Hirschprung's Disease Research Articles

Isolation of Enteric Nervous System Progenitor Cells from the Aganglionic Gut of Patients with Hirschsprung's Disease.

Enteric nervous system progenitor cells isolated from postnatal human gut and cultured as neurospheres can then be transplanted into aganglionic gut to restore normal patterns of contractility. These progenitor cells may be of future use to treat patients with Hirschprung’s disease, a congenital condition characterized by hindgut dysmotility due to the lack of enteric nervous system ganglia. Here we demonstrate that progenitor cells can also be isolated from aganglionic gut removed during corrective surgery for Hirschsprung’s disease. Although the enteric nervous system marker calretinin is not expressed in the aganglionic gut region, de novo expression is initiated in cultured neurosphere cells isolated from aganglionic Hirschsprung bowel. Furthermore, expression of the neural markers NOS, VIP and GFAP also increased during culture of aganglionic gut neurospheres which we show can be transplantation into cultured embryonic mouse gut explants to restore a normal frequency of contractility. To determine the origin of the progenitor cells in aganglionic region, we used fluorescence-activated cell sorting to demonstrate that only p75-positive neural crest-derived cells present in the thickened nerve trunks characteristic of the aganglionic region of Hirschsprung gut gave rise to neurons in culture. The derivation of enteric nervous system progenitors in the aganglionic gut region of Hirschprung’s patients not only means that this tissue is a potential source of cells for future autologous transplantation, but it also raises the possibility of inducing the differentiation of these endogenous cells in situ to compensate for the aganglionosis.

Clinical outcome and bowel function after surgical treatment in Hirschsprung's disease.

Background:Bowel function has been reported to be adversely affected following surgery in cases of Hirschsprung. We retrospectively studied both the clinical outcome and bowel function status following surgery in patients diagnosed with Hirschprung's disease (HD). 161 cases, who underwent pull-through operations for HD in Sheikh Pediatric Tertiary Centre, Mashhad, Iran. The specified time bracket spanned between 2006 and 2011.Materials and Methods:Data was extracted from Health Information System with the aim of investigating patients for both short and long-term gastrointestinal (GI) complications after surgery bases in addition to the concurrence of any associated anomalies. Three main procedures were analysed in this respect (Swenson, Duhamel and Soave).Results:In a study of 96 (59%) boys and 65 (40.3%) girls, mortality rate was reported to be 15.5% (15 males and 10 females). A considerable majority of almost three fourths were detected with both early and late GI complications after surgery. The latter mainly included constipation (30.8%), incontinence (19.8%), enterocolitis (8%), diarrhea (11%) in a declining order of incidence. Down syndrome and others HD-associated anomalies were detected in 3.7% and 24.3% of cases respectively.Conclusions:Constipation and foecal incontinence were the most prevalent postoperative complications, which were reported almost as frequent in other studies. Yet, Enterocolitis, was reported slightly less in prevalence. Also mortality rates were considerably higher, compared to developed nations.

In vitro study of contractile responses of bowel with Hirschprung Disease

Background: Hirschsprung’s disease (HD) is a congenital disorder in neonates which results from the absence of parasympathetic ganglion cells in the myenteric and submucosal plexus of the rectum, possibly extending to the colon. Aims & Objective: To assess the contractile status of intestinal tissue of HD for better understanding of motility problems. Materials and Methods: Circular muscle strips were prepared from freshly excised specimens of HD obtained from pediatric surgery operation theatre. The in vitro contractile activity of the tissue was assessed in an organ bath filled with physiological solution. Results: Spontaneous contractions were recorded in 66% cases. Dose-dependent increase in response with the application of histamine and acetylcholine (0.1–100 μM) was observed. Responses of histamine were significantly (P < 0.05) blocked by pre-application of H1 blocker pheniramine (80%). Pre-application of atropine significantly (P < 0.05) blocked (62%) acetylcholine responses. Conclusion: Large number of cases showed spontaneous contractions indicating functionally normal tissue.

