Diagnosis Of Intestinal Neuronal Dysplasia Research Articles

Efficacy of Sox10 Promoter Methylation in the Diagnosis of Intestinal Neuronal Dysplasia From the Peripheral Blood

OBJECTIVES:Intestinal neuronal dysplasia (IND) is a common malformation of the enteric nervous system. Diagnosis requires a full-thickness colonic specimen and an experienced pathologist, emphasizing the need for noninvasive analytical methods. Recently, the methylation level of the Sox10 promoter has been found to be critical for enteric nervous system development. However, whether it can be used for diagnostic purposes in IND is unclear.METHODS:Blood and colon specimens were collected from 32 patients with IND, 60 patients with Hirschsprung disease (HD), and 60 controls. Sox10 promoter methylation in the blood and the Sox10 expression level in the colon were determined, and their correlation was analyzed. The diagnostic efficacy of blood Sox10 promoter methylation was analyzed by receiver operating characteristic curve.RESULTS:The blood level of Sox10 promoter methylation at the 32nd locus was 100% (90%–100%; 95% confidence interval [CI], 92.29%–96.37%) in control, 90% (80%–90%; 95% CI, 82.84%–87.83%) in HD, and 60% (50%–80%; 95% CI, 57.12%–69.76%) in IND specimens. Sox10 promoter methylation in the peripheral blood was negatively correlated with Sox10 expression in the colon, which was low in control, moderate in HD, and high in IND specimens (r = −0.89). The area under the curve of Sox10 promoter methylation in the diagnosis of IND was 0.94 (95% CI, 0.874–1.000, P = 0.000), with a cutoff value of 85% (sensitivity, 90.6%; specificity, 95.0%). By applying a cutoff value of 65%, promoter methylation was more indicative of IND than HD.DISCUSSION:The analysis of Sox10 promoter methylation in the peripheral blood can be used as a noninvasive method for IND diagnosis.

Intestinal Neuronal Dysplasia Type B: Timely Diagnosis and Management

Abstract A 23-year-old female presented to the emergency department with abdominal pain and constipation. She reported an extensive history of constipation. Imaging showed distended bowel without an obstruction. During laparotomy, no obvious mechanical cause was found and a total colectomy was performed. Gross examination of the colectomy specimen showed cobblestoning in a 10-cm portion of the colon. Microscopic examination demonstrated hypoganglionosis of the myenteric plexus, hyperganglionosis of Auerbach’s plexus, and “giant ganglia.” This case met the 2006 Meier-Ruge criteria and diagnosis of intestinal neuronal dysplasia (IND) was established. IND was first described in 1971. The frequency of IND varies widely due to lack of consensus of diagnostic criteria and has a geographic distribution with the highest rates in Europe, which correlates to published research in this region. Diagnostic criteria are controversial and require standardization. Meier-Ruge suggests a quantitative analysis of the number of ganglion cells in the submucosal plexuses and the identification of at least 20% giant ganglia with at least 8 neurons each, in 25 analyzed ganglia. More recent diagnostic criteria are conservative with differences, including (1) elimination of increased AChE-positive nerve fibers around submucosal blood vessels, (2) stipulation that a giant ganglion contains more than 8 ganglion cells, (3) the requirement that more than 20% of at least 25 ganglia be giant ganglia, and (4) diagnostic exclusion of patients <1 year. Clinical management is also controversial. Schimpl et al reported satisfactory results in 80% of 105 patients treated with dietary changes, cisapride, and laxatives with a median 7.2 years follow-up. Since colonic peristalsis is impaired by dysganglionosis, subtotal colectomy procedures have been widely successful. Clinicians should be mindful of IND in patients with a history of chronic constipation with abdominal pain and nonspecific imaging, as timely diagnosis can spare the patient from total colectomy and improve quality of life.

Diagnostic efficacy of blood promoter methylation of Sox10 in intestinal neuronal dysplasia

