Giant Brunner gland adenoma manifesting as iron

deficiency anemia and intussusception

Prof. P. Kar, Rajiv Singla

DEPARTMENT OF MEDICINE
MAMC, Delhi
 History
43 yrs/female
R/o Assam
Presented to MOPD with chief complaint of
 Pain in abdomen x 6 months.
 Easy fatigability x 6 months.
 Generalised weakness x 6 months.
No h/o Nausea/Vomitting/Diarrohea
No h/o fever
No h/o Jaundice.
No h/o TB/DM/HTN.
No h/o blood in vomitus/stool.
No h/o wt. loss/decrease appetite.
No h/o bone pains.
No h/o abdominal distension.
No h/o any chronic drug intake.
PAST HISTORY

History of similar complaints on and off

for last 6-7 years present.

History of multiple blood transfusions for

same complaints present
History
 FAMILY HISTORY
No significant family history.

 PERSONAL HISTORY
Upper middle income group
Non-smoker
Non alcoholic
Vegetarian, but diet adequate

 MENSURAL HISTORY
Regular cycles, no excessive bleeding
GPE
 GC fair
 P = 74/min BP = 110/70 mm of Hg
 Pallor + RR = 14/min
 No Icterus
 No cynosis
 No clubbing
 JVP not raised
 No Peadal Oedema
SYSTEMIC EXAMINATION
CHEST
 B/L clear
 A/E equal
CVS
 S1 S2 are normal
 No MURMUR present
CNS
 WNL
P/A
 Soft non tender
 No organomeagly
 Bowl sounds +
 No Free Fluid
INVESTIGATIONS
Hb = 7.4
TLC = 7300
DLC = 74/24/1/1
P/C = 2.23 lac
P/S = microcytic hypochromic RBC
with few target cells.
RBS = 98
BU/S.Cr = 23/0.9
Na+/K+ = 143/4.2
T.Bil = 0.4
AST/ALT = 23/25
T.Pro/S.Alb = 6.8/3.4
S.Ferritin = 23.3 mcg/dl

Stool for occult blood= positive

Chest X-ray = WNL

Provisional Diagnosis
 Iron deficiency anemia due to GI blood loss
 UGIE

Esophagus - No varices
Stomach - Normal
Duodenum - Polypoidal mass with
pedunclated stalk in 2nd and 3rd part of
duodenum was found
Barium Enteroclysis :

S/O a pedunclated Polypoidal filling defect witin the third part of

Duodenum extending upto Duodeno-Jejunal junction.

M R Abdo with MR Enteroclysis :

A peduncalted polypoidal soft tissue mass in third and fourth part of

duodenum with stalk extending upto the Ampulla of Vater
?? Adenoma.
DIAGNOSIS :-

Iron deficiency Anemia with GI Blood

Loss due to Duodenal Adenoma
Course
 Patient was offered surgery, but patient
refused.
 Went back to Assam
 Had severe abdominal pain and was
diagnosed to have intussuception
 Was operated on emergency basis.
OPERATIVE FINDINGS
 Duodeno- duodenal intususception reaching upto
the Duodeno- jejunal junction, Could be reduced
partially.
 Longitudinal duodenotomy revealed a long stalk
like structure and a polypoidal mass at the tip of it
as an initiator of the intussusception.
 Polyp was excised with clearance of more than
three centimeters.
 Polyp-size = 4x3x2 cm greeish white in colour.
HISTOPATHOLOGICAL
EXAMINATION
 Shows normal intestinal villi with sheets of
proliferated benign looking submucosal glandular
structures. Focal areas shows small collections of
chronic inflammatory cells.
S/o Brunner gland Adenoma (BRUNNEROMA)
AFTER SURGERY
HB = 11.4
TLC = 7900
DLC = 78/20/2
P/C = 2.22 lac
Stool for Occult Blood = Negative
Final Diagnosis
 Brunner Gland Adenoma with iron
deficiency anemia
Role of Endoscopy in Iron
Deficiency anemia

