Brunner’s Gland Hyperplasia (BGH) is a rare, benign condition characterized by an overgrowth of glandular tissue in the duodenum, the first part of the small intestine. Although BGH is not malignant, large growths can cause significant symptoms, necessitating treatment. Management strategies range from observation and medication to interventional procedures. The choice depends heavily on the lesion’s size, location, and whether it is causing symptoms.
Defining Brunner’s Gland Hyperplasia
Brunner’s Gland Hyperplasia involves the excessive, non-cancerous proliferation of the submucosal Brunner’s glands within the duodenum. These glands are located beneath the mucosal layer, primarily in the duodenal bulb. Their main function is to secrete a thick, alkaline substance containing bicarbonate. This secretion neutralizes the highly acidic contents (chyme) entering the duodenum from the stomach, protecting the duodenal lining.
The condition is rare, accounting for approximately 10.6% of all benign tumors found in the duodenum. Most lesions are small, often less than one centimeter in diameter, and are typically discovered incidentally during an endoscopy performed for an unrelated reason. The most common location for BGH is the duodenal bulb, the section immediately following the stomach.
Clinical Reasons for Intervention
Despite its benign nature, BGH may require intervention when the overgrowth causes clinical symptoms or complications.
One primary reason for treatment is gastrointestinal bleeding, which can manifest as acute hemorrhage or chronic, slow blood loss leading to anemia. The bleeding occurs when the overlying duodenal mucosa becomes ulcerated or eroded due to the pressure or size of the submucosal mass. Chronic anemia resulting from this slow blood loss can cause symptoms like dizziness and fatigue.
A second indication for intervention arises when the lesion grows large enough to cause gastric outlet obstruction. This occurs because the large mass physically blocks the passage of food from the stomach into the small intestine. Patients with obstruction may experience severe symptoms, including abdominal pain, chronic vomiting of undigested food, and significant weight loss.
Intervention is also necessary for diagnostic certainty, even when symptoms are mild. Because BGH can appear similar to more serious lesions, such as duodenal adenocarcinoma, a tissue sample or complete removal is often performed. This diagnostic procedure is performed to definitively rule out malignancy, which guides the entire course of patient management.
Conservative and Pharmacological Management
For many patients, the initial approach to BGH is conservative, relying on careful monitoring rather than immediate removal. When a lesion is small and asymptomatic, the standard practice is watchful waiting, or surveillance. This involves periodic endoscopic check-ups to monitor the lesion’s size and appearance over time.
Pharmacological management focuses on treating symptoms rather than curing the hyperplasia itself. Since BGH is sometimes linked to hyperacidity, medications are used to reduce gastric acid production. Proton Pump Inhibitors (PPIs) and H2 blockers are commonly prescribed to lower stomach acid levels and manage symptoms like dyspepsia or acid reflux.
This medical treatment is supportive, aiming to alleviate discomfort and reduce the stimulus for further growth, though regression is rare. If the lesion continues to grow, causes significant bleeding, or leads to obstruction, a definitive interventional procedure will be required.
Interventional Removal Techniques
When BGH causes severe symptoms or when malignancy cannot be conclusively ruled out, definitive removal is necessary, primarily through endoscopic or surgical techniques.
Endoscopic Removal
Endoscopic removal is the preferred, minimally invasive method for smaller lesions. This approach utilizes specialized instruments passed through an endoscope. Endoscopic Polypectomy (EPR) is used for pedunculated lesions, which are attached to the duodenal wall by a stalk and are typically less than one centimeter in diameter.
For larger, flatter lesions that involve more of the duodenal wall, Endoscopic Mucosal Resection (EMR) is employed. EMR involves injecting a solution beneath the lesion to lift it away from the deeper muscle layers. This allows the physician to safely remove the entire mass using a snare.
An even more advanced technique, Endoscopic Submucosal Dissection (ESD), can achieve a complete en bloc removal for larger growths. However, ESD carries a higher risk of complications like perforation due to the duodenum’s thin wall. Endoscopic procedures offer the benefits of a shorter hospital stay, quicker recovery, and less invasiveness compared to open surgery.
Surgical Resection
Surgical resection becomes necessary for very large lesions, those deeply infiltrating the duodenal wall, or cases causing complete gastric outlet obstruction. Lesions exceeding five centimeters, or those with features suggestive of deep invasion on imaging, are better managed surgically to ensure complete removal and prevent complications.
Surgical procedures can range from a simple surgical polypectomy to more extensive operations, such as a wedge resection of the duodenal wall.
In rare instances where a giant BGH infiltrates surrounding structures or cannot be definitively distinguished from a malignant tumor, a complex operation like a partial duodenectomy or a pancreaticoduodenectomy (Whipple procedure) may be considered. These major operations are reserved for the most complicated cases to ensure no potential malignancy is left untreated. After successful removal, whether endoscopic or surgical, the prognosis is excellent, with no reported recurrence of the hyperplastic lesion.