primary duodenal tumors are rare , accounting for less than 1% among all gastrointestinal tumors [ 1 , 2 ] .
brunner 's gland adenoma , also known as brunner 's hamartoma is a rare benign small bowel neoplasm with an estimated incidence of less than 0.01% .
generally , it is an incidental finding discovered in an upper gastrointestinal endoscopy ( egd ) and presenting as a single pedunculated polyp , with an average size of 2 cm . occasionally , they may be larger than 5 cm , and located in the first section of the duodenum .
most duodenal tumors of brunner 's glands are demonstrated as hyperplastic or hamartomatous mucosal changes and their malignant transformation has been reported to be extremely rare [ 6 , 7 ] . in a recent study , dysplastic changes were seen in 2.1% and invasive carcinoma in 0.3% of all brunner 's gland hyperplasia .
most patients are asymptomatic , although they can present with common gastrointestinal symptoms like bleeding , nausea , vomiting , or chronic abdominal pain .
we present an illustrative case of a female patient with a duodenal polypoid mass of more than 6 cm who was admitted to our department with upper gastrointestinal bleeding .
a 47-year - old woman arrived at our emergency room with melena and anemia accompanied by epigastric pain .
physical examination on admission revealed normal vital signs ; she was afebrile with a soft and nontender abdomen .
however , melena was detected in the rectal examination and the laboratory data showed a hemoglobin concentration of 8.2 g / dl ( normal range : 12.016.0 ) , and mean corpuscular volume of 88 fl ( normal range : 8096 ) .
the emergency egd revealed a large pedunculated polyp ( 3  6 cm ) in the first section of the duodenum with stigmata of recent hemorrhage which almost occluded the duodenal lumen completely ( fig .
the patient was transferred to our intensive care unit and was administered pantoprazole intravenously at 10 mg / h after an 80-mg loading dose .
contrast - enhanced computed tomography scan showed a heterogeneously enhancing intraluminal mass arising from the proximal duodenum .
repeated upper endoscopy , performed 1 day later , revealed a not actively bleeding polyp located in the bulb of the duodenum .
because of the enormous size of the polyp , with a benign appearance , we decided to perform endoscopic resection . according to the high risk of bleeding an  endoloop 
this procedure was repeated 3 times until the bulk seemed to be removed ( fig .
the endoscopic view was quiet poor because the base was placed directly behind the pylorus . to avoid perforation ,
the intervention was stopped at the moment , and endoscopic ultrasound ( eus ) was performed the next day .
the brunner 's gland hyperproliferation was extended within the submucosa with a distance of 12 mm to the muscularis ( fig .
4 ) , though the endoscopic examination showed a strong vascularity of the submucosal lesions . evaluating the findings of endoscopy , eus and computed tomography scan we discussed either endoscopic mucosal resection ( emr ) , endoscopic submucosal dissection ( esd ) , or surgical management .
after discussions of all approaches with the patient , including the risk of endoscopic perforation or bleeding , the patient consented to an elective duodenotomy . following the preoperative checkup ,
the pylorus was identified and a longitudinal incision was made on the pylorus ring for duodenal mucosa exploration . during the exploration , the mass was removed from the base and sent for histopathological examination .
histologically , there was no evidence of malignancy , and once again , it was confirmed as a brunner 's gland adenoma measuring 16  15  6 mm with a residual peduncle of 4 mm .
the tumor was composed of lobules of brunner 's glands with a few dilated glands .
usually , polyps arise from the mucosal layer although some submucosal pathologies may cause mucosal protrusion into the lumen and resemble mucosal polyps .
brunner glands are branched acinotubular glands with submucosal location found exclusively between the pyloric ring and the papilla of vater .
they secrete an alkaline fluid composed of viscous mucin to protect the duodenal epithelium from acid chyme of the stomach .
brunner 's gland adenoma is a rare tumor - like lesion , mostly present in middle age without sex predominance .
curveilhier described the first case of benign duodenal brunner 's gland adenoma in 1835 . in 1688 , brunner gave a precise anatomic description of the duodenal submucosal glands and coined the term  pancreas secundarium  . in 1846 , middeldorpf corrected these glands name as brunner 's glands .
presently , fewer than 200 cases have been described with synonyms of brunner gland adenoma , brunner gland hamartoma , or brunneroma .
