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Role of Computed Tomography in the Diagnosis of Brunner Gland Hamartoma
Papel de la tomografía computarizada en el diagnóstico del hamartoma de las glándulas de Brunner
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"titulo" => "Role of Computed Tomography in the Diagnosis of Brunner Gland Hamartoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e17" "paginaFinal" => "e19" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Andrés García-Marín, Ramón José Lirón-Ruiz, Enrique Luis Girela-Baena, José Luis Aguayo-Albasini" "autores" => array:4 [ 0 => array:4 [ "nombre" => "José Andrés" "apellidos" => "García-Marín" "email" => array:1 [ 0 => "joseandresgarciamarin@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ramón José" "apellidos" => "Lirón-Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Enrique Luis" 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"Papel de la tomografía computarizada en el diagnóstico del hamartoma de las glándulas de Brunner" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 999 "Ancho" => 995 "Tamanyo" => 162099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT in portal phase: the pedunculated mass stemming from the first portion of the duodenum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Brunner gland hamartoma is an uncommon lesion that is usually located in the first portion of the duodenum. Its origin is submucosal and it has a potential risk for bleeding.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are no specific symptoms nor are there any endoscopic images to aid in the initial diagnosis. Endoscopic ultrasound has been suggested as the gold standard method due to its capability to identify this pathology. We present a clinical case with CT diagnosis and its unique radiological characteristics, and we review the literature published to date.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is a 40-year-old male with no history of interest who came to our hospital due to syncope and melenas.</p><p id="par0020" class="elsevierStylePara elsevierViewall">He had had no previous episodes of gastrointestinal bleeding until 48<span class="elsevierStyleHsp" style=""></span>h before, when the melenas had begun. The patient was haemodynamically stable, and the abdomen was soft and non-painful. Lab workup showed haemoglobin 10.3<span class="elsevierStyleHsp" style=""></span>g/dL, HCT 29.6%, 13<span class="elsevierStyleHsp" style=""></span>400 leukocytes and 81% PMN; the remaining haemogram and biochemistry levels were normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Gastroscopy revealed a polypoid lesion in the superior duodenal knee; gastrointestinal stromal tumour was ruled out, and no signs of previous bleeding were observed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We requested an abdominal CT. The results reported the mass was a polypoid lesion measuring 3<span class="elsevierStyleHsp" style=""></span>cm×2.6<span class="elsevierStyleHsp" style=""></span>cm in the second portion of the duodenum, which had a 3<span class="elsevierStyleHsp" style=""></span>cm pedicle that was implanted in the posterior side of the duodenal bulb. The lesion presented heterogenous uptake, with a peculiar presence of areas of fatty density in its interior, which provided a probable diagnosis of Brunner gland hamartoma (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">We performed gastroscopy with polypectomy and haemostatic control of the pedicle with adrenalin and endoclips.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathology study defined the lesion as a mucosal–submucosal mass of hyperplastic Brunner glands and observed proliferated hyperplastic glandular lobules with cystic dilatations, separated by fibrous tissue, adipocytes and smooth muscle fibres. These findings were compatible with Brunner gland hamartoma.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was discharged. He continues to be asymptomatic, and endoscopic follow-up studies have shown good progress.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The Brunner glands are acinar structures that are mainly situated in the first portion of the duodenum, which diminish in number distally.