Objective To explore the efficacy of blood promoter methylation of Sox10 gene in diagnosis of intestinal neuronal dysplasia(IND) and to seek a non-invasive genetic diagnosis method based on peripheral blood for diagnosis of IND. Methods Children diagnosed as Hirschsprung disease(HD)or IND from the Shengjing Hospital of China Medical University and the Capital Institute of Pediatrics were enrolled in 2017-2018.The blood and colon specimens were collected from 9 IND, 15 HD and 15 controls(the colon trauma cases). The blood promoter methylation of Sox10 and its expression level in colon were both detected and the correlation between them was analyzed.The diagnostic efficacy of blood promoter methylation of Sox10 was analyzed by receiver operating characteristics(ROC)curve. Results The blood promoter methylation level at the 32nd locus of Sox10 was 100%(90%-100%; 95%CI: 91%-98%)in the control, 80%(70%-90%; 95%CI: 65%-90%)in HD and 60%(50%-80%; 95%CI: 52%-82%)in IND.The expression level of Sox10 in the colon was(1.00±0.04)in the control, (2.75±0.16)in HD and(3.99±0.10)in IND.Western blot showed that the expression of Sox10 protein in the colon of the control group, the HD group and the IND group increased, and the difference was statistically significant(P<0.05). The blood promoter methylation level was negatively correlated with its expression level in colon(r=-0.88). ROC curve indicated area under curve (AUC) of Sox10 methylation in diagnosis of HD was 0.818, with a cut-off value of 85% and low diagnostic sensitivity.The AUC in IND was 0.907, with a cut-off value of 85%, producing a sensitivity of 88.9% and a specificity of 93.3% respectively. Conclusion Blood promoter methylation of Sox10 might be used as a non-invasive method for diagnosis of IND. Key words: Intestinal neuronal dysplasia; Peripheral blood; Sox10; Methylation; Gene diagnosis

Paediatric constipation for adult surgeons--article 1: targeting the cause.

Constipation is very common in all age groups and can be resistant to standard therapies, producing chronic morbidity. Childhood onset constipation frequently produces symptoms that persist into adulthood. Recent advances have been made in the diagnosis and treatment of childhood constipation that could have application in adult practice. In the first part of the present review, the methods of differentiation of patients with a disorder of colonic motility from those with an anorectal hold-up are discussed. Slow transit constipation, with distinct features on colonic manometry and scintigraphy, has only recently been recognized in children. This diagnosis, together with a novel method of placement of a manometric catheter, is described. While the cause of slow transit constipation remains unclear, clinical features that differ between children and adults may provide an insight into the aetiology. The diagnosis of intestinal neuronal dysplasia is explained and the controversy surrounding the diagnosis outlined. We propose that the traditional histological criteria exclude many other clinically significant forms of dysplasia of the enteric nervous system and should be extended.

Associated anomalies in intestinal neuronal dysplasia

Background/Purpose: Intestinal neuronal dysplasia (IND) is a complex alteration of the enteric nervous system (ENS) that may involve rectum, colon, or the whole intestine. This disorder is a frequent cause of intestinal dysmotility and pseudo-obstruction in the first 3 years of life. The aim of this study was to identify possible associations and correlations of IND with other gastrointestinal and nongastrointestinal anomalies. Methods: From 1986 to 2000, 95 cases of IND type B without aganglionosis were diagnosed. Fifteen cases were diffuse IND, whereas the remaining 80 were rectocolonic neuronal dysplasia. The diagnosis was performed on rectal suction biopsy specimens taken 2 to 10 cm above the pectinate line. Acetylcholinesterase (AChE), lactic dehydrogenase (LDH), and NADPH-diaphorase (NADPH-d) histochemical techniques were performed on serial cryostatic sections. We used Schärli and Meier-Ruge criteria (1981) for the diagnosis of IND until 1992, when we adopted Borchard et al criteria (1991). A retrospective analysis of the clinical data was performed to identify IND-associated anomalies. Results: These anomalies included anorectal malformations (9 cases), intestinal malrotation (8), megacystis (5), congenital short small bowel (4), hypertrophic pyloric stenosis (3), necrotizing enterocolitis (2), mental retardation (2), short stature (2), facial dysmorphism (2), Down syndrome (1), intestinal atresia (1), diffuse intestinal angiomatosis (1), histiocytosis (1), microvillus agenesia (1), and hearing loss (1). Overall, 43 associated anomalies were found in 29 IND cases (30.5%). Gastrointestinal anomalies accounted for 67.4% (29 of 43 anomalies) of associated disorders. The incidence of associated anomalies was higher in diffuse IND (80% of cases, 12 of 15) than in rectocolonic forms (21.2%, 17 of 80). Conclusions: Unlike Hirschsprung's disease, which is determined genetically, IND pathogenesis is unknown. The analysis of associated anomalies in IND population is an important clinical approach to investigate possible pathogenetic correlations. Two recessive syndromes were identified (3 families). The first was characterized by IND, intestinal malrotation, and congenital short bowel, the second by IND, short stature, mental retardation, and facial dysmorphism. In this study, gastrointestinal anomalies accounted for 67.4% of all associated disorders. These data suggest a strong correlation between IND and intestinal development. Abnormalities of the fetal ENS could determine the IND phenotype, which is likely to contribute to the pathogenesis of different intestinal malformations and in particular of anorectal and “rotation” anomalies. J Pediatr Surg 37:219-223. Copyright © 2002 by W.B. Saunders Company.

