is to secrete bile juice, which helps in the emulsification of fats.
What is the heaviest gland in the body? ›
liver, the largest gland in the body, a spongy mass of wedge-shaped lobes that has many metabolic and secretory functions.
What will happen if mucus is not secreted by the gastric glands? ›Non-secretion of mucus leads to acidity and ulcers in the stomach of an individual.
Is Brunner's gland exocrine or endocrine? ›Brunner glands are present in the duodenum of the small intestine. These exocrine glands are submucosal and produce a mucous product that protects the duodenum from acid released from the stomach.
Is Brunner's gland a serous gland? ›IN Brunner's glands of the rabbit's duodenum there are numerous groups of serous-type cells lying among the mucous acini. It has long been believed that these cells are of a nature similar to those of the pancreatic acini.
Where exclusively are Brunner's glands found? ›Brunner's glands are unique to mammalian species and in eutherians are confined primarily to the submucosa of the proximal duodenum. In the majority of species examined, they begin at the gastrointestinal junction and extend for variable distances distally in the wall of the proximal small intestine.
Which gland affects how the kidneys operate? ›The adrenal glands are 2 triangle-shaped endocrine glands. One sits on top of each kidney. They form part of the body's hormonal system.
Which hormone is secreted by intestinal glands of duodenum? ›secretin, a digestive hormone secreted by the wall of the upper part of the small intestine (the duodenum) that regulates gastric acid secretion and pH levels in the duodenum.
In which layer of stomach are gastric glands located? ›Gastric glands are mostly exocrine glands and are all located beneath the gastric pits within the gastric mucosa—the mucous membrane of the stomach. The gastric mucosa is pitted with innumerable gastric pits which each house 3-5 gastric glands.
Do Brunner's glands release digestive enzymes? ›These submicroscopic cytologic data taken together with other physiologic data would suggest that, in the horse, Brunner's glands function both to provide mucosal protection in the proximal duodenum as well as to release digestive enzymes, such as lipase or other unidentified materials.
What is one hormone that is secreted mostly from the intestine? ›Secretin is secreted from S cells in the duodenum in response to H+ and fatty acids in the lumen. Specifically, a pH less than 4.5 signals arrival of gastric contents, which initiates the release of secretin. GLP-1 is also produced in the small intestine and secreted from L cells.
What are the two hormones released from the duodenum? ›
Upon entering the duodenum, the chyme causes the release of two hormones from the small intestine: secretin and cholecystokinin (CCK, previously known as pancreozymin) in response to acid and fat, respectively. These hormones have multiple effects on different tissues.
What is malignant version of adenoma? ›Malignant adenomas represent an early form of colorectal cancer, in which cancer has invaded by direct continuity through the muscularis mucosa into the submucosa.
What is the difference between adenoma and benign tumor? ›Adenomas are benign (noncancerous) tumors. However, you should treat adenomas as precancerous because they may turn into cancer if left undetected. The severity of an adenoma can vary greatly, depending on its size and location. If an adenoma is small, you may not need treatment right away.
What is the pathology of Brunner's gland hyperplasia? ›Brunner's gland hyperplasia is a rare elusive duodenal pathology, symptomatically mimicking alarming duodenal lesions and mostly diagnosed on histopathology of specimen. Patients may harbour the lesion for long periods with little symptoms and upon treatment have good outcomes.
Can females have Brunner syndrome? ›Some people with monoamine oxidase A deficiency have episodes of skin flushing, sweating, headaches, or diarrhea. Similar episodes can occur in female family members of males with monoamine oxidase A deficiency, although females do not experience other signs or symptoms of the condition.
How common is Brunner syndrome? ›Since the syndrome is so rare, it is usually only suspected and tested for if there are other diagnosed instances of the syndrome in one's direct family.
What is a Brunner's gland tumor in radiology? ›Brunner's gland adenoma can be categorized as symptomatic tumors and those that are asymptomatic. Symptomatic tumors can further be subdivided into hemorrhagic and obstructive tumors. In the former, gastrointestinal hemorrhage occurs because of ulceration or erosion of the tumor.
What happens if hyperplasia is left untreated? ›Left untreated, endometrial hyperplasia may develop into endometrial cancer. Treatments are available to effectively manage the condition, which, in turn, helps to lower the risk that endometrial hyperplasia will advance to cancer.
Can hysterectomy cure hyperplasia? ›A hysterectomy is usually not necessary for treating endometrial hyperplasia. Most people respond well to progestin treatment. If your risk for uterine cancer is high and your healthcare provider diagnoses you with complex atypical endometrial hyperplasia, hysterectomy may be a possible treatment option.
What are the stages of hyperplasia? ›There are four types of endometrial hyperplasia. The types vary by the amount of abnormal cells and the presence of cell changes. These types are: simple endometrial hyperplasia, complex endometrial hyperplasia, simple atypical endometrial hyperplasia, and complex atypical endometrial hyperplasia.
How fast do adenomas grow? ›
Polyp Growth Rates
Cancerous polyps tend to grow slowly. It is estimated that the polyp dwell time, the time needed for a small adenoma to transform into a cancer, may be on average 10 years (17).