The role of fecal occult blood test in IDA

Brunner Gland Tumor
IRON DEFICIENCY ANEMIA
 ETIOLOGY:
• INCREASED IRON REQUIRMENT (JUVENILE
AGE, PREGNANCY, LACTATION)
• DECREASED IRON INTAKE/ABSORBTION
• CHRONIC BLEEDING
• MENORRHAGIA
• GI LOSS
• URINARY LOSS
• EPISTAXIS
• HEMOPTYSIS
Four per cent of referrals for endoscopy are
initiated because of iron-deficiency anemia
(IDA)
Moses PL, Smith RE. Endoscopic evaluation of iron
deficiency anemia. Postgrad Med 1995;98:213-24.
VALUE OF UGI ENDOSCOPY

 Esophagogastroduodenoscopy (EGD)
demonstrates pathology in 27% to 60% of
individuals with IDA

 strong correlation between a positive history of

upper gastrointestinal tract symptoms and
consequent lesions identified on EGD

 More controversial is whether EGD is necessary

in individuals without upper gastrointestinal
symptoms
VALUE OF UGI ENDOSCOPY
 Diseases important to diagnose, such as
gastric cancer (up to 7% of cases causing
IDA) or peptic ulcers (7% to 21%), cannot
be ruled out on the basis of whether upper
gastrointestinal symptoms are present.
 Given the low risk of EGD presently, the
expected benefit-to-risk ratio of EGD
favours this procedure even in the absence
of symptoms.
VALUE OF SMALL BOWEL BIOPSY

 Trials have convincingly demonstrated that IDA may be

the only manifestation of celiac sprue in absence of the
classical findings of celiac sprue.

 Prevalence of celiac sprue has been shown to be as high as

6% in a population of patients with IDA, emphasizing the
need for small bowel biopsy in IDA even when other
features of small bowel disease are not present.

 On the other hand, the cost effectiveness of small bowel

biopsy in IDA has not yet been calculated.
VALUE OF COLONOSCOPY
 Because colorectal cancer is the most life-
threatening disease among the common
causes of IDA, colonoscopy is highly
recommended, at slightest suspicion, as the
initial procedure.
 Anywhere from 16% to 30% of
gastrointestinal lesions causing IDA can be
identified by colonoscopy
 Barium studies with or without
sigmoidoscopy are less superior methods of
examining the colon
VALUE OF COLONOSCOPY
 Classically, it is the patients with carcinoma of the
right colon who present with IDA, but carcinomas
in the rectum and other parts of the colon may
represent patients with IDA and no symptoms
referable to the lower bowel.
 Vascular malformations (angiodysplasia) have
been associated with IDA in 3% to 9% of patients.
 Other pathological lesions identified by
colonoscopy include neoplastic polyps (5% to
15%), and much less commonly, colitis and
colonic ulcerations.
CONCURRENT LESIONS
 A number of studies have identified patients with
concurrent lesions in the upper and lower tract.
 The frequency of such findings ranged from 1% to 17%,
with only one study quoting a frequency greater than 10%
 The data suggest that the older the population being
investigated, the greater the chance of identifying
concurrent lesions.
 Impossible to be certain which lesion is the major
contributor to blood loss; therefore, both lesions often have
to be treated.
 No consensus on whether EGD is necessary after a lesion
is found oncolonoscopy in a patient with IDA without
symptoms referableto the upper gastrointestinal tract.
SITE-SPECIFIC SYMPTOM CORRELATION

 In their prospective study of 100 patients, Rockey and

Cello (28) found that symptoms do predict the location of
the lesions underlying IDA. For example, in their article,
the positive predictive values of history for predicting
lesions in the upper and lower tract were 82% and 86%,
respectively.
 However, other investigators have been unable to confirm
such a correlation and thus do not recommend the use of
symptoms to direct the initial investigation (26-30).
 Certainly, there is universal agreement that a lack of
symptoms does not rule out disease and should not deter
gastrointestinal investigation.
Assessment of Obscure GI Bleed
 In 7% to 47% of cases of IDA, the etiology of the anemia
remains unexplained after colonoscopy, gastroscopy and
small bowel biopsy.
 Several observations have been made about IDA of
obscure origin by long term follow-up studies.
– enteroclysis (small bowel enema) has a low yield if there are no
symptoms referable to the small bowel.
– In about two-thirds of patients with IDA of obscure origin, the
anemia resolves by itself after a course of oral iron
supplementation
– a high yield of finding a bleeding lesion can be expected from
repeating colonoscopy and gastroscopy in a specialist unit
– enteroscopy shows a cause for obscure IDA in about 10% to 50%
of cases
 With the advent of enteroscopy, laparoscopy combined
with intraoperative endoscopy is less often necessary
THE ROLE OF FECAL
OCCULT BLOOD TEST IN IDA
 THE ROLE OF FECAL OCCULT BLOOD
TEST IN IDA