Intestinal neuronal dysplasia: Results of treatment in 33 patients

Purpose: Intestinal neuronal dysplasia (IND) is a disease of the enteric nervous system, which clinically resembles Hirschsprung's disease. The authors reviewed their experience of IND over an 8-year period. Methods: Between 1992 and 1999, 418 patients underwent rectal suction biopsy for persistent constipation. Thirty-three (7.8%) patients had histologic evidence of IND. There were 26 boys and 7 girls (age range, 1 week to 10 years). The diagnosis of IND was based on the presence of hyperganglionosis of the submucous plexus and giant ganglia and at least one of the following features in rectal biopsies: (1) ectopic ganglia, (2) increased acetylcholinesterase (AChE) activity in the lamina propria, and (3) increased AChE nerve fibers around the submucosal blood vessels. All patients were started on laxatives with or without enemas after the diagnosis was made. Patients have been followed up from 1 to 8 years (mean, 2.4 years). Results: Twenty-one (64%) patients had a good response to conservative management and currently have normal bowel habits. Twelve patients (36%) underwent internal sphincter myectomy after failed conservative management. Seven of these patients now have normal bowel habits. Two patients are able to stay clean with regular enemas. Three patients who continued to have persistent constipation after myectomy and underwent resection of redundant and dilated sigmoid colon now have normal bowel habits. Conclusion: The majority of patients with IND can be treated successfully with conservative treatment. J Pediatr Surg 36:777-779. Copyright © 2001 by W.B. Saunders Company.

Rectal mucosal biopsy compared with laparoscopic seromuscular biopsy in the diagnosis of intestinal neuronal dysplasia in children with slow-transit constipation

Background/Purpose: Intestinal neuronal dysplasia (IND) as a cause for severe chronic constipation remains controversial. The aim of this study is to examine the correlation between a deficiency of substance P (SP) immunoreactive nerve fibers in the colon and enzyme histochemistry of rectal biopsies in children with slow-transit constipation. Methods: Fifty children with intractable constipation have been assessed by rectal biopsies examined with histochemical staining for lactate dehydrogenase, and 32 children among those 50 have been studied by laparoscopic seromuscular biopsy of the colon labelled with antibodies to SP using immunofluorescence methods. Results: Four children have evidence of IND. Fifteen children, including all 4 IND cases, showed a deficiency of SP immunoreactivity. There is a significant correlation between giant ganglia and SP deficiency (P <.01). Conclusion: This study is attempting to propose that a deficiency of SP immunoreactivity in colonic circular muscle nerves may be used as a histologic marker for slow-transit constipation and that IND may be a small subset of patients with SP deficiency. J Pediatr Surg 35:1724-1727. Copyright © 2000 by W.B. Saunders Company.

Rectal biopsy for diagnosis of intestinal neuronal dysplasia in children: a prospective multicentre study on interobserver variation and clinical outcome

BACKGROUNDIntestinal neuronal dysplasia (IND) of the colonic submucous plexus is considered to be a congenital malformation of the enteric nervous system causing symptoms resembling those of Hirschsprung’s disease. In contrast...

Morphometric aspects of the submucous plexus in whole-mount preparations of normal human distal colon

Background/Purpose: The diagnosis of intestinal neuronal dysplasia (IND) has traditionally been based on the finding of hyperplasia of the submucous plexus and increased acetyl-cholinesterase activity in parasympathetic nerve fibers in the lamina propria. However, recently it has been suggested that proposed diagnostic criteria relating to nerve cell density may overlap with age-related changes and that the finding of giant ganglia (ganglia containing more than seven ganglion cells) is the most relevant diagnostic parameter of IND. Ganglion cell counting is usually performed on conventional histological sections, whereas the topology of whole ganglia has been poorly studied. The aim of this study was to define the number of ganglion cells per ganglion and the ganglion cell density (the number of ganglion cells per surface area) in submucous whole-mount preparations of normal human colon. Methods: Specimens from distal colon were obtained during postmortem examination from 14 patients who died of nongastrointestinal disease. The submucous layer was prepared as a whole mount and stained for NADPH diaphorase (a nitrergic neurotransmitter marker) and cuprolinic blue (a general neuronal marker). Ganglion cell density was estimated by counting at least 10 mm 2. The number of ganglion cells per ganglion was counted in at least 20 ganglia per case. Results: Ganglion cell density (NADPH diaphorase) fell markedly during the first 5 to 6 years of life (r = −0.60, P < .05). Most ganglion cells formed ganglia of 3 to 64 cuprolinic blue staining cells. The mean number of ganglion cells per ganglion did not vary with age. Conclusions: The density of NADPH diaphorase-positive ganglion cells in the submucous plexus of human distal colon decreases markedly with age. However, the number of ganglion cells per ganglion remains constant. These findings indicate that the age of the patient has crucial importance for the histolopathologic evaluation of enteric nervous system disorders.

