Brunner’s gland hamartoma presenting as a large duodenal polyp Eliahu Shemesh, MD, Shomron Ben Horin, MD, Iris Barshack, MD, Simon Bar-Meir, MD Brunner’s gland hamartoma is a rare benign tumor of the duodenum. 1 Less than 100 sympto- matic patients are reported; the main presenting manifestations are GI hemorrhage and intestinal obstruction. 2 These lesions are most often located in the proximal duodenum and are usually diagnosed by endoscopy. 3 Symptomatic patients are usually treated by surgical excision. 3 This is a report of a patient presenting with recurrent episodes of mele- na who had a polypoid Brunner’s gland hamartoma with a long stalk in the distal duodenum that was diagnosed and resected during enteroscopy. CASE REPORT A 55-year-old man presented with melena without abdominal pain or heartburn. His hemoglobin level dropped from 15 to 7.5 g/dL. The patient had no previous illness and denied taking any medication. EGD revealed mild duodenitis with a positive urease test for Helicobacter pylori. Small-bowel barium contrast radiography, abdomi- nal CT, and an isotope Meckel’s scan were all normal. Colonoscopy revealed a small angiodysplasia in the cecum but was otherwise normal. H pylori infection was treated with antibiotics, and the patient remained asymptomatic. Ten months later he presented with a second episode of melena and his hemoglobin level was found to be 10.4 g/dL. Repeat EGD was normal. Nine months later the patient had a third episode of melena, with hemoglobin level of 9.3 g/dL. On small-bowel enteroscopy, using the SIF-100 push videoenteroscope (Olympus America, Inc., Melville, N.Y.), a 3 × 2 cm ulcerated polyp was found. Its base was located at the junction of the second and third parts of the duodenum. The polyp had a 10 cm long stalk and moved freely from the fourth part of the duodenum to the stomach. Biopsies from the polyp showed normal duo- denal mucosa. On a subsequent enteroscopy the polyp was removed by electrosurgical snare polypectomy using coag- ulation current. Macroscopically the surface of the polyp was smooth with small areas of ulceration and exudate. Histologically the polypoid nodule was composed of multi- ple lobules of Brunner’s glands, present mainly in the sub- mucosa but also in the mucosa, without encapsulation (Fig. 1). The glands retained their lobular architecture, with fibrotic septa coursing between the lobules. There was a pathologic diagnosis of Brunner’s gland hyperplasia. During the 6 months after removal of the hamartoma, the patient was asymptomatic and his hemoglobin level returned to normal. DISCUSSION Brunner’s glands are mucus-secreting glands found mainly in the duodenum, although occasion- ally observed in the pylorus and distally as far as the jejunum. 4 The abundance of Brunner’s glands in the proximal part of the duodenum suggests a prob- able function of protection by virtue of their alkaline mucus secretion of the duodenal epithelium from the acid chyme of the stomach. 5 Brunner’s gland polyps are rare benign lesions, accounting for less than 1 % of small intestinal tumors. 1 They are most- ly situated in the proximal duodenum, usually pedunculated, and generally from 1 to 6 cm in diam- eter, although Brunner’s gland polyps greater than 2 cm are exceedingly rare. 2,3 These lesions have been variously referred to in the published reports as adenoma, Brunneroma, or Brunner’s gland hyperplasia. 4,5 Several patterns of hyperplasia have been described, ranging from diffuse mucosal tumors to solitary pedunculated polyps. 6 However, Goldman, reviewing the Brunner’s gland “hyper- plastic” polyps, pointed out that the histologic archi- tecture of these lesions consists of a combination of ductal and acinar structures, along with fibromus- cular and adipose elements and with lack of encap- sulation, thereby fitting the criteria for neither ade- noma nor hyperplasia. 7 He was the first to point out that these histologic features strongly suggest a hamartomatous origin for Brunner’s gland polyps, 7 a view that has recently gained wider acceptance. 8,9 Most patients with Brunner’s gland hamartomas VOLUME 52, NO. 3, 2000 GASTROINTESTINAL ENDOSCOPY 435 From the Department of Gastroenterology and Pathology, Chaim Sheba Medical Center, Tel-hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Reprint requests: Simon Bar-Meir, MD, Department of Gastro- enterology, Chaim Sheba Medical Center, Tel-hashomer 52621, Israel; fax 972-3-5303070. Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 0 37/54/108291 doi:10.1067/mge.2000.108291 Figure 1. Photomicrograph of resection specimen showing Brunner’s gland hyperplasia (H&E, orig. mag. ×20).