Path Quiz Case-87 :  Diagnosis-

         Dr  Sampurna Roy  MD

    Path Case 87:Case history and images:

Curveilhier reported the first case of Brunner's gland adenoma in 1835 and Salvioli reported a case in 1876.  

Brunner's gland adenoma (BGA) of the duodenum appear to be nodular hyperplasia of the normal Brunner's gland with an unusual admixture of normal tissues, including ducts, adipose tissue and lymphoid tissue.

Overgrowth of Brunner's gland forming a tumour larger than 1cm in size in diameter is referred to as BGA and less than 1cm as Brunner's gland hyperplasia.

The etiology of Brunner's gland adenoma remains obscure. Concurrent H. pylori infection is very common in patients with Brunner's gland adenoma. However, the role of H. pylori infection in the pathogenesis and development of Brunner's gland hyperplasia remains unclear.

Age: The lesion presents predominantly in the fifth and sixth decades of man's life with no sex predominance.

Clinical presentation: Patients may present with obstructive symptoms or gastrointestinal hemorrhage, but the lesion is usually an incidental finding. The patient may complain of dyspepsia, nausea ,diarrhea or jaundice. Anemia  may results from chronic blood loss. In some cases patient may present with congestive heart failure secondary to profound iron deficiency anemia. Enlarged Brunner glands have also been associated with uremia and duodenal ulcers.

Site:  Most common location for the lesion is the posterior wall of the duodenum near the junction of its first and second portions.  Brunner's gland adenoma is rarely found extending to the proximal jejunum

Gross:   Brunner`s gland adenoma can be multinodular or a single polyp. It is usually non-encapsulated but well-circumscribed nodules of white, pink, or tan tissue.  Size of adenoma might extend from 1-12 cm, it is generally 1-2 cm in diameter. The surface is typically smooth and nodular , but can be eroded. 

Microscopic features:

Normal Histology of Brunner's gland:   These are branched acinotubular glands located in the submucosa . Glands are lined by cells with cytoplasm which stain strongly for mucin . The normal function of brunner's gland is to secrete alkaline secretion which empty into the Crypts of Lieberkuhn in the duodenum and protects the duodenal mucosa from the damaging action of acid chyme.

In Brunner`s gland adenoma  histologically normal Brunner glands are arranged in a nodular manner and is separated by thin fibromuscular bands. 

Ducts are distributed normally. Inspissated secretions of periodic acid–Schiff (PAS)-positive neutral mucin admixed with nuclei, due to the extrusion of glandular material into the ducts, may dilate the latter.

It has been referred to as an adenoma, but its lobular structure, presence of ductal elements, and lack of dysplasia are more consistent with hyperplasia. ( Some authors reserve the term "hamartoma" for those lesions greater than 5 mm and hyperplasia for those smaller ).

Note:  Diagnosing well-preserved tissue is not difficult, but small crushed biopsy fragments can appear neoplastic, especially in a PAS reaction where cells are admixed with abundant mucin.

 

Normal histology of the small intestine for anatomic pathologists An approach to evaluation of small intestinal biopsy. Malabsorption syndrome (causes  and clinical investigations) Tropical Sprue Coeliac Disease Enteropathy-associated T-cell lymphoma Intestinal lymphangiectasia Pathogens commonly affecting Small Intestine Ascariasis Cryptosporidium Cytomegalovirus infection Giardiasis Hookworm Infection Isosporiasis Microsporidia Mycobacterium Avium Intracellulare Schistosomiasis Whipple's disease Peptic Ulcer Lesions causing small bowel obstruction and bleeding -  Intussusception : Adhesions : Volvulus Meckel's diverticulum Ischemic bowel disease  Duodenal  Gangliocytic Paraganglioma Lymphoma of the small intestine

Cutaneous lesion associated  with AIDS Amoebiasis   Anthrax Infection Avian Influenza Blackwater Fever Blastomycosis Bartonellosis Candidosis(Candidiasis) Coccidioidomycosis Cryptococcosis Cytomegalovirus infection Dengue Dermatophytosis Dematiaceous fungal infection Giardiasis Histoplasmosis Leishmaniasis  Malaria Meningococcal Infection Measles Molluscum Contagiosum Pneumocystis Pneumonia Q Fever (Coxiella burnetii) Rhinosporidiosis Schistosomiasis Subacute Sclerosing Panencephalitis Histopathological patterns in cutaneous infections