INTESTINAL NEURONAL DYSPLASIA: A PROSPECTIVE MULTI-CENTER STUDY ON INTEROBSERVER VARIATION AND CLINICAL OUTCOME

Intestinal neuronal dysplasia (IND) of the colonic submucous plexus is considered to be a congenital disorder causing symptoms resembling those of Hirschsprung's disease (HD). The diagnostic criteria using enzyme-histochemistry on rectal biopsies were published by a group of German speaking pathologists (Pathologe 1991;12:171-4), but have been questioned by others due to absence of morphological data in healthy children. Patients and methods: Biopsies from 108 children (62 male, median age 2.1 yrs, range 4 days - 15.3 yrs.) with colonic motility problems were sent from 7 University hospitals (4 departments of paediatric surgery, 3 of paediatric gastroenterology) and examined by 3 pathologists for histology (acetylcholinesterase, LDH, SDH). In a total of 377 biopsies the 3 pathologists independently coded 21 features and the final diagnosis without knowledge of clinical symptoms. Interobserver variation was analysed by kappa statistics. Clinical data were recorded at the time of biopsy and 6 and 12 months later. Results:Observer-variability: There was full agreement between the 3 pathologists with respect to final diagnosis in all 20 children with HD (Kappa=1), but in only 14% of the remaining patients. In 15 children, at least one pathologist judged the case as,,normal”, while another diagnosed,,classic IND”. Kappa values were very low for more,,subjective” items (i.e. signs of immaturity, Kappa = 0.00 - 0.020), but unsatisfactory even for,,objective” items like,,presence of ganglion with > 8 ganglion cells” (kappa = 0.52 - 0.58). Clinical outcome: The 88 children without HD were clinically divided into 2 groups: children with constipation only (n=57) and additional different complications i.e. ileus, malformations etc. (n=31). In the 57 constipated patients, there were no significant differences between the 30 children looked after by pediatric surgeons compared to the 27 from pediatricians regarding items indicating severity of constipation (duration of symptoms, stool frequency, presence of encopresis, abdominal and rectal fecal mass). However, 13 sphinctermyectomies and 1 colonic resection were performed in those children that were looked after by surgeons. Cure rate (normal bowel pattern, off laxatives) after 1 year was higher in children classified as,,IND” or,,not normal” (40% & 60%) compared to histologically,,normal” or,,no IND” (23% & 27%). Operated children had a lower cure rate (17%) than conservatively treated patients (30%). Conclusions: In contrast to HD, there is an unacceptably high interobserver variation regarding the different morphological signs and final diagnosis of IND with the criteria and conditions used here. Abnormal findings have no predictive value for long-term prognosis in constipated children and seem to provoke a surgical pro-cedure. With the current knowledge, rectal biopsies for enzymehistochemistry should only be performed in constipated children to diagnose or exclude HD.

An evaluation of the role of suction rectal biopsy in the diagnosis of intestinal neuronal dysplasia.

German pathologists have developed a consensus for histological features of intestinal neuronal dysplasia. A blind reevaluation of ganglionic suction rectal biopsies from infants and children who initially presented with symptoms of intestinal dysmotility was made. 84 of 411 specimens had sufficient depth of submucosa for adequate assessment. Questionnaires or clinical interviews were employed 3-5 years after biopsy in these 84 patients to assess the relationship between histological changes and persistent symptomology. Eighteen children were lost to follow-up, 4 others had Hirschsprung's disease the study biopsy specimen having been taken from the pulled-through bowel after surgical resection of the aganglionic segment. The remaining 62 patients were divided into three groups. There were six patients in group A (both obligatory criteria) and 28 in group B (nonessential, or just one of the obligatory criteria), and 28 in group C (normal appearances). On follow-up, two of the 28 (7%) in group B, and six of the 28 (21%) in group C had persistent dysmotility symptoms. Histological criteria of the consensus of German Pathologists for intestinal neuronal dysplasia was unhelpful in predicting the clinical outcome and therefore, should not influence clinical management. As one of the obligatory criteria, hyperplasia of the submucosal plexus was significantly more common in neonates (< 4 weeks), it is concluded that this is an age-related variation.