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Their function seems to be related with gastric acid, as their secretions inactivate the acidity of gastric juices.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Since their discovery in 1688, the nomenclature of the lesions associated with their growth has gone through different stages. Currently, the lesions are considered hamartomas given the abnormal proliferation of morphologically normal tissues (without atypia) within the lesion.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is a rare tumour with a reported approximate incidence of 1% of small bowel tumours and 5% of duodenal tumours.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> They are most frequently diagnosed between the 5th and 6th decades of life, with a slightly greater prevalence in men.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The aetiology is not clear. Initially, it was proposed that their growth could possibly be a consequence of hyperchlorhydria, based on their function as an acid buffer, but this possibility was ruled out since the lesions are not more frequent in cases of Zollinger–Ellison syndrome. Furthermore, they do not recede with antisecretory treatment.</p><p id="par0070" class="elsevierStylePara elsevierViewall">There seems to be a certain correlation with recurring pancreatitis episodes that lead to chronic pancreatitis, possibly as a mechanism for adapting to the exocrine insufficiency caused by these conditions.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Clinically, most published case reports to date are based on the diagnosis as a consequence of upper gastrointestinal bleeding<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> or intestinal obstruction. Indeed, it seems that what is most common is that the lesion, especially when it reaches a certain size (larger than 1<span class="elsevierStyleHsp" style=""></span>cm), debuts with symptoms of upper gastrointestinal bleeding.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,5–7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">On other occasions, the diagnosis can be incidental or due to symptoms of duodenal/intestinal obstruction, intussusception, non-painful jaundice or pancreatitis.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The diagnosis is histological. Endoscopic biopsy generally does not reach planes beyond the mucosa, which provides for visualisation of the hamartomatous tissue. Endoscopic ultrasound is useful for the diagnosis. And in most cases, a well-defined heterogenous hypoechoic submucosal nodule is observed.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our case, it was not necessary to recur to endoscopic ultrasound because the CT scan was diagnostic. Hur et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> described the radiological–pathological association of Brunner gland hamartomas studied by CT. In general, the lesions are observed to be nodules in the first duodenal portion that are hypoattenuated compared to the pancreatic parenchyma and heterogeneous. The heterogeneity corresponds to the areas of adipose tissue and smooth muscle proliferation. On other occasions, where there is less amount of mesenchymal tissue, the lesion can be described as homogeneously hypoattenuated, but this is less frequent.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The differential diagnosis should include adenomatous polyps, gastrointestinal stromal tumours, lymphomas, carcinoid tumours and tumours of the pancreatic and periampullary areas.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2,6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical approach should be endoscopic and is recommended when symptoms arise. Surgery by means of duodenotomy or segmental resection should be reserved for cases that cannot be treated with endoscopy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The prognosis is excellent. Although cases of malignant degeneration of hamartomas have been described,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> these may actually be focal adenocarcinomas over a non-dysplastic Brunner hamartoma.