Rockey D. N Engl J Med 1999;341:38-46

Sites of Gastrointestinal Bleeding, Intraluminal Metabolism of Hemoglobin, and Accuracy of

Fecal Occult-Blood Tests
 THE ROLE OF FECAL OCCULT BLOOD
TEST IN IDA

Rockey D. N Engl J Med 1999;341:38-46

Characteristics of Different Classes of Fecal Occult-Blood Tests

THE ROLE OF FECAL OCCULT BLOOD
TEST IN IDA
 Intuitively, fecal occult blood tests (FOBTs) appear to be
helpful in IDA to determine whether there is a bleeding
lesion in the bowel
 However, the literature does not support this hypothesis,
chiefly because the pretest probability of the presence of a
gut lesion in IDA is almost as high as the sensitivity of the
FOBT
 Accordingly, it is not surprising that most studies do not
show any correlation in IDA between a positive FOBT and
the presence or absence of a lesion in the bowel.
 FOBT similarly is not helpful in determining the location
of the bleeding lesion in the gut
 FOBT is used best for screening (healthy individuals for
colorectal cancer) rather than determining whether IDA is
due to a bowel lesion
An approach to iron-deficiency anemia. Can J Gastroenterol Vol 15
No 11 November 2001
Brunner Gland Adenoma
Brunner Gland Adenoma
 Brunner’s gland adenoma (BGA ） is a very rare benign
tumour of the duodenum. Less than 30 cases reported till
date
 BGA has a tendency to be predominant in the fifth or sixth
decade of life with equal gender distribution
 Clinical presentation is variable.
 Majority of cases are asymptomatic or present with non
specific, vague symptoms such as abdominal pain or
discomfort, nausea or bloating.
 BGA is usually an incidental finding during imaging
studies or EGDS
Brunner Gland Adenoma
 In symptomatic patients, the most common clinical
presentations are gastrointestinal bleeding (37%) and
obstructive symptoms (37%)[5].
 Gastrointestinal bleeding manifests in the majority of cases
as chronic loss of blood with iron deficiency and
anaemia[6].
 Less frequently, when erosion or ulceration of the tumour
occurs, patients can present with melena or haematemesis.
 These findings are usually described in BGA occurring
beyond the fi rst portion of the duodenum, probably
because these lesions are subjected to more stress and
vascular damage from gastrointestinal motility[
Brunner Gland Adenoma
 Aetiology and pathogenesis of BGA still remain to be
elucidated.
 Due to the “anti-acid” function of Brunner’s glands, it has
been postulated that an increased acid secretion could
stimulate these structures to undergo
 A second hypothesis suggests that this lesion is of
inflammatory origin due to the presence of a dense
inflammatory cell infiltration. Since lymphocytes are usually present
in the normal submucosa of the intestinal tract, the presence of inflammatory
foci in the BGA is not sufficient to sustain the “inflammatory hypothesis”.
 Finally, it has been suggested that H pylori infection may
play a rolein the pathogenesis of BGA.
Brunner Gland Adenoma
 The duodenal bulb is the most frequent
localizationof BGA (57%)
 In the majority of cases, these lesions develop into
a polypoid mass, usually pedunculated (88%),
being 1 to 2 cm in size while few cases reaching
several centimetres as the ”giant BGA” have been
reported
 On the other hand, lesions < 1 cm are referred to
as Brunner’s gland hyperplasia
Brunner Gland Adenoma
 Diagnosis can be obtained by histological
examination of the excised mass.
 Traditional endoscopy of pinching biopsies
is usually negative since the biopsy forceps
are unable to reach the tumoral tissue
localized completely in the submucosa layer
Brunner Gland Adenoma
 Endoscopic or surgical removal of BGA has been
suggested to prevent the development of
complications (haemorrhage, severe anaemia,
obstruction or intussusception).
 Endoscopic polypectomy represents the ideal
approach, which is more cost-effective and less
invasive of the abdominal surgery [22, 23].
However, the success depends on site and size of
the BGA and presence of a peduncle.