About the Respective Roles of Central and Intraorgan Nervous Systems in Regulation of the Gastrointestinal Tract Physiology and Morphology

The role played by central nervous system in the general regulation and coordination of organ, tissue and even cell activities does not stop to excite the curiosity of investigators. Recently important data were obtained in the field of new neurotransmitters and other active molecules which mechanisms of actions and interactions were clarified. But the function of intra organ, local nervous system, its relations with the main brain and medullar centers remain a little enigmatic though much is known about tiny paths of afferent, efferent and inter neuronal transmission. In order to isolate the influence of central and intramural nervous system of the intestine, several situations were considered: 1) surgical interruption of nervous reflex links (NRI), which is always present in organ transplantation and often occurs in spinal cord trauma, 2) injury of the intramural nervous system with perfectly conserved links with central nervous system, for instance after intestinal ischemia and in Hirschprung disease. As control a technique of surgical directed re innervation (SDR) of the intestinal graft by suture of the divided mesenteric plexus was elaborated. A model of ontogenetic reconstruction of adult-like organs after syngeneic implantation into an adult organism of a fetal organ containing (intestine) or not (liver, pancreas) an organized intramural nervous system, was also used. The experiences on 101 dogs and 300 rats and 25 mice were conducted by the same team according to the rules of Bioethics. Performed investigations concerned testing nervous connection with central nervous system (Recto-enteric reflex presence, normal reaction to anticholinergic substance), evaluation of motility, secretion, membrane digestion of the intestine, as well as optic and electron microscopy of the target organs. The results may be summarized as following: Disconnection from the CNS does not significantly affect more than a few days (influence of operation trauma) the intrinsic functions and the morphology of the intestine but has an incidence on the own rhythm of the organ activity which becomes “autonomous” and stops to be integrated into the whole regulation of digestive tract function. It creates such disorders as accelerated nutrient transit, hyper secretion, body weight loss. The activity of the remaining linked with central nervous system stomach and colon is modified in such a way that final digestive process is adapted and correctly realized (central nervous coordinating intervention). Restoration of central nervous reflex control of the operated intestine leads to the normalization of its activity and of the whole digestive process. The destruction of intramural nervous system either by prolonged ischemia, or by congenital dysplasia affects both function and morphology of the intestine. The ontogenetic complete development of a grafted fetal organ is possible only when it presents an intramural nervous system (for instance, intestine). If intra organ neurons are not organized as plexus, the graft development is partial and not coordinated: only isolated weakly organized structures develop (for instance in the ectopically grown fetal liver - bile ducts, hepatocytes column, in pancreas - endocrine cells isolated or in clusters), without any links between each other. These findings may be interesting for the development of organ transplantation, when it may be useful to restore not only the vascular connections of the graft with the host, but also the nervous links of the transplant with the recipient central nervous system (brain and spinal medulla). This conception may be worthwhile in the treatment of such pathology as digestive difficulties in tetra and paraplegia patients on one side, of Hirschprung disease on the other side. It may also help to consider and understand the problems which may be either the consequences of central nervous system alterations for digestion or, on the contrary, the incidence of severe peripheral disorders for the brain activity.

Prospective identification and culture of rat enteric neural stem cells (ENSCs).

Hirschprung's disease (HD), a very common congenital abnormality in children, occurs mainly due to the congenital developmental defect of the enteric nervous system. The absence of enteric ganglia from the distal gut due to deletion in gut colonization by neural crest progenitor cells may lead to HD. The capacity to identify and isolate the enteric neuronal precursor cells from developing and mature tissues would enable the development of cell replacement therapies for HD. However, a mature method to culture these cells is a challenge. The present study aimed to propose a method to culture enteric neural stem cells (ENSCs) from the DsRed transgenic fetal rat gut. The culture medium used contained 15% chicken embryo extract, basic fibroblast growth factor, and epidermal growth factor. ENSCs were cultured from embryonic day 18 in DsRed transgenic rat. Under inverted microscope and fluorescence staining, ENSCs proliferated to form small cell clusters on the second day of culture. The neurospheres-like structure were suspended in the medium, and there were some filaments between the adherent cells from day 3 to day 6 of the culture. The neurospheres were formed by ENSCs on day 8 of the culture. Network-like connections were formed between the adherent cells and differentiated cells after adding 10% FBS. The differentiated cells were positive for neurofilament and glial fibrillary acidic protein antibodies. The present study established a method to isolate and culture ENSCs from E18 DsRed transgenic rats in the terminal stage of embryonic development. This study would offer a way to obtain plenty of cells for the future research on the transplantation of HD.