Adenomatous polyps are a common type. They are gland-like growths that develop on the mucous membrane that lines the large intestine. They are also called adenomas and are most often one of the following: Tubular polyp, which protrudes out in the lumen (open space) of the colon.
What is the best treatment for adenoma? ›Early intervention provides the best chance for cure or control of a pituitary tumor and its side effects. There are three types of treatment used for pituitary tumors: surgical removal of the tumor, radiation therapy using high-dose x-rays to kill tumor cells and medication therapy to shrink or eradicate the tumor.
What happens if part of duodenum is removed? ›If the pyloric valve located between the stomach and first part of the small intestine (duodenum) is removed, the stomach is unable to retain food long enough for partial digestion to occur. Food then travels too rapidly into the small intestine producing a condition known as the post-gastrectomy syndrome.
Can you live without your duodenum? ›Can you live without a duodenum? Yes. If you have a Whipple operation, your surgeon removes your duodenum. Without your duodenum, you may have trouble with digestion or nutrient absorption.
How long is recovery from duodenum surgery? ›Duodenal switch recovery time
After 2 or 3 days in the hospital, the patient is usually discharged home but it is important to remember that for the first 2 or 3 weeks after the surgery, patients should not go back to work and everyday responsibilities. The full duodenal switch recovery time is about 4 to 6 weeks.
The three most common hormonally active adenomas are prolactinomas, GH-secreting tumors causing acromegaly, and ACTH-secreting tumors causing Cushing's disease.
Is adenoma life threatening? ›The larger the adenoma, the higher the risk for pituitary apoplexy. Pituitary apoplexy usually has a quick onset of symptoms, which can be life-threatening. Symptoms often include: Severe headache.
Is adenoma a cancerous tumor? ›A tumor that is not cancer. It starts in gland-like cells of the epithelial tissue (thin layer of tissue that covers organs, glands, and other structures within the body).
What enzyme is secreted by Brunner's gland? ›Secretin and cholecystokinin(CCK) are hormones secreted by the Brunner's gland present in the submucosal layer of the duodenum.
Does Brunner's gland secrete any enzyme? ›
Brunner glands secrete mucus and alkaline fluid with proteolytic enzymes. These are most prominent within the proximal duodenum and may enlarge to simulate multiple polyps (Brunner gland hypertrophy) or may develop into a benign neoplastic mass (Brunner gland adenoma).
What stimulates the secretion of Brunner's gland? ›Glucagon stimulates Brunner's gland secretion.
What is the other name for Brunner's glands? ›Brunner's glands (or duodenal glands) are compound tubular submucosal glands found in that portion of the duodenum which is above the hepatopancreatic sphincter (i.e sphincter of Oddi).
What are the three major enzymes secreted by the pancreas into the duodenum? ›- Lipase. This enzyme works together with bile, which your liver produces, to break down fat in your diet. ...
- Protease. This enzyme breaks down proteins in your diet. ...
- Amylase. This enzyme helps break down starches into sugar, which your body can use for energy.
What are Brunner's Glands? Brunner's glands function to neutralize acids from your stomach. The chyme released from the upper stomach is very acidic. As this chyme enters into the beginning of the small intestine, called the duodenum, you are meant to have a protective coating there.
What four nutrients are absorbed in the duodenum? ›Duodenum: Absorbs Vitamin A, D, E, and K. Jejunum: Absorbs protein, carbohydrates, vitamins and minerals. Ileum: Passes food to the colon and absorbs Vitamin B12.
What 3 glands produce digestive enzymes? ›Your stomach, small intestine and pancreas all make digestive enzymes. The pancreas is really the enzyme “powerhouse” of digestion. It produces the most important digestive enzymes, which are those that break down carbohydrates, proteins and fats.
Which organ secretes enzymes into the duodenum? ›Among other functions, the pancreas aids in digestion by producing digestive enzymes and secreting them into the duodenum (the first segment of the small intestine). These enzymes break down protein, fats, and carbohydrates.
Which glands secrete the enzyme in small intestine? ›- pancreatic amylase.
- pancreatic lipase.
- peptidases.
- trypsin.
The pancreas is responsible for secreting digestive enzymes into the small intestine. These enzymes are responsible for digesting lipids (lipase), proteins (trypsin), nucleic acids (nucleases), and starches (amylase).
Which hormone stimulates intestinal glands to secrete intestinal juice? ›
Gastrin is a hormone that is secreted into the bloodstream by the stomach wall in response to the presence of food. It stimulates the secretion of gastric juice for the process of digestion to take place.
What triggers the release of these hormones in the duodenum? ›Secretin is secreted from S cells in the duodenum in response to H+ and fatty acids in the lumen. Specifically, a pH less than 4.5 signals arrival of gastric contents, which initiates the release of secretin.
What stimulates glands in the stomach that secrete mucus and acid? ›Gastric secretion is stimulated by the act of eating (cephalic phase) and the arrival of food in the stomach (gastric phase). Arrival of the food in the intestine also controls gastric secretion (intestinal phase). The secreted fluid contains hydrochloric acid, pepsinogen, intrinsic factor, bicarbonate, and mucus.