Brunneroma (Adenoma of the Brunner's Gland) - A Case Report

Bhat M.L (1), Chowdhary ND (1), Reshi Ruby (1), Naqshbandi Ashaq Hussain (1), Rather Assar Ahmad (1), Shiekh Bilal(1), Khan Suraya1(1), Kadri SM (1),
Shylashree Chikkamuniyappa (2), Vladica Tasic (3)

(1) Government Medical College, Srinagar, Kashmir, India
(2) University Texas Health Science Center, San Antonio, USA
(3) Zdravstveni centar, Vladičin Han, Serbia

Napomena: sažetak na srpskom jeziku
Note: summary in Serbian

INTRODUCTION

Benign tumours of the small intestine are rare. Usually such tumours are being identified on autopsies and the percentage is 0.16¹. These tumours form 23% of all benign tumours of gastrointestinal tract². The most common benign tumours of small intestine are adenoma and 25% of these occur in duodenum. Among the benign tumours of duodenum 30-50% arise from Brunner’s glands and are called Brunner gland adenoma. The clinical presentation of such tumours is usually bleeding within the small intestine, partial or complete obstruction giving rise to symptoms. Many such patients may be asymptomatic, where the adenoma size is very small.

CASE HISTORY

A 40 year old male presented with a history of malena and was admitted in the Department of Surgery SMHS Hospital, Srinagar, Kashmir attached to Government Medical College, Srinagar, Kashmir, India. for treatment. At the first instance the patient was managed conservatively and was discharged from the hospital. The patient was re admitted in the Department of Surgery with second bout of malena, patient was once again managed conservatively and upper gastrointestinal endoscopy was performed which revealed a polypoid mass in the duodenum at the junction of first and second part. Surgical intervention was carried out and polypoid mass from the duodenum was removed successfully.
GROSS EXAMINATION.The Department of Pathology, Government Medical College, Srinagar, Kashmir received greyish white polypoid soft tissue with stalk attached to it, measuring 4x2.5x2 cms, the stalk measured 1 cms long.
Cut section, revealed greyish white lobulated mass, it was sectioned and pieces were passed.
MICROSCOPIC EXAMINATION Multiple sections studied showed a nodular proliferation of Brunner’s glands accompanied by ducts and stromal elements. The Brunner’s glands were histologically normal.

The presence of duodenal glands in duodenum was first reported by Wepfer³ in 1679. Later Brunn (Brunner)⁴ described these glands in detail⁵.
Embrylogically the gland develops during 6^th month when the cells at the base of crypts of lieberkuhn extend into the sub mucosa and on maturity the glands acquire a compound tubular form arranged in lobules, which are 0.5 to 1 mm in diameter. They are usually numerous in first portion of duodenum and distally less in number. Ever since adenoma of Brunner gland was reported in 1876 by Salvioli⁶, the terminology given has been in dispute as it lacks features of true neoplasm. However other such terms of adenomatous or hamartomatous polyp were suggested. Many authors^7,8,9 considered the lesion to be the hamartoma for the tumour is neither encapsulated nor clearly demarcated from anatomic Brunner’s gland, but for the fact it comprises of lobulations of ductular and acinar elements. Infrequently it may have smooth muscles and muscular elements.
The commonest location of adenoma of Brunner gland is posterior wall of duodenum near the junction of first and second portion and these tumours are detected in the 4th to 6th decade of life. However the age range reported has been from 11 days to 80 years. In the present case the patient was a 40 year old male who presented with history of malena twice and the tumour mass was located in the posterior wall of duodenum at the junction of first and second part and is similar to as reported by authors. The unusual presentation of the adenoma of Brunner gland has been reported by Verma D et al.¹⁰ as a circumferential involvement of the duodenum as the rarest presentation.

REFERENCES

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5. Brunn(Brunner) cited by Kaplan et al. Hyperplasia of Brunner’s glands of duodenum. Surgical Gynae Obst 1968;126:371-375
6. Salvioli cited by Kaplan EL. Hyperplasia of Brunner’s glands of duodenum. Surgical Gynae Obst 1968;126:371-375
7. Beeman EA. Hamartoma of the duodenum: a tumour composed of Brunner’s gland and fat. Gastroenterology 1965;48:256-260
8. Goldman RL. Hamartomatous polyp of Brunner’s glands. Gastroenterology 1963;44:57-62
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