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Experience of acetylcholinesterase histochemistry application in the
diagnosis of chronic constipation in children.Medicina
(Kaunas). 2007;43(5):376-84.
The aim of this
study was to review our experience in applying acetylcholinesterase
histochemistry for diagnosing colonic dysganglionoses in children.
PATIENTS AND METHODS: We analyzed acetylcholinesterase histochemistry
results of rectal biopsy specimens obtained from 85 children. The
indications for biopsy were suspicion of Hirschsprung's disease in
neonates and infants (Group 1; n=21) and older children (Group 2;
n=17); megarectum (Group 3; n=44); and colostomy (Group 4; n=3).
Specimens were taken at 5 and 10 cm using endoscopic forceps or
excised with scissors at 2.5 cm above the dentate line.
Acetylcholinesterase activity was evaluated using Karnovsky-Roots
method. RESULTS: The diagnosis of Hirschsprung's disease was confirmed
in 17 children of the first group and in 3 of the second group. In the
third group, 2 children were diagnosed with ultrashort-segment
Hirschsprung's disease and 3 children with intestinal neuronal
dysplasia. In one case, acetylcholinesterase reaction was false
positive. Hirschsprung's disease was diagnosed in 2 children with
colostomies; in one case acetylcholinesterase activity caused
false-positive results. Colonic dysganglionoses were diagnosed in 78%
of infants and in 14% of children over 1 year of age. The diagnostic
specificity of acetylcholinesterase in Hirschsprung's disease was 92%.
CONCLUSIONS: 1) The analysis of acetylcholinesterase activity in
children's rectal biopsy specimens is a reliable method for diagnosing
Hirschsprung's disease, especially in infants; 2) This method of
examination is irreplaceable in diagnosing ultrashort-segment
Hirschsprung's disease and remains the only method to confirm the
diagnosis of this disease; 3) Acetylcholinesterase histochemistry is
not sufficiently informative in diagnosing intestinal neuronal
dysplasia type B, because authors applying other neurohistochemical
investigation methods have reported higher incidence of this disease.
Duhamel
operation vs neonatal transanal endorectal pull-through procedure for
Hirschsprung disease: which are the changes for pathologists?
J
Pediatr Surg. 2007 Apr;42(4):688-91.
BACKGROUND:
The aim of this study was to evaluate whether performing definitive
surgery for Hirschsprung disease (HD) in neonatal period with a
transanal endorectal pull-through (TEPT) procedure had modified our
diagnostic relevance, particularly during intraoperative frozen
sections (IOFS), compared to classic Duhamel (DH) surgery performed in
older children. METHODS: We collected pathologic data for 47 children
who underwent surgery for neonatal nontotal HD over a 5-year period.
RESULTS: Twenty-nine patients underwent TEPT and 18 the DH operation.
Mean age at operation was 19 days for TEPT and 4 months for DH
operation. The mean number of IOFS was 2.6 for TEPT and 2.4 for DH
operation. Gross examination could be fully completed in all TEPT
cases, but was incomplete in 5 DH cases. The average total lengths of
bowel, and aganglionic, transitional, and ganglionic segments were
12.3, 7.3, 3, and 2 cm for TEPT, and 17.6, 9.3, 3.5, and 4.8 cm for DH
operation, respectively. Discordance between IOFS and paraffin-section
analysis occurred in 5 cases (3 TEPT and 2 DH operation). CONCLUSION:
When TEPT was used, the gross examination and sampling was more
accurate, leading to a clearer pathology report. The TEPT procedure
facilitates the work of the pathologist without modifying the results
of IOFS, if some precautions are taken.
Enzyme
histochemistry of classical and ultrashort Hirschsprung's disease.
Pathologe.
2007 Mar;28(2):105-112.
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.
Conventional histological diagnostics in coloproctology.
Pathologe.
2007 Mar;28(2):101-104.
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.
At what
age is a suction rectal biopsy less likely to provide adequate tissue
for identification of ganglion cells?J
Pediatr Gastroenterol Nutr. 2007
Feb;44(2):198-202.
OBJECTIVE: The
objective of this study was to determine at what age suction rectal
biopsy is less likely to provide adequate tissue to detect submucosal
ganglion cells in a child being evaluated for Hirschsprung disease.
