ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Uncommon Cause of Recurrent Duodenal Intussusception Huiying Zhao,1 Ye Li,2 and Dianbo Cao2 1
Department of Internal Medicine, and 2Department of Radiology, The First Hospital of JiLin University, Chang Chun, China
Questions: A 49year-woman was admitted to our hospital with 1-year history of intermittent black stool and epigastric pain. She occasionally experienced itchy skin and yellow sclera. Physical examination was unremarkable. Except for the decrease of hemoglobin values down to 76 g/L, all other laboratory values were within the normal limits. Endoscopy before admission showed a long, friable, ulcerated, pedicle-like structure with granular surface of the distal end, extending from the duodenal bulb into the second part of duodenum (Figure A). Axial computed tomography (CT) done 2 months previously showed proximal jejunal mass and on the next day contrast-enhanced CT showed a mass in the second portion of duodenum, suggesting duodenal intussusception and spontaneous resolution (Figure B, C). Subsequent abdominal CT on admission revealed a duodenal hypodense mass with intussusception involving the duodenum and proximal jejunum (Figure D). No adenopathy, ascites, or other mass lesions were noted. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.10.003
Gastroenterology 2014;146:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 4: Brunner’s Gland Hamartoma
Intraoperatively, duodenal intussusception was found associated with the leading edge of a firm mass in the proximal jejunum. Manipulation of the mass back to the duodenum was successful and the mass was removed by local excision of the tumor pedicle (Figure E). On its cut surface, it resembled as pancreas or salivary gland with multiple cystic spaces (Figure F). Histopathologically, the mass was a typical Brunner’s gland hamartoma (Figure G). Brunner’s gland adenoma (BGA), also known as Brunneroma or polypoid hamartoma, is a rare, benign, proliferative lesion arising from Brunner’s gland of the duodenum, accounting for 10.6% of benign tumors of the duodenum. Development of BGA may be related to chronic renal failure, chronic pancreatitis, and peptic ulcer disease, or Helicobacter pylori infection.1 These lesions are most commonly located in the duodenal bulb and less frequently the second and the third portions of duodenum. Most are asymptomatic and discovered incidentally. In symptomatic patients, the most common manifestations are gastrointestinal hemorrhage and duodenal obstruction. Obstructive symptoms depend on tumor’s size and location. There also have reports of these hamartomas presenting as painless jaundice, chronic pancreatitis, chronic diarrhea, acute pancreatitis, and biliary fistula.1 BGA may also present with gastric outlet obstruction, duodenal obstruction, or occasionally with intussusception of the duodenal wall. Our patients’ occasional yellow skin and sclera discoloration suggests intermittent biliary obstruction owing to the intussusception. Duodenoduodenal or duodenojejunal intussusception is very rare in adults because the duodenum is fixed in the retroperitoneum.2 The diagnosis of intussusception can be easily established, but to make a diagnosis for BGA can be difficult because they are usually covered by normal mucosa, making pinch biopsy obtained during endoscopy nondiagnostic. CT is regarded as the modality of choice for its evaluation, including its origin, internal composition, enhancement pattern, and extent of the lesion. When BGA is small or pedunculated, endoscopic polypectomy is satisfactory. Open operative excision is reserved for cases where snaring has failed or the tumor is too large.
References 1. 2.
Gupta V, Gupta P, Jain A. Giant Brunner’s gland adenoma of the duodenal bulb presenting with ampullary and duodenal obstruction mimicking pancreatic malignancy. J Pancreas 2011;12:413–419. Watanabe F, Noda H, Okamura J, et al. Acute pancreatitis secondary to duodenoduodenal intussusceptions in duodenal adenoma. Case Rep Gastroenterol 2012;6:143–149.
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Department of Internal Medicine, and 2Department of Radiology, The First Hospital of JiLin University, Chang Chun, China
Questions: A 49year-woman was admitted to our hospital with 1-year history of intermittent black stool and epigastric pain. She occasionally experienced itchy skin and yellow sclera. Physical examination was unremarkable. Except for the decrease of hemoglobin values down to 76 g/L, all other laboratory values were within the normal limits. Endoscopy before admission showed a long, friable, ulcerated, pedicle-like structure with granular surface of the distal end, extending from the duodenal bulb into the second part of duodenum (Figure A). Axial computed tomography (CT) done 2 months previously showed proximal jejunal mass and on the next day contrast-enhanced CT showed a mass in the second portion of duodenum, suggesting duodenal intussusception and spontaneous resolution (Figure B, C). Subsequent abdominal CT on admission revealed a duodenal hypodense mass with intussusception involving the duodenum and proximal jejunum (Figure D). No adenopathy, ascites, or other mass lesions were noted. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.10.003
Gastroenterology 2014;146:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 4: Brunner’s Gland Hamartoma
Intraoperatively, duodenal intussusception was found associated with the leading edge of a firm mass in the proximal jejunum. Manipulation of the mass back to the duodenum was successful and the mass was removed by local excision of the tumor pedicle (Figure E). On its cut surface, it resembled as pancreas or salivary gland with multiple cystic spaces (Figure F). Histopathologically, the mass was a typical Brunner’s gland hamartoma (Figure G). Brunner’s gland adenoma (BGA), also known as Brunneroma or polypoid hamartoma, is a rare, benign, proliferative lesion arising from Brunner’s gland of the duodenum, accounting for 10.6% of benign tumors of the duodenum. Development of BGA may be related to chronic renal failure, chronic pancreatitis, and peptic ulcer disease, or Helicobacter pylori infection.1 These lesions are most commonly located in the duodenal bulb and less frequently the second and the third portions of duodenum. Most are asymptomatic and discovered incidentally. In symptomatic patients, the most common manifestations are gastrointestinal hemorrhage and duodenal obstruction. Obstructive symptoms depend on tumor’s size and location. There also have reports of these hamartomas presenting as painless jaundice, chronic pancreatitis, chronic diarrhea, acute pancreatitis, and biliary fistula.1 BGA may also present with gastric outlet obstruction, duodenal obstruction, or occasionally with intussusception of the duodenal wall. Our patients’ occasional yellow skin and sclera discoloration suggests intermittent biliary obstruction owing to the intussusception. Duodenoduodenal or duodenojejunal intussusception is very rare in adults because the duodenum is fixed in the retroperitoneum.2 The diagnosis of intussusception can be easily established, but to make a diagnosis for BGA can be difficult because they are usually covered by normal mucosa, making pinch biopsy obtained during endoscopy nondiagnostic. CT is regarded as the modality of choice for its evaluation, including its origin, internal composition, enhancement pattern, and extent of the lesion. When BGA is small or pedunculated, endoscopic polypectomy is satisfactory. Open operative excision is reserved for cases where snaring has failed or the tumor is too large.
References 1. 2.
Gupta V, Gupta P, Jain A. Giant Brunner’s gland adenoma of the duodenal bulb presenting with ampullary and duodenal obstruction mimicking pancreatic malignancy. J Pancreas 2011;12:413–419. Watanabe F, Noda H, Okamura J, et al. Acute pancreatitis secondary to duodenoduodenal intussusceptions in duodenal adenoma. Case Rep Gastroenterol 2012;6:143–149.
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