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Marín JA, Lirón-Ruiz RJ, Girela-Baena EL, Aguayo-Albasini JL. Papel de la tomografía computarizada en el diagnóstico del hamartoma de las glándulas de Brunner. Cir Esp. 2016;94:e17–e19.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 812 "Ancho" => 995 "Tamanyo" => 135117 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial CT in arterial phase: heterogeneous mass with areas of fat density in the second portion of the duodenum.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 999 "Ancho" => 995 "Tamanyo" => 162099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT in portal phase: the pedunculated mass stemming from the first portion of the duodenum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brunner's gland hyperplasia and hamartoma: imaging features with clinicopathologic correlation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N.D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 21 | 11 | 32 |
| 2024 September | 26 | 6 | 32 |
| 2024 August | 30 | 6 | 36 |
| 2024 July | 30 | 6 | 36 |
| 2024 June | 23 | 6 | 29 |
| 2024 May | 10 | 7 | 17 |
| 2024 April | 22 | 6 | 28 |
| 2024 March | 24 | 2 | 26 |
| 2024 February | 27 | 2 | 29 |
| 2024 January | 32 | 1 | 33 |
| 2023 December | 57 | 5 | 62 |
| 2023 November | 30 | 6 | 36 |
| 2023 October | 24 | 4 | 28 |
| 2023 September | 13 | 2 | 15 |
| 2023 August | 16 | 3 | 19 |
| 2023 July | 21 | 7 | 28 |
| 2023 June | 32 | 6 | 38 |
| 2023 May | 48 | 22 | 70 |
| 2023 April | 41 | 3 | 44 |
| 2023 March | 44 | 3 | 47 |
| 2023 February | 43 | 1 | 44 |
| 2023 January | 50 | 5 | 55 |
| 2022 December | 37 | 14 | 51 |
| 2022 November | 32 | 25 | 57 |
| 2022 October | 43 | 11 | 54 |
| 2022 September | 49 | 13 | 62 |
| 2022 August | 51 | 13 | 64 |
| 2022 July | 21 | 8 | 29 |
| 2022 June | 20 | 9 | 29 |
| 2022 May | 16 | 13 | 29 |
| 2022 April | 24 | 8 | 32 |
| 2022 March | 38 | 6 | 44 |
| 2022 February | 29 | 7 | 36 |
| 2022 January | 62 | 8 | 70 |
| 2021 December | 36 | 9 | 45 |
| 2021 November | 34 | 11 | 45 |
| 2021 October | 70 | 10 | 80 |
| 2021 September | 28 | 8 | 36 |
| 2021 August | 49 | 11 | 60 |
| 2021 July | 31 | 12 | 43 |
| 2021 June | 27 | 11 | 38 |
| 2021 May | 24 | 7 | 31 |
| 2021 April | 62 | 17 | 79 |
| 2021 March | 42 | 8 | 50 |
| 2021 February | 23 | 11 | 34 |
| 2021 January | 35 | 14 | 49 |
| 2020 December | 33 | 5 | 38 |
| 2020 November | 37 | 7 | 44 |
| 2020 October | 35 | 6 | 41 |
| 2020 September | 18 | 8 | 26 |
| 2020 August | 24 | 10 | 34 |
| 2020 July | 12 | 4 | 16 |
| 2020 June | 16 | 10 | 26 |
| 2020 May | 26 | 12 | 38 |
| 2020 April | 21 | 1 | 22 |
| 2020 March | 23 | 4 | 27 |
| 2020 February | 18 | 2 | 20 |
| 2020 January | 23 | 10 | 33 |
| 2019 December | 35 | 8 | 43 |
| 2019 November | 25 | 14 | 39 |
| 2019 October | 23 | 9 | 32 |
| 2019 September | 36 | 9 | 45 |
| 2019 August | 13 | 9 | 22 |
| 2019 July | 26 | 13 | 39 |
| 2019 June | 68 | 29 | 97 |
| 2019 May | 146 | 64 | 210 |
| 2019 April | 50 | 15 | 65 |
| 2019 March | 11 | 2 | 13 |
| 2019 February | 14 | 6 | 20 |
| 2019 January | 8 | 6 | 14 |
| 2018 December | 9 | 3 | 12 |
| 2018 November | 12 | 4 | 16 |
| 2018 October | 15 | 10 | 25 |
| 2018 September | 11 | 8 | 19 |
| 2018 August | 11 | 3 | 14 |
| 2018 July | 11 | 1 | 12 |
| 2018 June | 10 | 2 | 12 |
| 2018 May | 9 | 1 | 10 |
| 2018 April | 6 | 2 | 8 |
| 2018 March | 17 | 0 | 17 |
| 2018 February | 7 | 2 | 9 |
| 2018 January | 12 | 3 | 15 |
| 2017 December | 18 | 4 | 22 |
| 2017 November | 14 | 0 | 14 |
| 2017 October | 7 | 2 | 9 |
| 2017 September | 15 | 4 | 19 |
| 2017 August | 13 | 1 | 14 |
| 2017 July | 15 | 1 | 16 |
| 2017 June | 23 | 1 | 24 |
| 2017 May | 24 | 2 | 26 |
| 2017 April | 28 | 2 | 30 |
| 2017 March | 19 | 33 | 52 |
| 2017 February | 26 | 2 | 28 |
| 2017 January | 19 | 4 | 23 |
| 2016 December | 31 | 8 | 39 |
| 2016 November | 17 | 7 | 24 |
| 2016 October | 54 | 11 | 65 |
| 2016 September | 35 | 3 | 38 |
| 2016 August | 15 | 5 | 20 |
| 2016 July | 14 | 2 | 16 |
| 2016 June | 22 | 13 | 35 |
| 2016 May | 19 | 8 | 27 |
| 2016 April | 10 | 2 | 12 |
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