Brunner's Gland Lesions: Diagnostic and Management Approach
Overview and Clinical Significance
Brunner gland hamartomas are uncommon, benign, often solitary pedunculated lesions arising from lobular proliferation of normal duodenal Brunner glands, typically 2-5 cm in size, and resection is generally unnecessary unless they are symptomatic or large (>2 cm) causing partial obstruction, pain, or bleeding. 1
These lesions are most frequently identified in the duodenal bulb and are usually asymptomatic, discovered incidentally during upper endoscopy. 1 However, large lesions may cause acute upper gastrointestinal hemorrhage associated with iron deficiency anemia. 1 Rare cases of dysplasia have been reported, though the malignant potential remains largely unknown. 1, 2
Diagnostic Approach
Initial Endoscopic Evaluation
Careful optical evaluation and pathologic inspection are critical, as non-neoplastic duodenal lesions (including Brunner gland hamartomas, metaplastic foveolar epithelium, and gastric heterotopia) may mimic neoplastic adenomatous pathology. 1
Identification of the major and minor papilla with photodocumentation is essential to ensure no involvement by the lesion before considering any intervention. 1
Endoscopic examination typically reveals a submucosal nodule or pedunculated mass, often with a stalk originating from the duodenal bulb. 3
Imaging Characteristics
CT and MRI may reveal internal cystic changes within the mass and a stalk originating in the duodenal bulb, which are useful diagnostic features for Brunner gland hamartoma. 3
Abdominal CT may show circumferential thickening or a stenosing mass in the first part of the duodenum when lesions are large and obstructive. 4
Imaging and endoscopy findings can be strongly suggestive of malignancy, particularly with larger lesions, making extensive pre-operative evaluation critical. 4
Tissue Diagnosis
Endoscopic biopsies are essential but may be falsely negative, as demonstrated by cases where pre-operative biopsies were negative despite significant lesions. 4
Cytological diagnosis reveals monomorphic cells arranged as loosely clustered epithelial cells with abundant, clear, and granular cytoplasm, eccentrically located nuclei, and immunoreactivity for MUC-6. 5
Repetitive tumor biopsies may be necessary to avoid radical surgical procedures when malignancy cannot be definitively excluded. 4
Management Algorithm
For Asymptomatic or Small Lesions (<2 cm)
No endoscopic resection is required for asymptomatic Brunner gland hamartomas or those <2 cm in size. 1
Conservative management with observation is appropriate. 1
Endoscopic surveillance is not routinely indicated unless symptoms develop. 1
For Symptomatic or Large Lesions (≥2 cm)
Endoscopic resection is indicated for Brunner gland hamartomas that are symptomatic (causing bleeding, pain, or obstruction) or large (>2 cm). 1
Specific Indications for Resection:
- Gastrointestinal bleeding (acute upper GI hemorrhage or chronic bleeding with iron deficiency anemia) 1, 2
- Partial duodenal obstruction with obstructive symptoms (recurrent vomiting, weight loss, epigastric pain) 4
- Abdominal pain attributed to the lesion 1
- Lesions causing surface ulceration with bleeding risk 1
Endoscopic Resection Technique:
The duodenal bulb is thicker than the descending duodenum, making tissue transection by diathermy much slower, analogous to the gastric antrum. 1
Confirmation that the lesion is not adjacent to or involving the major papilla is critical before polypectomy. 1
For lesions on the medial wall within 5 cm of the papilla, a duodenoscope should be used. 1
Complete resection during the initial session is essential, as the initial attempt provides the highest chance of success and lowest risk of complications. 1
Surgical Management
Surgical treatment should be conservative since Brunner gland lesions are not premalignant, and local excision is the treatment of choice if complications occur. 6
Indications for Surgery:
- Emergency situations with severe obstruction or uncontrolled bleeding 1
- Failure of endoscopic resection 1
- When malignancy cannot be excluded despite extensive evaluation 4
Duodenocephalopancreatectomy should be avoided when possible, as it represents overly aggressive treatment for a benign condition. 4 However, when imaging and endoscopy are strongly suggestive of malignancy and biopsies remain inconclusive, surgical resection may be necessary. 4
Critical Pitfalls to Avoid
Never assume all duodenal masses are benign—extensive pre-operative evaluation including repetitive biopsies is necessary to avoid both under-treatment of malignancy and over-treatment of benign lesions. 4
Do not attribute gastrointestinal bleeding to Brunner gland hamartomas without proper evaluation, as fatal hemorrhage has been reported. 2
Avoid partial resection or leaving lesions incompletely resected, as this increases recurrence risk and complication rates. 1
Do not perform endoscopic resection without confirming the lesion's relationship to the major papilla, as inadvertent injury can cause serious complications. 1