Brunner's gland adenoma is a rare benign proliferative lesion developing most commonly in the posterior wall of the duodenum. It is usually small in size and asymptomatic. Depending on its size or location, however, the clinical manifestations of this tumor may be variable from nonspecific symptoms to gastrointestinal bleeding or obstruction. Brunner's gland adenoma in the proximal jejunum is extremely rare. We report a very rare case of giant Brunner's gland adenoma developing in the proximal jejunum which presented as iron deficiency anemia and mimicked intussusceptions on radiologic studies.
Brunner's glands are submucosal glands found in the first portion of the duodenum and in decreased numbers in the distal duodenum. In children, the glands also may present in the proximal jejunum.
A 50-year-old woman presented with abdominal discomfort and general weakness lasting for 2 months. She visited a private clinic and anemia has been detected in her blood tests. She was referred to our hospital for further evaluation of IDA. She had no other medical problems. The physical examination revealed no abdominal tenderness, rebound tenderness, or palpable mass. Her complete blood counts were as follows; hemoglobin 6.3 g/dL, hematocrit 19.2% (mean corpuscular volume 91.4 fL, mean corpuscular hemoglobin 29.9 pg), and platelet 366,000/mm3. The levels of iron and ferritin were 7 µg/dL (normal value, 50 to 130) and 7.5 ng/mL (normal value, 10 to 291), respectively. Liver function tests were within normal limits. Stool occult blood test was negative, and esophagogastroduodenoscopy and colonoscopy revealed no obvious cause of IDA. For the next diagnostic evaluation, abdominal computed tomography (CT) and small bowel follow-through were performed and intussusceptions in the proximal jejunum were suspected (
Brunner's gland adenoma (also referred to as Brunneroma or Brunner's gland hamartoma) is a rare benign tumor of the duodenum. Cruveilhier
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Brunner's gland adenoma is usually asymptomatic and detected incidentally. However, the clinical manifestations may be variable depending on its size, type or location. It can cause upper gastrointestinal hemorrhage from ulcer or erosion over the surface of a polyp, biliary obstruction, pancreatitis, or gastric outlet obstruction.
Useful diagnostic tools of Brunner's gland adenoma are barium contrast studies, abdominal CT and endoscopy. Large adenomas may be detected by ultrasonography. Upper gastrointestinal barium studies may reveal multiple small filling defects ('Swiss cheese' appearance) in the cases of Brunner's gland hyperplasia, adenomas, or smooth surfaced polypoid lesions.
In this patient, we performed a small bowel follow-through and CT for further evaluation of IDA, which suggested intussusceptions in the proximal jejunum. Then we performed DBE because it appeared impossible to reach the lesion using a conventional endoscope. An elongated mass covered with normal looking mucosa was detected in the proximal jejunum. For accurate diagnosis and treatment, we resected the tumor using the push enteroscopy with colonoscope. Push enteroscopy with conventional colonoscope is sometimes very useful for lesions located in the proximal jejunum because it is easier than DBE to handle the scope and to apply various therapeutic devices like Endo-Loop.
Treatment of Brunner's gland adenoma may be conservative as long as it remains asymptomatic. Brunner's gland adenoma has been considered as a benign disorder. Although it is rare, however, malignant transformation was also reported in the literatures.
In conclusion, we report a very rare case of giant Brunner's gland adenoma in the proximal jejunum which presented as IDA and mimicked intussusceptions on the radiological studies.
The authors have no financial conflicts of interest.
Abdominal computed tomography images. (A) Axial image shows suspected intussusception or intraluminal tumor less likely in the proximal jejunum. (B) Coronal reconstruction image also shows suspected intussusceptions or an elongated intraluminal mass with soft tissue attenuation.
Small bowel follow-through. It shows a segmental dilatation with the contrast filled along the inner wall of the lumen in the proximal jejunum, which suggests suspected intussusceptions rather than an intraluminal mass as considered with computed tomography findings.
Enteroscopic findings. (A) It shows a huge intraluminal mass with normal appearing mucosa in the proximal jejunum through double balloon enteroscopy. (B) It has a long stalk and wide base. (C) This tumor is resected by snare polypectomy after snaring Endo-loop through push enteroscopy. (D) After polypectomy, Endo-loop has been left at the base of stalk with no bleeding.
Pathologic findings. (A) Gross finding right after the endoscopic resection. It shows a giant polypoid mass, 9×2 cm in size. (B) Microscopic finding showing the lobules forming the tumor composed of normal appearing Brunner's gland without unusual mixture of normal tissues including Brunners glands, ducts, adipose tissue, and lymphoid tissue (H&E stain, ×40).