Experience of the MACE Procedure at A Regional Pediatric Surgical Unit: A 15-Year Retrospective Review

The Malone antegrade continence enema (MACE) procedure is an established treatment option for children with constipation or fecal incontinence. This study retrospectively analyses the management and outcomes of children who underwent MACE procedures at a regional pediatric surgery unit. Children who underwent a MACE procedure in our unit between 1998 and 2012 were identified. Demographic and clinical data were obtained from contemporaneous records. Using the continence scale described by Malone, overall outcomes were categorized as full, partial, or failure (full: totally clean or minor rectal leakage on night of washout; partial: clean but significant stoma or rectal leakage, occasional major leak and/or still wearing protection but perceived by child or parent to be an improvement; failure: regular soiling or constipation persisted, no perceived improvement, procedure was abandoned). Data entry and statistical analysis were performed using Excel and SPSS (IBM Corp., Armonk, New York, United States). A total of 40 children (29 male) were identified for inclusion. Underlying diagnoses were idiopathic constipation (16), anorectal anomalies (14) and Hirschprung's disease (10). The MACE procedure was performed laparoscopically in 26 cases and using an open technique in 14 cases. Mean age at the time of surgery was 8.9 years (range, 3-19 years) and mean follow-up time was 6.5 years (range, 1-10 years). Outcomes categorized as full were 62.5% for chronic idiopathic constipation (CIC), 71.4% for anorectal malformation (ARM), and 70% for Hirschsprung disease (HD). Overall success rates (full and partial outcomes combined) were 87.5% for CIC, 92.8% for ARM, 100% for HD, and 92.5% for all diagnoses taken together. Eleven MACE procedures (27.5%) were reversed, in seven (17.5%) due to the return of spontaneous and regular bowel movements and in four (10%) due to stomal problems. This study identified a high success rate (combining full and partial outcomes) of 92.5% for MACE procedures within our unit. An encouraging finding is that the procedure was reversed in a significant proportion of patients following the return of normal bowel habits.

Transanal endorectal pull-through for classic segment Hirschsprung's disease: With or without laparoscopic mobilization of the rectosigmoid?

BackgroundIt has been suggested that the outcome of transanal endorectal pull-through for classic Hirschprung's disease can be improved by laparoscopically mobilizing the colon before the pullthrough. MethodsCharts of 43 patients (2005–2009) with proven recto-sigmoid aganglionosis were retrospectively analyzed with respect to postoperative outcomes. Twenty-one had been treated with the transanal endorectal pull through (TERPT) and 22 with the laparoscopically assisted TERPT (LTERPT). ResultsGender ratio, congenital anomalies, preoperative enterostomy, and follow up did not differ between the groups. More colon was resected in the TERPT group: median 25cm vs. 15cm in the L-TERPT group (p<0.001). The TERPT-procedure took less time: median 153min. vs. L-TERPT 263min (p<0.001). Postoperatively, three patients showed colonic torsions after TERPT (p=0.07). The long-term clinical outcomes did not differ significantly between both groups. There was a significant association between length of resection and obstructive symptoms (OR=0.92, p=0.01). ConclusionPostoperative and clinical outcomes are similar using the TERPT or L-TERPT to correct classic segment Hirschsprung's disease. Prevention of colonic torsion should be the prime concern during the TERPT procedure. L-TERPT requires laparoscopic equipment and takes more operation time, whereas TERPT leaves no visible scars. The positive relation between the larger length of resection and obstructive symptoms requires additional research.

Intraoperative rapid diagnosis of Hirschsprung's disease

Objective To evaluate the superiorities and disadvantages of reduced nicotinamide adenine dinucleotide dehydrogenase (NADPH-d),acetylcholinesterase (AchE) enzyme histochemistry and hematoxylin and eosin (HE) staining in the intraoperative rapid diagnosis of Hirschprung' s disease (HD),increase the intraoperative diagnostic accuracy and decrease the risks of reoperation.Methods Eighteen children with HD underwent intraoperative full-thickness intestinal biopsies,including 11 boys,and 7 girls,with average age of (8.6 ± 3) months.Frozen sections at three levels (narrow segments,transitional region and dilated segments) were taken,and the extent of aganglionosis was examined by using NADPH-d staining,traditional rapid HE and AchE staining respectively.TUJ-1,a marker of enteric neural cells,was used for identification of NADPH-d positive myenteric plexus and ganglion cells by immunofluorescence staining.Results The positve rate of NADPH-d staining,HE staining and AchE staining for HD was 94.4％ (17/18),83.3％ (15/18),and 88.9％ (16/18),respectively (P ＞ 0.05).Time comsuming in NADPH-d,HE and AchE staining was (7.0 ± 1.7),(23.2 ± 2.9) and (30.9 ± 2.2) min,respectively(P ＜ 0.01).Conclusion The combination of NADPH-d and HE staining,with high idiosyncrasy and sensibility,simple and convenient,can be used as a routine intraoperative diagnosis method to identify HD and detect cutting range of colon.AchE staining was the best technique to demonstrate hypertrophic nerve trunks in the mucosa and submucosa and was well suited to suction rectal biopsy. Key words: Hirschprung's disease ; Intraoperative diagnosis; Pathology ; Colorectal surgery

