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IMAGE IN EUS
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 266-267

An unusual case of large symptomatic Brunner's gland adenoma: Endoscopic ultrasound imaging


1 Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
2 Department of General Surgery, Indiana University School of Medicine, Indianapolis, IN; Department of General Surgery, Roudebush VA Medical Center, Indianapolis, IN, USA
3 Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN; Division of Gastroenterology and Hepatology, Roudebush VA Medical Center, Indianapolis, IN, USA

Date of Submission31-Aug-2014
Date of Acceptance07-Oct-2014
Date of Web Publication17-Aug-2015

Correspondence Address:
Dr. Leticia P Luz
Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN; Division of Gastroenterology and Hepatology, Roudebush VA Medical Center, Indianapolis, IN
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.163021

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How to cite this article:
Martinez MA, Zyromski NJ, Luz LP. An unusual case of large symptomatic Brunner's gland adenoma: Endoscopic ultrasound imaging. Endosc Ultrasound 2015;4:266-7

How to cite this URL:
Martinez MA, Zyromski NJ, Luz LP. An unusual case of large symptomatic Brunner's gland adenoma: Endoscopic ultrasound imaging. Endosc Ultrasound [serial online] 2015 [cited 2019 Nov 12];4:266-7. Available from: http://www.eusjournal.com/text.asp?2015/4/3/266/163021

A 60-year-old man presented with intermittent epigastric discomfort and postprandial vomiting. Physical exam and laboratory data were unremarkable. Computerized tomography of the abdomen [Figure 1] showed a 3.4 cm × 2.1 cm soft tissue mass in the duodenal bulb. Upper esophagogastroduodenoscopy (EGD) showed a medium-sized subepithelial mass in the duodenal apex [Figure 2]; pinch biopsies were unrevealing. Endoscopic ultrasound (EUS) showed a 27 mm × 16 mm isoechoic lesion originating from the deep mucosa and sub-mucosa without invasion to adjacent structures [Figure 3]; fine-needle aspiration (FNA): nondiagnostic. Follow-up EUS 2 years later revealed interval growth of the mass to 30 mm × 40 mm and new cystic changes [Figure 4]; repeat FNA with atypical cells. Due to the increase in lesion size, presence of atypia on cytology and persistence of symptoms, surgical resection was performed [Figure 5]. Surgical pathology showed Hyperplastic Brunner's glands (BG) with lymphoid aggregates consistent with BG adenoma (BGA) [Figure 6].
Figure 1. Computerized tomography abdomen: Soft tissue mass in the duodenal bulb

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Figure 2. Esophagogastroduodenoscopy: Subepithelial mass in the duodenal apex

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Figure 3. Radial endoscopic ultrasound: Isoechoic lesion originating from the deep mucosa and sub-mucosa without invasion to adjacent structures

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Figure 4. Repeat radial endoscopic ultrasound exam (2 years later): Growth of the lesion, with new cystic changes

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Figure 5. Surgical pathology specimen

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Figure 6. Hyperplastic Brunner's glands (BG) with lymphoid aggregates consistent with BG adenoma (H and E)

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Brunner's glands are submucosal mucin-secreting glands predominantly located in the proximal duodenum. A BGA is a benign tumor arising from BG with an estimated incidence of 0.008%. It usually presents in the fifth to sixth decade of life and involves the posterior wall of the proximal duodenum. Its pathogenesis is thought to be related to acid hypersecretion. [1],[2],[3] Patients can be asymptomatic (11%), or more frequently have vague upper gastrointestinal symptoms. Clinical presentations may include obstructive symptoms, pancreatitis, and upper gastrointestinal bleeding. [2],[4] The diagnosis of BGA can be difficult, it can be diagnosed by EGD; However, as BG proliferations may be covered with normal mucosa, pinch biopsies might be negative. Radiological findings are often nonspecific. [3] EUS can be useful to diagnose BGA; The features include: Involvement of the mucosa and submucosal layers; variable echogenicity (mixed to hypoechoic); and multiple cystic changes within the tumor. [2],[3] Resection of an asymptomatic BGA is controversial. Traditionally, symptomatic BGA has been removed surgically. Endoscopic resection can be considered in smaller or pedunculated lesions in which EUS confirms only submucosal involvement. No recurrence has been reported after resection. [2],[3]

 
  References Top

1.
Rocco A, Borriello P, Compare D, et al. Large Brunner's gland adenoma: Case report and literature review. World J Gastroenterol 2006;12:1966-8.  Back to cited text no. 1
    
2.
Gao YP, Zhu JS, Zheng WJ. Brunner's gland adenoma of duodenum: A case report and literature review. World J Gastroenterol 2004;10:2616-7.  Back to cited text no. 2
    
3.
Ohba R, Otaka M, Jin M, et al. Large Brunner's gland hyperplasia treated with modified endoscopic submucosal dissection. Dig Dis Sci 2007;52:170-2.  Back to cited text no. 3
    
4.
Babich JP, Klein J, Friedel DM. Endoscopic removal of a brunneroma with EUS guidance. South Med J 2010;103:250-2.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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