Ultrashort Hirschsprung's Disease Research Articles

Postoperative Hirschsprung’s associated enterocolitis (HAEC): transition zone as putative histopathological predictive factor

AimsHirschsprung’s-associated enterocolitis (HAEC) is the most severe complication of Hirschsprung disease (HD), and its pathogenesis is still unknown. Length of transition zone (TZ) interposed between aganglionic and normal bowel has...

A Practical Guide for the Diagnosis of Primary Enteric Nervous System Disorders

Primary gastrointestinal neuropathies are a heterogeneous group of enteric nervous system (ENS) disorders that continue to cause difficulties in diagnosis and histological interpretation. Recently, an international working group published guidelines for histological techniques and reporting, along with a classification of gastrointestinal neuromuscular pathology. The aim of this article was to review and summarize the key issues for pediatric gastroenterologists on the diagnostic workup of congenital ENS disorders. In addition, we provide further commentary on the continuing controversies in the field. Although the diagnostic criteria for Hirschsprung disease are well established, those for other forms of dysganglionosis remain ill-defined. Appropriate tissue sampling, handling, and expert interpretation are crucial to maximize diagnostic accuracy and reduce interobserver variability. The absence of validated age-related normal values for neuronal density, along with the lack of correlation between clinical and histological findings, result in significant diagnostic uncertainties while diagnosing quantitative aberrations such as hypoganglionosis or ultrashort Hirschsprung disease. Intestinal neuronal dysplasia remains a histological description of unclear significance. The evaluation of cellular quantitative or qualitative abnormalities of the ENS for clinical diagnosis remains complex. Such analysis should be carried out in laboratories that have the necessary expertise and access to their own validated reference values.

Autosomal-dominant non-syndromic anal atresia: sequencing of candidate genes, array-based molecular karyotyping, and review of the literature

Anorectal malformations (ARM) range from mild anal to severe anorectal anomalies. Approximately 50% are estimated to be non-syndromic with multiple familial cases reported that suggest underlying genetic factors. These, however, still await identification. We report a familial case of non-syndromic ARM with a mother and her two children being affected. Mother and daughter had mild ARM that had only been diagnosed after the index patient was born with a more severe form and ultrashort Hirschsprung's disease. To reveal the genetic cause in our family genome-wide array analysis was carried out to ascertain microaberrations characterized by loss or gain of genomic material. In addition, sequence analysis of four major Hirschsprung's disease genes (RET, EDNRB, EDN3, and GDNF) and the HLXB9 gene was performed to identify a mutation common to all three family members; however, these analyses did not reveal any causal genetic alteration. To demonstrate the frequency of familial non-syndromic cases, we performed a literature search revealing 59 families with at least two affected members. Sufficient description of ARM phenotype and affection status of relatives to surely classify them as familial non-syndromic forms was given for 22 families. The present family suggests that mild ARM may be overlooked in patients with non-specific clinical symptoms and that the incidence of ARM may thus be higher than previously estimated. With the new possibilities of whole exome sequencing, even small families hold the possibility to identify causal defects.

Enzymhistochemie des klassischen und des ultrakurzen Morbus Hirschsprung

Hirschsprung's disease is the most important type of gastrointestinal dysmotility in neonatal pathology. Aberrant craniocaudal migration of neural crest stem cells results in an intestinal aganglionic segment of variable length. In 'classical' Hirschsprung's disease (60-75% of cases), the aganglionic segment spans the rectum and sigma. Ultrashort Hirschsprung's disease (5-10%) is restricted to the most distal 3-4 cm or immediate rectoanal transition only. In the normal enteric nervous system, myenteric ganglia modulate the parasympathetic innervation of the sacral roots S2-S4. The absence of myenteric ganglia in Hirschsprung's disease results in massively increased parasympathetic activity with abundant acetylcholine release and pseudo-obstruction in the aganglionic segment. This can be demonstrated in an enzyme histochemical reaction for acetylcholinesterase on frozen sections, which is sufficient to diagnose the classical disease in rectal mucosal biopsies. In ultrashort Hirschsprung's disease, increased acetylcholinesterase activity is demonstrable only in nerve fibres of the muscularis mucosae and submucosa, but not the lamina propria mucosae. Submucosal and myenteric ganglia are physiologically scarce in the most distal rectum; absence of ganglia in a biopsy of the rectoanal transition must not be (wrongly) interpreted as ultrashort Hirschsprung's disease. Therefore, a diagnosis of ultrashort Hirschsprung's disease can be made exclusively using an enzyme histochemical reaction for acetylcholinesterase.