brunner gland adenoma is generally a single pedunculated polyp , with an average size of 2 cm , rarely larger than 5 cm , and located in the first section of the duodenum . nonetheless , primary duodenal tumors are rare , accounting for less than 1% among the total gastrointestinal tumors even though they rarely have a malignant transformation [ 5 , 6 ] . in a recent study ,
dysplastic changes were seen in 2.1% and invasive carcinoma in 0.3% of all brunner 's gland hyperplasia .
the precise pathogenesis is poorly understood but the excessive local irritation from acidic gastric chyme , vagal stimuli , or unidentified antral hormones seems to have relevance .
helicobacter pylori infection is accused of contributing to the pathogenesis of brunner 's gland hamartoma . in a study , 5 of 7 cases had concurrent h. pylori infection .
nevertheless , the definite relationship has not yet been proven because of the high prevalence of h. pylori and the rarity of this lesion in the general population .
some authors have further divided these lesions as follows : for lesions of less than 1 cm , the term  hyperplasia  is used while the term  adenoma  has been used for lesions of more than 1 cm and the term  hamartoma  if it also contains mesenchymal elements .
the main differential diagnoses are gastrointestinal stromal tumor , lymphoma , carcinoid , peutz - jeghers polyps , prolapsed pyloric mucosa , or aberrant pancreatic tissue .
after histopathological examination , treatment is recommended for tumors larger than 2.0 cm , even if they are asymptomatic .
although endoscopic techniques of removal are more helpful , this procedure can be limited by difficult anatomical sites , so that various strategies , such as endoscopic , surgical , or a combination of both , are used , depending on the situation [ 3 , 13 ] . presently , there is no relevant data of recurrence in such a lesion as well as any guidance in the follow - up .
initially , we performed a partial endoscopic resection using endoloop and snare alternatively to prevent severe bleeding .
however , on request of the patient , an elective surgical duodenotomy with submucosal resection of the remaining small duodenal tumor was performed . to better define the patient 's characteristics and treatment options of these lesions , a systematic review of the available literature in pubmed was performed ( table 1 ) . nowadays
, an endoscopic removal of such lesions has commonly increased , and became a safe treatment modality utilizing advanced endoscopic equipment , particularly for benign submucosal tumors .
various endoscopic procedures , including snare resection , esd , and the endoloop technique have been introduced for safe resection of benign tumors .
duodenal lesions susceptible to endoscopic resection include premalignant lesions like adenomas , benign lesions ( brunner hyperplasia or lipoma ) , and submucosal lesions with malignant potential like neuroendocrine tumors ( net ) or gastrointestinal stromal tumors ( gist ) ( table 2 ) [ 14 , 15 ] .
furthermore , submucosal dissection in coagulation mode is used to control the depth of the cut and reduce the risk of bleeding . due to high complication rates ( bleeding , perforation )
, esd could be a safe modality of treatment and less invasive in our case .
informed consent has also been obtained from the involved patient , and there is no identifying patient information in the manuscript .
the authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest ( such as honoraria ; educational grants ; participation in speakers bureaus ; membership , employment , consultancies , stock ownership , or other equity interest ; and expert testimony or patient - licensing arrangements ) , or non - financial interest ( such as personal or professional relationships , affiliations , knowledge or beliefs ) in the subject matter or materials discussed in the manuscript .
 brunner 's gland adenoma is an extremely rare benign small bowel neoplasm , often discovered incidentally during upper gastrointestinal endoscopy or radiological diagnostics . in few cases 
 , it tends to cause gastrointestinal hemorrhage or intestinal obstruction . 
 we report here our experience with a 47-year - old woman with a brunner 's gland adenoma of more than 6 cm in size , located in the first part of the duodenum and causing gastrointestinal bleeding . 
 initially , we performed a partial endoscopic resection using endoloop and snare alternatively to prevent severe bleeding . a rest endoscopic polypectomy with the submucosal dissection technique was planned . however , on request of the patient , an elective surgical duodenotomy with submucosal resection of the remaining small duodenal tumor was performed . to better define the patient 's characteristics and treatment options of such lesions 
 , we performed a systematic review of the available literature in pubmed . 
 recently , an endoscopic removal is being increasingly practiced and is considered as a safe treatment modality of such lesions . 
Introduction
Case Report
Discussion and Conclusions
Statement of Ethics
Disclosure Statement