Giant Brunner's Gland Adenoma of the Proximal Jejunum Presenting as Iron Deficiency Anemia and Mimicking Intussusceptions
A 50-year-old woman presented with abdominal discomfort and general weakness lasting for 2 months. She visited a private clinic and anemia has been detected in her blood tests. She was referred to our hospital for further evaluation of IDA. She had no other medical problems. The physical examination revealed no abdominal tenderness, rebound tenderness, or palpable mass. Her complete blood counts were as follows; hemoglobin 6.3 g/dL, hematocrit 19.2% (mean corpuscular volume 91.4 fL, mean corpuscular hemoglobin 29.9 pg), and platelet 366,000/mm3. The levels of iron and ferritin were 7 µg/dL (normal value, 50 to 130) and 7.5 ng/mL (normal value, 10 to 291), respectively. Liver function tests were within normal limits. Stool occult blood test was negative, and esophagogastroduodenoscopy and colonoscopy revealed no obvious cause of IDA. For the next diagnostic evaluation, abdominal computed tomography (CT) and small bowel follow-through were performed and intussusceptions in the proximal jejunum were suspected (, ). However, she had no apparent symptoms pertaining to intussusceptions. We performed a double balloon enteroscopy (DBE) for direct inspection of the proximal jejunum and differential diagnosis between intussusception and an intraluminal mass. A polypoid mass with a very long and wide stalk arising from the proximal jejunum was detected. The lesion was more than 9 cm in length, with soft consistency and normal appearing mucosa (). We changed the double balloon enteroscope to push enteroscopy using colonoscope for endoscopic treatment using Endo-Loop (Ethicon, Sommerville, NJ, USA). We first ligated the mid part of stalk for prevention of immediate bleeding using Endo-Loop and then removed the polypoid mass using snare polypectomy. The resected polypoid mass was histologically confirmed a giant Brunner's gland adenoma (). Her hemoglobin was normalized (12.1 g/dL) 3 months after the endoscopic treatment.