ENDOSCOPIC RESECTION OF A LARGE SUB-EPITHELIAL TUMOR

Brunner's glands hamartomas (BGH) are rare and benign tumors that occur mainly in the duodenal bulb. They represent about 5 to 10% of benign duodenal tumors and have an estimated incidence of less than 0.01%. Most cases of GH have been reported between the ages of 40 – 60 years, with no gender predominance. BGH consist of an abnormal proliferation of Brunner's glands embedded in a fibrous stroma with bundles of smooth muscle and contain cystic dilated ducts. They appear pedunculated in the majority of cases and arise from the deep mucosa or submucosa. Although often asymptomatic, patients can also present anemia, gastrointestinal bleeding or obstruction. Removal of the suspected BGH, whether endoscopic or surgical, is recommended to both confirm the diagnosis and to avoid potential complications.

We report the case of a 59-year-old woman with no relevant past medical history that was referred to the Gastroenterology Outpatient Clinic for iron-deficiency anemia reaching a minimum level of hemoglobin of 6.8 g/dL without visible blood loss. The upper endoscopy showed a large smooth-surfaced and subpedunculated polypoid lesion occupying most of the duodenal bulb. Ileocolonoscopy was normal.

For better assessment of the duodenal lesion, an endoscopic ultrasound was performed and showed a heterogeneous mixed echogenic lesion with multiple cystic areas located in the submucosa, measuring 36 × 24 mm, with a 14 mm thick short pedicle and a feeding artery. Biopsies were taken where Brunner's glands hyperplasia was identified. After multidisciplinary discussion, endoscopic resection was planned. On general anesthesia, an upper endoscopy was performed in the operation room, due to the risk of intra-procedural bleeding and perforation. Resection of the lesion with a hot snare after submucosal injection of diluted adrenaline was performed, without complications. The histopathology diagnosis was BGH with hemorrhagic areas. Three weeks later she had no complaints and the hemoglobin level was 11 g/dL.