A 62-year-old woman visited our hospital for further evaluation of a large elongated
polypoid mass in the duodenum, which was incidentally discovered during a health check-up
endoscopy. The patient had a medical history of hypertension and hyperlipidemia. At
endoscopy, a 10-cm subepithelial mass with a long stalk was observed in the second
portion of the duodenum ([Fig. 1]
a); nodular mucosal changes were observed in the distal portion of the mass ([Fig. 1]
b). Endoscopic ultrasonography (EUS) revealed that the mass was a heterogeneously mixed
echogenic lesion with cystic changes in the deep mucosal and submucosal layers [Fig. 1]
c).
Fig. 1 A duodenal subepithelial mass is seen on: a, b endoscopy; c endoscopic ultrasonography showing: a a
10-cm subepithelial mass with a long stalk in the second portion of the duodenum;
b nodular mucosal changes in the distal portion of the mass; c a heterogeneously mixed echogenic mass with cystic changes in the
deep mucosal and submucosal layers.
Endoscopic mucosal resection was planned to exclude the possibility of malignancy
owing to
the nodular mucosal changes on the surface of the mass and its large size ([Video 1]). Because we were unable to place the snare at the base of the mass, it was first
expelled from the duodenum into the stomach using mucosal forceps ([Fig. 2]
a, b). The snare was then placed at the base of the mass and the
resection was performed ([Fig. 2]
c). Spurting bleeding occurred after the tumor resection ([Fig. 2]
d); however, hemostasis was successfully achieved by ligation
using an O-ring ([Fig. 2]
e).
Endoscopic resection of a large Brunner’s gland hamartoma.Video 1
Fig. 2 Endoscopic images of the resection of a duodenal subepithelial mass showing: a, b the mass being expelled from the duodenum to the stomach using
mucosal forceps; c the snare being placed at the base of the mass,
before resection is performed; d spurting bleeding after tumor
resection; e successful hemostasis by ligation using an O-ring.
f Photograph of the resected specimen, which was a 10.0 × 1.7-cm
elongated subepithelial mass.
The resected specimen was a long polypoid subepithelial mass, measuring 10.0 × 1.7
cm ([Fig. 2]
f). Histopathologically, the mass comprised of proliferating adipose tissue and hyperplastic
Brunner’s glands in the deep mucosa and submucosa, consistent with a Brunner’s gland
hamartoma (BGH) ([Fig. 3]). No dysplastic areas were observed in the resected tumor. The patient’s post-procedural
course was uneventful and she was discharged on postoperative day 3.
Fig. 3 Histopathologic findings showing: a on gross evaluation, a well-defined heterogeneous yellow-to-white solid mass with
cystic changes mainly located in the deep mucosa and submucosa; b microscopically, proliferating adipose tissue and hyperplastic Brunner’s glands,
consistent with a Brunner’s gland hamartoma (hematoxylin and eosin [H&E] stain, magnification
× 100).
BGH is a benign proliferative disorder of the Brunner’s glands in the duodenum [1]. It is often discovered incidentally during endoscopy, with typical findings indicating
mucosal protrusions or polyps [2]. The American Institute of Radiologic Pathology categorizes lesions <5 mm as
“Brunner’s gland hyperplasia” and those >5 mm as “BGH” [3]. The exact pathogenesis of BGH remains unknown. Although it is commonly regarded
as a
benign duodenal condition, it can enlarge and cause gastrointestinal bleeding or obstruction.
In
addition, malignant transformation can occur, especially when there is a significant
increase in
size or the presence of a shallow central depression on its surface [3]. Treatment depends on the tumor size, symptoms, and the possibility of malignancy.
Previously, surgical resection was the primary treatment modality. Given however that
the BGH is
located in the deep mucosa and submucosa, endoscopic resection can be successfully
performed, as
in the present case, even when it is large.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AB
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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