Choices choices: regulation of precursor differentiation during enteric nervous system development

Background The enteric nervous system (ENS) is the largest subdivision of the peripheral nervous system and forms a complex circuit of neurons and glia that controls the function of the gastrointestinal (GI) tract. Within this circuit, there are multiple subtypes of neurons and glia. Appropriate differentiation of these various cell subtypes is vital for normal ENS and GI function. Studies of the pediatric disorder Hirschprung's Disease (HSCR) have provided a number of important insights into the mechanisms and molecules involved in ENS development; however, there are numerous other GI disorders that potentially may result from defects in development/differentiation of only a subset of ENS neurons or glia. Purpose Our understanding of the mechanisms and molecules involved in enteric nervous system differentiation is far from complete. Critically, it remains unclear at what point the fates of enteric neural crest cells (ENCCs) become committed to a specific subtype cell fate and how these cell fate choices are made. We will review our current understanding of ENS differentiation and highlight key questions that need to be addressed to gain a more complete understanding of this biological process.

Zespół Haddada

Haddad syndrome is a rare genetically conditioned disease. We present a female newborn with congenital central hypoventilation syndrome associated with Hirschprung's disease. The infant is mechanically ventilated and parentally fed in a home setting. The diagnosis has been confirmed by the presence of 20/26 PHOX2B genetic mutation.

Congenital chloride diarrhea presenting in newborn as a rare cause of meconium ileus

Postpartum abdominal distention and meconium ileus may occur due to intestinal obstruction, Hirschprung disease or cystic fibrosis. However, other rare and challenging etiologies such as congenital chloride diarrhea (CCD) should be included in differential diagnosis of such presentation. We present a premature baby girl who had distended abdomen and lack of meconium immediately after birth. Surgical etiology was excluded and she was mistakenly suspected of having cystic fibrosis due to meconium ileus. CCD was diagnosed by recognition of watery diarrhea in association with hyponatremic, hypochloremic metabolic acidosis. Mutation analysis confirmed the diagnosis.

Microbiome Analysis and Bacterial Enteroinvasion in a Murine Model of Hirschprung's Disease

Microbiome Analysis and Bacterial Enteroinvasion in a Murine Model of Hirschprung's Disease

Heparin-binding epidermal growth factor–like growth factor promotes murine enteric nervous system development and enteric neural crest cell migration

Background/PurposeDevelopmental defects of the enteric nervous system lead to a variety of disorders including Hirschprung disease. We have previously shown that heparin-binding epidermal growth factor–like growth factor (HB-EGF) exerts neuroprotective effects on injured neurons. The goals of this study were to assess the role of HB-EGF in enteric nervous system development and to evaluate the effect of HB-EGF on enteric neural crest–derived cell (ENCC) migration in the developing gastrointestinal tract of mice. Materials and MethodsHB-EGF immunohistochemistry was used to examine HB-EGF protein expression in the hindgut of embryonic mice. Gut specimens were stained for PGP9.5 (a neuronal cell marker) to examine the extent of ENCC migration in the intestine at different embryonic stages in HB-EGF knockout (KO) and wild-type (WT) mice. Embryonic gut organ cultures were established to examine the effect of HB-EGF on ENCC migration. ResultsThe expression of HB-EGF was limited to the endodermal epithelium of the hindgut in early gestation, but rapidly involved the hindgut mesenchyme after ENCC migrated into this region. ENCC migration was significantly delayed in HB-EGF KO compared with WT embryos, leading to defects in neural colonization of the distal gut in postnatal HB-EGF KO mice. Addition of HB-EGF to WT embryonic intestine significantly promoted ENCC migration, as demonstrated by a significant increase in the ratio of ENCC migration distance toward the distal hindgut/total colon length (78% ± 4% vs 53% ± 2%, P = .001). ConclusionsDeletion of the HB-EGF gene leads to enteric nervous system developmental defects. HB-EGF stimulates ENCC migration in the gut, supporting a potential role for administration of HB-EGF in the future for the treatment of patients with intestinal neuronal disorders.

