Significance of Brunner’s glands in perforation of a tubular adenoma of the duodenum during endoscopic mucosal resection

Abstract

A 59-year-old man with chronic glomerulonephritis─who had undergone kidney transplantation─was incidentally found on routine upper gastrointestinal (GI) endoscopy to have- a 5-mm 0-IIa tumor in the descending portion of the duodenum. Histological findings of a biopsy specimen showed atypical cells. Upper GI endoscopy was therefore repeated, and adenoma was suspected based on these latest biopsy findings. One month later, the structure of the tumor was noted on endoscopy to have changed and elevating the tumor by physiological saline injection was not possible. The decision was made to perform endoscopic mucosal resection (EMR) as the tumor was small. However, perforation occurred immediately upon starting the procedure. The defect was closed by endoscopic clipping, and it healed with conservative treatment. Histological assessment of the EMR specimen showed Brunner’s glands in the submucosal layer beneath the tumor. The second biopsy specimen was reviewed and similarly found to contain Brunner’s glands in the submucosal layer. Perforation likely occurred due to failure of the physiological saline injection for two reasons-firstly because there were Brunner’s glands beneath the tumor, and secondly because the submucosal layer had become thin due to removal of Brunner’s glands by biopsy. Physicians should recognize the presence of Brunner’s glands during EMR for duodenal neoplasms.