Clinical Quiz

A 14-year-old girl arrived with complaints of abdominal pain and vomiting. Consultation revealed that she had occasional abdominal pain for one week and severe abdominal pain including vomiting for 3 days. She had been followed-up for 6 years by a nephrology polyclinic for chronic renal failure due to Family Intermittant Fever amyloidosis. Her mother and father are first-degree relatives and she has a healthy brother who is 8-years-old. Physical examination revealed abdominal tenderness. On laboratory examination, leukocyte count was 13100/mm3, red blood cells 4.77 × 106, hemoglobin 10.6 g/dl, hematocrit 32.3%. Her serum electroliytes, amylase and lipase values were normal; urea 130 mg/dl, creatinine 3.8 mg/dl, cholesterol 327 mg/dl, trygliceride 120 mg/dl. Her fasting serum gastrin was 243 ng/L (N < 90 ng/L). In serum, H. pylori IgG was found negative. No pathology was found upon a complete urine examination except (+++) proteinuria qualitatively. At a 24-hour urine examination massive proteinuria was detected. No growth was seen in the urine culture. Abdominal ultrasonography was normal. At the upper gastrointestinal system endoscopy, hyperemia in antrum was seen, and a polyp of 0.5 × 0.5cm with an ulcer-pedunculated top was found in the duodenal bulb and removed by polypectomy (Fig. 1). The hystopathologic examination is shown in Figure 2. Ranitidine therapy was started. There have been no complaints for 10 months, and the patient continues to be followed-up.FIG. 1FIG. 2What is your diagnosis? A. Duodenal Diverticulosis B. Duodenal Gastrinoma C. Brunner's Gland Adenoma D. Familial Adenomatosis Polyposis ANSWER/DISCUSSION Answer C: The hystopathologic examination of the antrum revealed full-thickness mucosal chronic gastritis with submucosal nodules in the duodenum due to Brunner's gland proliferation, thus the diagnosis was Brunner's gland adenoma. Brunner's gland adenoma was first diagnosed in 1835 by Cruveilhier in a woman who had died due to obstruction-related intusseption (1). It is known that 25% of all small intestine tumors are located in duodenum, and 10% of those are Brunner's gland adenomas. The Brunner's gland adenoma turns to an encapsulated, elongated or lobulated polypoid mass. These can be pedunculated or sessile. Although these adenomas are mostly 2–4 cm in size, bigger cases are reported in the literature. Brunner's adenoma occurs frequently at the beginning and the second section of duodenum and rarely in the third section (2). Although Brunner's Gland Adenomas are mostly seen in men aged 40 in 60 years, it was also recently reported to be found in uremic patients (3). Our patient was also followed with the diagnosis of chronic renal failure. It has been suggested that hyperplasia of the glands follows gastric acid hypersecretion in chronic renal failure (4). Another suggestion is that in chronic renal failure the neuroendocrine cells in the gastric mucosa are affected, thus they release local proliferation factors such as insulin-like growth factor 1 and TGF-α, which results in glandular hyperplasia (5,6). Whatever their etiology, these are benign formations like polypoid tumors. Most of Brunner's gland adenomas are asymptomatic and are only detected coincidentally (3). The symptomatic ones present with complaints like bleeding, melena, obstruction, vomiting and abdominal pain (7). Therefore, Brunner's gland adenoma may be detected incidentally during endoscopic examination of abdominal pain, of which the reason remains unexplained (7). In our case, as we also couldn't identify the cause of the abdominal pain and vomiting, we performed an endoscopy and found a non-capsulated and pedunculated polypoid formation. After the histopathologic examination we diagnosed it as Brunner's gland adenoma. The therapy of Brunner's gland adenoma is generally conservative. However, when complications like obstruction or gastrointestinal bleeding are observed, the polyp should be removed surgically or endoscopically (7). Although the diameter of the duodenal polyp that we detected was <2 cm, we removed the polyp by endoscopic polypectomy; we believed the clinical information indicated intestinal obstruction. After the endoscopic polypectomy, the patient's severe abdominal pain and vomiting instantly subsided.