What is the management approach for an adult patient with a periampullary mass showing benign histopathologic findings of duodenal mucosa with villi and Brunner glands?

Management of Periampullary Mass with Benign Brunner Gland Histology

For a periampullary mass showing only benign duodenal mucosa with villi and Brunner glands on histopathology, resection is generally unnecessary unless the lesion is symptomatic, large (>2 cm), or causing complications such as bleeding or obstruction. 1

Understanding the Pathology

Brunner gland hamartomas are uncommon, benign lesions arising from lobular proliferation of normal duodenal Brunner glands. 1 These lesions:

• Are typically solitary and pedunculated, potentially reaching 2-5 cm in size 1
• Represent non-neoplastic proliferations without malignant potential in the vast majority of cases 1, 2
• Can mimic neoplastic adenomatous pathology on endoscopic appearance, requiring careful optical evaluation and pathologic inspection 1

Clinical Decision Algorithm

Asymptomatic Lesions ≤2 cm

• No intervention required - observation is appropriate 1, 2
• Document the lesion's relationship to the major and minor papilla with photodocumentation to ensure no papillary involvement 1
• Confirm benign histology shows no dysplasia (rare cases of dysplasia have been reported) 2, 3

Symptomatic Lesions or Size >2 cm

Consider endoscopic or surgical resection if the lesion causes: 1, 2

• Partial duodenal obstruction 1, 3, 4
• Gastrointestinal bleeding or melena 3, 5, 6
• Abdominal pain related to the mass 3, 4
• Biliary or pancreatic duct obstruction (rare but reported) 4

Resection Approach Based on Size and Location

• Pedunculated lesions: May be amenable to endoscopic polypectomy 7, 6
• Large sessile lesions (>5 cm): Often require surgical resection via transduodenal polypectomy or segmental duodenal resection 3, 4
• Periampullary location: Requires careful assessment to avoid ampullary injury; may necessitate surgical rather than endoscopic approach 4

Critical Pitfalls to Avoid

Biopsy-induced complications: While diagnostic biopsy confirmed benign histology in this case, be aware that biopsy can induce submucosal scarring that complicates subsequent endoscopic resection if later needed. 8

Bleeding risk: The duodenal location carries higher post-procedural bleeding risk than other GI sites, with risk proportional to lesion size (>25% for lesions >3 cm). 1, 2 For large symptomatic lesions requiring resection, patients should be counseled about this risk and monitored for 48 hours post-procedure. 1

Misdiagnosis of malignancy: Large Brunner gland lesions can mimic pancreatic or periampullary malignancy on imaging, potentially leading to unnecessary pancreaticoduodenectomy. 4 Endoscopic evaluation combined with endoscopic ultrasound helps establish the correct diagnosis and avoid overtreatment. 4

Incomplete histologic sampling: Ensure adequate tissue sampling, as superficial biopsies may miss deeper pathology. 7 However, in this case with confirmed benign Brunner gland histology showing normal duodenal architecture, malignancy is effectively excluded.

Follow-Up Recommendations

• For observed lesions: No specific surveillance protocol is established for benign Brunner gland lesions, but repeat endoscopy may be considered if symptoms develop 5
• After resection: Endoscopic surveillance to monitor for recurrence, though recurrence of truly benign Brunner gland lesions is uncommon 7, 5
• Acid suppression: Consider H2 antagonists or proton pump inhibitors as adjunctive therapy, as hyperacidity may contribute to Brunner gland hyperplasia 5