Total Colonic Aganglionosis—A Diagnostic Intricacy

Total colonic aganglionosis (TCA) is an unusual variety of aganglionosis. Although appearing to be an extension of Hirschprung's disease (HD), it may differ from it in many ways and thus is difficult to diagnose on the basis of features applied for HD. The aim of this case report is to discuss the difficulties encountered in recognition of TCA and identification of features which can help in early diagnosis.

Primary laparoscopic pull-through procedure for Hirschprung disease at a low resource setting: Experience and early results

The Journal is the primary organ of Continuing Paediatric Medical Education in Sri Lanka. The journal also has a website. Free full text access is available for all readers.The Sri Lanka Journal of Child Health is now indexed in SciVerse Scopus (Source Record ID 19900193609), Index Medicus for South-East Asia Region (IMSEAR), CABI (Centre for Agriculture and Bioscience International Global Health Database), DOAJ and is available in Google, as well as Google Scholar.The policies of the journal are modelled on the Committee on Publication Ethics (COPE) Guidelines on Principles of Transparency and Best Practice in Scholarly Publishing. Sri Lanka Journal of Child Health is recognised by the International Committee of Medical Journal Editors (ICMJE) as a publication following the ICMJE Recommendations.

Undiagnosed distal hirschprung’s disease in a 19-year-old female: autopsy findings

A 19-year-old female had a lifetime history of alternating diarrhoea and constipation. After developing acute lower abdominal pain for several days, she was taken to hospital but died soon after admission. A coronial autopsy showed massive distension and infarction of the descending colon and rectum, which were loaded with faeces. Microscopic features of the distal colon were indicative of Hirschprung's disease. A diagnosis of Hirschprung's disease is usually made in early infancy, however this can be delayed for many reasons. In this unusual case, no medical investigation of this debilitating condition was ever performed, despite its near 20 year course.

Small bowel skip segment Hirschprung’s disease presenting with perforated Meckel’s diverticulum

Skip segment Hirschprung's disease (SSHD) is an uncommon variant of Hirschprung's disease where normal intestine is interspersed proximally and distally by abnormal, aganglionated intestine. These segmental changes have no well-defined embryological explanation. We present a case of SSHD in the small bowel and concomitant perforated Meckel's diverticulum, with review of the literature relevant to SSHD.

Duodenal Duplication in a Patient with Downʼs Syndrome

Purpose: A 23-year-old man with Down's Syndrome presented with a 1 day history of nausea, vomiting, diarrhea, and abdominal pain. He had a significant history of gastrointestinal problems, including recurrent pancreatitis with stones, long segment Hirschprung's disease with surgical resection, gastrointestinal malrotation, and duodenal stenosis with surgical revision. EGD and upper GI series with contrast demonstrated the existence of two duodenal lumens, one of which was non-communicating. Although rare, gastrointestinal duplications are observed in 1 of every 4,500 autopsies. Gastrointestinal duplications in patients with Down's Syndrome are even more uncommon. To date, only one case report has described gastrointestinal duplication in a patient with Down's Syndrome. This case report describes the second one.

Ramos‐Arroyo syndrome: Confirmation of an entity

In 1987, Ramos-Arroyo et al. described a family with a previously unreported combination of features, which included corneal anesthesia, short stature, sensorineural deafness, learning difficulties, and a characteristic facial appearance. The family was reviewed in 2008 and additional features were noted. The name Ramos-Arroyo syndrome was proposed. The condition can be delineated by corneal anesthesia, absence of the peripapillary choriocapillaris and retinal pigment epithelium, bilateral sensorineural hearing loss, unusual facial appearance, persistent ductus arteriosus, Hirschprung disease, short stature, and intellectual disability. No other patient has been described since. Here, we report on a 5-year-old girl with features consistent with Ramos-Arroyo syndrome. We propose an overlap of this condition with dysautonomia syndromes.

Hirschprung's disease in adults

A 19-year-old man came to the emergency room because of diarrhea of 4 weeks duration, accompanied by constipa-tion. As background, he reported fecal incontinence with encopresis since he was 12 year-old, initially ascribed to a childpsychiatric disorder. Physical examination revealed an important thinness (BMI 18,51 kg/m