AIRP Best Cases in Radiologic-Pathologic Correlation: Brunner Gland Hamartoma

Abstract

A 68-year-old woman with a 2-month history of nausea and occasional vomiting was referred to the gastroenterologist. The patient complained of vague upper abdominal discomfort that was not influenced by meals. Laboratory findings were normal, and, specifically, no anemia was present (hemoglobin level, 8.4 mmol/L [normal, 7.1-9.9 mmol/L]; hematocrit level, 0.41 [normal, 0.34-0.48]). The patient reported normal bowel movements but mentioned a recent short period of diarrhea. Neither rectal bleeding nor melena was present, and fecal occult blood testing was not performed.A gastroscopy was performed by the gastroenterologist, who noted an extrinsic impression at the greater curvature of the stomach. The pyloric orifice was poorly recognized, and there was suspicion for an intussusception of part of the antrum into the duodenum. Rotation of the proximal part of the duodenum and reduction of the diameter of the duodenal lumen by more than 50% were present as the result of an external mass (Fig 1). The surface of the mass was mostly covered with normal-looking mucosa but became firm and ulcerative more distally. Because of the limited view at gastroscopy, it was difficult to determine whether the duodenal lumen reduction was the result of a submucosal mass or an external invading mass. Several biopsy specimens were obtained from both the normal-appearing mucosa proximal to the narrowed part of the duodenum and the more distal ulcerative surface.

Brunner’s Gland Hyperplasias and Hamartomas in Association with Helicobacter pylori

“…BG hamartomas are found in 0.01–0.07% of routine EGD patients [14–16]. They constitute 5–10% of benign duodenal masses [17–20]. They are generally seen in the posterior wall of the first part of the duodenum and are solitary (57–70%) [4, 8, 20, 21].…”

“…They constitute 5–10% of benign duodenal masses [17–20]. They are generally seen in the posterior wall of the first part of the duodenum and are solitary (57–70%) [4, 8, 20, 21]. They may vary in size between 0.5 and 12 cm.…”

“…Of the symptomatic patients, 28–61% may present with gastrointestinal haemorrhage, 51% with abdominal pain, and 44–50% with nausea and vomiting. Rarely there are signs of intestinal obstruction, duodenal intussusception, obstructive jaundice, or recurrent pancreatitis [1, 20, 21].…”

Benign and non-neoplastic tumours of the duodenum

“…Endoscopic ultrasound (EUS) together with fine needle aspiration biopsy (FNA) may be helpful in obtaining a proper diagnosis [27]. The American Institute for Radiologic Pathology arbitrarily adopts the term "overgrowth of the Brunner gland" for lesions (whether alone or not) less than 5 mm, and the term "hamartoma of the Brunner glands" for polyps with a diameter of more than 5 mm [28].…”

“…In 1934, Feyrter divided the histopathologically hypertrophic changes of the Brunner glands into three types: type 1 -diffuse nodular hyperplasia within the entire duodenum, type 2 -limited tubular hyperplasia of the duodenal gland, and type 3 -polypoid tumour with tumour-like dimensions [29]. Typically, hamartomas of the Brunner glands are composed of normal Brunner glands occurring in various proportions with adipose tissue, smooth muscle, and lymphatic tissue, and, in some cases, with areas containing sclerotic Brunner glands [28]. A study conducted by Sakurai et al shows that the probability of Brunner glandular hypertrophy being switched to dysplastic lesions is about 2.1%, whereas the conversion into the invasive cancer is 0.3% [30].…”