Brunner's gland adenoma: unusual cause of duodenal haemorrhage and obstruction.

A 70-year-old man was admitted to hospital for repeated vomiting and passing tarry stool for 1 week in October 2011. On physical examination, the patient was pale. The abdomen was not distended but there was a succussion splash in the epigastric area. Laboratory tests revealed microcytic anaemia with a haemoglobin level of 60 g/L. His creatinine level was 140 μmol/L, and his bilirubin level was 30 μmol/L. Liver enzyme and amylase levels were within normal limits. Upper endoscopy showed a deformed pylorus with duodenal obstruction where a very limited view showed an ulcerative tumour at the duodenal bulb. Computed tomography (CT) with intravenous contrast revealed a large tumour occupying the first and second parts of the duodenum (Fig 1). Local resection of the lesion was planned and pancreaticoduodenectomy was offered in case the ampulla of Vater was involved. During the operation, full kocherisation of the duodenum was performed, and upon enterotomy of the first part of the duodenum, a well-encapsulated submucosal tumour measuring 10 cm x 6 cm x 8 cm was revealed (Fig 2). After identification of the ampulla of Vater, distal gastrectomy with local resection of the first and second parts of the duodenum was performed. The duodenal stump was closed with 4/0 Prolene suture. Gastrojejunostomy was constructed as a Billroth operation. The patient resumed diet on day 3 and was discharged on day 4. Histopathology of the resected specimen showed features of Brunner's gland adenoma (BGA) of the duodenum (Fig 3). Discussion The commonest tumour of the duodenum is a gastro-intestinal stromal tumour, which may have malignant potential. Other possibilities include adenocarcinoma of the duodenum, paraganglioma, and BGA. 1 In theory, endoscopic ultrasound (EUS) can provide adequate information on the depth of involvement of the lesion within the duodenum. The origin of the lesion and whether there is full thickness involvement with a breach of the serosal layer may provide more information for management. 2 Fine-FIG 1. Contrast computed tomography of the abdomen shows a heterogeneous mass occupying the first and second parts of the duodenum: (a) transverse cut and (b) coronal cut FIG 2. Operative view of the duodenum being transected revealing a pedunculated mass without involvement of the ampulla of Vater (a) (b)