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Brunner’s gland hyperplasia is a very rare lesion of the duodenum, which is usually asymptomatic and diagnosed incidentally during upper gastrointestinal endoscopy. Brunner’s glands are duodenal glands localized predominantly in the submucosa of proximal duodenum. Benign duodenal tumours are very rare with an estimated incidence of 0.008% reported in a series of 215 000 autopsies (1).
Here we report a rare case of hemorrhagic shock caused by intestinal bleeding from Brunner’s gland hyperplasia.
Two weeks before the patient had an episode of upper gastrointestinal bleeding and underwent an upper gastrointestinal endoscopy with hemostasis and biopsy of a 2cm duodenal polyp, which revealed Brunner’s gland hyperplasia. When the patient presented in the emergency department he was pale and tachycardic, with no other symptoms or signs.
The patient was admitted to an Intermediate Surgical Care Unit but due to the hemodynamic instability with significant blood loss (melena) and transfusion requirements of more than 6 units of blood he required laparotomy on the third day. Histological examination confirmed Brunner’s gland hyperplasia, with lobular proliferation of Brunner’s glands, some of which were cystically dilated. A well-defined histopathologic classification of Brunner’s gland lesions is still lacking, and the terms hyperplasia, hamartoma, adenoma and Brunneroma are currently being used without distinction (3).

Brunner’s gland hyperplasia is most often found in the proximal duodenum, representing the normal Brunner’s glands distribution, with 70% found in the duodenal bulb, 26% in the second portion of the duodenum, and 4% in the third portion (2). Brunner’s gland hyperplasia is usually asymptomatic and diagnosed incidentally during upper gastrointestinal endoscopy (2). Gastrointestinal bleeding manifests in the majority of cases as chronic loss of blood with iron de?ciency and anaemia (10). Diagnosis requires histological examination of excised mass, usually by upper gastrointestinal endoscopy with excision or biopsy, although simple biopsies can be indeterminate given the submucosal location of the lesions. In the case herein reported the patient had increased risk of severe hemorrhage due to chronic c-virus hepatitis and anticoagulation with warfarine for atrial fibrillation. Brunner’s gland hyperplasia is a rare entity which is usually diagnosed and treated by upper gastrointestinal endoscopy. It can cause gastrointestinal bleeding but hemorrhagic shock is a rare clinical presentation of Brunner’s gland hyperplasia.
They secrete alkaline fluid composed of mucin (Muc-6) which protects duodenal epithelium by counteracting the acid chime from stomach (1). Brunner’s gland hyperplasia is usually asymptomatic and an incidental finding during upper gastrointestinal endoscopy.
His past medical history included ischemic cardiomyopathy, atrial fibrillation, renal insufficiency due to IgA nephropathy and C virus chronic hepatitis. After a Kocher manoeuvre and duodenotomy, a pedunculated polyp, 2?2cm in size, was found on the second portion of the duodenum with active bleeding, and the polypectomy was performed (Fig.2). The overlying mucosa exhibits duodenitis (original magnification, ?40; hematoxylin-eosin stain). They are diagnosed predominantly in the fifth or sixth decade of life with equal gender distribution (2). It was suggested that lesions less than 1 cm would represent hyperplasia, lesions more than 1 cm should be called adenoma, and one that contained a mixture of muscular and fatty elements should be called hamartoma (4).
Due to the “anti-acid” function of Brunner’s glands, an increased acid secretion could stimulate these structures to undergo hyperplasia, but no regression was found with acid secretion inhibitors (5). Although usually described as entirely benign lesions, malignant transformation has been identified in a few reports (7,8,9), so Brookes et al postulate that it may be dangerous to presume that all Brunner’s gland hyperplasia are non-dysplastic and non-malignant (7). The majority are pedunculated (88%) and commonly 1–2 cm in diameter, although larger tumors (10cm) have been reported.

When symptoms occur the most common manifestations are gastrointestinal bleeding and intestinal obstruction, and rarely ampullary obstruction, pancreatitis and intussusception. Less frequently there are melena and haematemesis when erosion of the tumour occurs, which is described in Brunner’s gland hyperplasia occurring beyond the ?rst portion of the duodenum. CT-scan and EUS examination can demonstrate the submucosal origin of Brunner’s gland adenoma and exclude invasion of adjacent structures. Upper gastrointestinal endoscopy with polypectomy seems to be the ideal option because it is less invasive, more cost-effective and can be done in an outpatient setting. We had taken this image on the net we believe would be probably the most representative images for 9 11 jumpers impact with ground. We got this picture on the net that we feel would be one of the most representative images for east los angeles college swim stadium.
We got this picture on the net we consider would be probably the most representative images for were bodies recovered from columbia disaster. The authors present a case of a patient with hemorrhagic shock due to a bleeding Brunner’s gland hyperplasia, treated by urgent laparotomy and polypectomy.
There are several cases of endoscopic polypectomy reported but success depends on the location and the size of Brunner’s gland hyperplasia and clinical presentation. After a period of close observation in the intermediate surgical care unit, with optimization of his coagulation status, the patient was submitted to laparotomy and polypectomy. He underwent a repeat upper gastrointestinal endoscopy for hemostasis of bleeding Brunner’s gland hyperplasia (Fig.1). Laparotomy is reserved for large and sessile tumours, failure of endoscopic approach, and rarely in unstable patients due to a bleeding Brunner’s gland hyperplasia. Another hypothesis suggests that Brunner’s gland hyperplasia could be of in?ammatory origin.

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