Konventionelle histologische Diagnostik in der Koloproktologie

With the introduction of immunohistochemical methods, histopathological diagnosis based on formalin fixed, paraffin embedded tissue in coloproctology has substantially improved. In recent years, the routine use of immunohistochemistry for S100, cathepsin D and a picrosirius red staining has proven to be sufficient for the diagnosis of hypoganglionosis of the myenteric plexus and desmosis of the muscularis propria. In some cases, an immunohistochemical reaction for CD 117 is also necessary for the evaluation of Cajal cells. In contrast, in ultrashort Hirschsprung's disease, aganglionosis of the anal ring, aganglionosis of the musculus corrugator cutis ani, and internal sphincter, the histochemical acetylcholinesterase reaction is essential and not replaceable by any immunohistochemical method.Immunohistochemistry, classical histological stains and enzyme histochemistry are complementary histopathological techniques. In contrast to immunohistochemistry, enzyme histochemistry requires native cryostat sections for the assessment of enzyme activity. As a consequence, biopsy performance and transport to pathology departments should be particularly well organized.

Gastrointestinal phenotype of ATR‐X syndrome

X-linked alpha thalassemia mental retardation (ATR-X) syndrome is associated with profound developmental delay, facial dysmorphism, genital abnormalities, and alpha thalassemia. Patients with ATR-X syndrome frequently present with gastrointestinal problems, in particular feeding difficulties, regurgitation and vomiting, abdominal pain, distension, and chronic constipation. Parental reports of prolonged food refusal and distress in these children are common and although these episodes are suspected to be gastro-intestinal in origin they are rarely investigated. Death in early childhood from aspiration of vomitus or from pneumonia presumed to be secondary to aspiration has been recorded in a number of ATR-X cases. In this report we review the gastrointestinal phenotype of ATR-X syndrome in 128 cases. We also demonstrate that in two siblings, regurgitation was secondary to gastric pseudo-volvulus, a condition in which the stomach does not have a normal system of peritoneal ligaments and changes position with possible torsion around itself. Furthermore, ultra-short Hirschsprung disease with colonic hypoganglionosis was shown and this may contribute to the severe constipation affecting these children.

Surgery and Constipation: When, How, Yes, or No?

Surgery and Constipation: When, How, Yes, or No?

Diagnosis and therapy of ultrashort Hischsprung's disease: Meier-Ruge WA, Bruder E, Holschneider, et al. Eur J Pediatr Surg 2004 (December);14:392-397

Although ultrashort Hirschsprung's disease (UHD) was enzyme-histochemically characterised about 35 years ago, its existence is still often ignored. The aim of this study was to summarize diagnostic criteria, incidence, gender ratio, morphology and therapy over 15 years. Reliable diagnosis of suspected UHD requires contrast enema to exclude HD. In UHD, no reflux of contrast medium is observed during pressing or crying. Final proof of UHD is enzyme-histochemical biopsy examination of distal rectal mucosa. The biopsies must be taken from the dentate line and 1, 2, 4 and 6 cm above the dentate line and then subjected to an enzyme-histochemical acetylcholinesterase (AChE) reaction of native sections of rectal mucosa. UHD develops with first symptoms of therapy resistant chronic constipation during the second half of the first year of life. In contrast, constipation occurs in the first weeks of life or after weaning in HD. Also in contrast to HD, no nerve fibers with increased AChE activity are observed in the lamina propria mucosae in UHD. Nets of nerve fibers with increased AChE activity can be found only in the muscularis mucosae and the musculus corrugator cutis ani (MCCA). Therapy of choice has proven to be partial myectomy of the distal internal sphincter if dilatation of the internal sphincter is ineffective. UHD is either limited to the anal ring, or extends only 3-4 cm into the distal rectum. UHD had an incidence of 13.4% of all aganglionoses in the series presented. Gender ratio boys to girls was 2:1.

Diagnosis and Therapy of Ultrashort Hirschsprung's Disease

Although ultrashort Hirschsprung's disease (UHD) was enzyme-histochemically characterised about 35 years ago, its existence is still often ignored. The aim of this study is to summarise the clinical diagnostic, incidence, gender ratio, morphological characteristics, and therapy over 15 years. The reliable diagnosis of suspected UHD requires a minimal enema of contrast medium to exclude Hirschsprung's disease (HD). In UHD during pressing or crying no reflux of contrast medium is observed. Final proof of UHD is an enzyme-histochemical biopsy examination of distal rectal mucosa. The biopsies must demonstrate submucosa and be taken from the dentate line and 1 cm, 2 cm, 4 cm and 6 cm above the dentate line. The cryostat sections must be cut 15 microm thick; this thickness is reduced to 4.5 microm by the thawing, spreading and drying of the sections on microscope slides. A reliable diagnosis of UHD needs an enzyme-histochemical acetylcholinesterase reaction of native sections of rectal mucosa. UHD develops with first symptoms of chronic constipation in the second half of the first year of life. The chronic constipation proves to be therapy resistant. In HD constipation occurs in the first weeks of life or after weaning. In contrast to HD, no nerve fibres with increased AChE activity are observed in the lamina propria mucosa. Nets of nerve fibres with increased AChE activity can be found only in the muscularis mucosa and the musculus corrugator cutis ani (MCCA). The therapy of choice has proven to be a partial myectomy of the distal internal sphincter if dilatation of the internal sphincter was ineffective. UHD is either limited to the anal ring, or extends 3 - 4 cm into the distal rectum. Over the past 15 years, UHD had in our series an incidence of 13.4 % of all aganglionoses. The gender ratio of girls to boys was 1 : 2. UHD is reliably diagnosed by an AChE reaction in native biopsy sections from the anocutaneous transitional zone and, potentially, from 3 - 4 cm above the pectinate line. As UHD is always accompanied by aganglionosis of the distal internal sphincter, an increase in AChE activity is observed in the nerve fibres of the MCCA. The therapy of choice is a partial myectomy of the distal internal sphincter.

Granular-cell tumorlike Schwann cell degeneration in the anal sphincter of an infant suspected of having ultrashort Hirschsprung's disease

A 19-month-old girl who had a history of constipation since birth and suspected cytomegalovirus (CMV) infection was admitted. Barium enema revealed no caliber change in the colon, anorectal manometry failed to show sphincter relaxation on rectal distension, and biopsied rectal specimens contained ganglion cells. She underwent rectal myectomy, after which her symptoms improved significantly. Morphologic studies, including electron micrographs of the muscle, demonstrated nerve plexuses with degenerative Schwann cells containing abundant eosinphilic cytoplasmic granules that resembled those of a granular-cell tumor. Granular-cell tumorlike change of the plexus is an unprecedented finding in any form of Hirschsprung's disease or its allied disorders, but appears to have been responsible for her symptoms. CMV as a causative agent is also discussed with a review of the literature.

Ultrashort Hirschsprung's disease: Myth or reality

The term ultrashort Hirschsprung's disease has been used to define a spectrum of conditions with clinical presentation similar to Hirschsprung's disease but with presence of ganglion cells on rectal biopsy. Incontrast to Hirschsprung's disease, there is no transition zone on barium enema. However, as in classical Hirschsprung's disease, there is no reflex internal sphincter relaxation on rectal manometry. We reviewed the presentation of five patients with chronic constipation who fulfilled the criteria for ultrashort Hirschsprung's disease. After positive anorectal manometry, despite the presence of ganglion cells on suction rectal biopsy, internal sphincter myomectomy was performed in four patients. Resolution of symptoms was noted in all operated patients. Normal ganglion cells were present throughout the entire length of all myomectomy specimens. There is controversy in the literature concerning the diagnosis of ultrashort Hirschsprung's disease. Most of the confusion concerns whether a short segment of aganglionosis proximal to the dentate line is permissible for the diagnosis of ultrashort Hirschsprung's disease and to what extent such aganglionosis is physiological. Perhaps it would be more accurate to define this entity by the presence of ganglion cells on rectal biopsy as well as the failure of the internal sphincter to relax on rectal manometry and to describe it as anorectal achalasia in severely constipated patients.

Ultrashort segment Hirschsprung disease. An objective picture of the disease substantiated by biopsy

The enzyme histotopochemical characteristics of 18 cases with ultrashort Hirschsprung's disease - investigated during the past 20 years - are analysed. The aganglionic segment, having an extension of 1-3 cm, is characterised by an increase of acetylcholinesterase activity in parasympathetic nerve fibres of the muscularis mucosae. A similar increase of acetylcholinesterase in the nerve fibres of the lamina propria mucosae - as characteristic in Hirschsprung's disease - is usually absent. Strip biopsies which include mucosa of the linea dentata and the distal rectum often show the transition from the aganglionic to the innervated mucosa. To avoid a faulty diagnosis by overlooking an ultrashort Hirschsprung's disease, it is recommended to take the first biopsy from the linea dentata, and biopsies 1 cm, 2 cm and 4 cm above this level, or to conduct a strip biopsy of 1-2 cm length taken from this area. 2/3 of the cases investigated were diagnosed during the first year of life. In 1/3 of the cases the diagnosis was made in patients who were 4 to 21 years of age. The average incidence of the ultrashort Hirschsprung's disease is 10% in relation to all aganglionoses studied. In recent years, however, diagnosis of this particular rectum disease was made more often (14%) due to a better knowledge of the disease (6.8% of all investigated inborn innervation failures of the colon). Ultrashort Hirschsprung is a rare disease, although it is observed more often than total aganglionosis of the colon (Zuelzer-Wilson syndrome). The sex ratio, being 5 male male: 1 female, is within the range of Hirschsprung's disease. Hence, enzyme histotopochemical means enable substantiation of ultrashort Hirschsprung's disease as a special form of an aganglionosis of the distal rectum.