PATIENTS AND METHODS: Children > or =1 year of age undergoing a rectal
biopsy at a single children's hospital had 1 biopsy each obtained
simultaneously with a suction biopsy device and a grasp biopsy
forceps. The biopsies were examined by 2 pathologists for adequacy of
the submucosa (none, scant, adequate, or ample) and the presence of
ganglion cells. The 2 specimens were compared with each other.
RESULTS: One hundred fifty-two children 1 to 17 years of age were
included. Fifty-three were female. Subjects were grouped into 4 age
categories: 1 to 3 years (group A), 4 to 6 years (group B), 7 to 9
years (group C), and > or =10 years (group D). Similar numbers of
patients were recruited for each group. Ganglion cells were identified
in 73% and 90% by the suction and grasp devices, respectively, in
group A. In groups B through D, ganglion cells were identified in 50%
to 53% vs 92% to 97% of the suction and grasp biopsies, respectively
(P < 0.001). Submucosa was present in 88% (suction) vs 98% (grasp) in
group A, 70% vs 95% in group B, 69% vs 94% in group C, and 45% vs 92%
in group D. CONCLUSION: The suction rectal biopsy is less likely to
provide adequate submucosa for identification of ganglion cells after
3 years of age.
Evolution of
the technique in the transanal pull-through for Hirschsprung's
disease: effect on outcome.J
Pediatr Surg. 2007 Jan;42(1):36-9.
BACKGROUND:
The transanal pull-through has become the standard operation for
Hirschsprung's disease in many pediatric surgical centers. Over the
past 8 years, we have modified our technique by leaving a short-rather
than a long-rectal cuff and by doing routine intraabdominal colonic
biopsies through an umbilical incision before beginning the anal
dissection. The aim of this study was to determine if these
modifications have changed the outcome for children undergoing this
operation. METHODS: A retrospective cohort study of all patients who
underwent transanal pull-through by a single surgeon between 1997 and
2005 was conducted. RESULTS: There were 23 children who had a long
cuff (10-15 cm) and 22 who had a short cuff (<2 cm). The short cuff
group tended to be younger (25 +/- 23 vs 139 +/- 67 days; P < .05) and
smaller (3.5 +/- 0.7 vs 6.0 +/- 2.7 kg; P < .05) at the time of
surgery. The operating time was shorter (167 vs 186 minutes; P = .05)
in the short cuff group. Outcomes were improved in the short cuff
group, as evidenced by decreased hospital stay (1.9 +/- 0.6 vs 2.7 +/-
0.9; P < .05), decreased incidence of enterocolitis (9% vs 30%; P =
.1), and lower incidence of narrowing requiring daily dilatations (5%
vs 30%; P < .05). Preliminary colonic biopsy was performed on 18 of
the 45 patients. This had no significant effect on narcotic use (66%
vs 70%; P = .8) and did not increase operating time (174 +/- 31 vs 179
+/- 34 minutes; P = .6). Hospital stay was shorter in the umbilical
biopsy group (1.9 +/- 0.6 vs 2.6 +/- 0.9 days; P = .006). CONCLUSION:
Results of the transanal pull-through have improved likely as a result
of a combination of experience and use of a shorter rectal muscular
cuff. The use of a preliminary colonic biopsy through an umbilical
incision has not increased postoperative pain, prolonged operative
time, or lengthened hospital stay.
A new rapid
acetylcholinesterase staining kit for diagnosing Hirschsprung's
disease.Pediatr
Surg Int. 2007 May;23(5):505-8.
Conventional
acetylcholinesterase (AChE) histochemistry is both time consuming and
complicated and requires the mixing of reagents that are toxic to the
human body. We developed a rapid technique for performing AChE
histochemistry, which has already been published, and now present a
kit for performing AChE histochemistry that is a further improvement.
Rectal suction biopsy specimens taken from 20 constipated patients and
three full thickness biopsy specimens taken from 4 Hirschsprung's
disease (HD) patients during pull-through surgery from aganglionic,
transitional, and ganglionic bowel segments were tested using our
rapid technique and the new kit. Each specimen was incubated for only
6 min. All ganglion cells stained clearly for AchE in just 6 min using
both techniques. However, the kit was able to stain AchE positive
nerve fibers more clearly and did not detect endogenous peroxidase-containing
histiocytes, as did the earlier rapid technique. The kit could also
detect AchE positive nerve fibers in the circular and longitudinal
muscle layers, unlike the earlier rapid technique. The kit allows AChE
histochemistry to be performed rapidly with complete accuracy, without
any risk for toxicity. Moreover, the kit provides more focused
information on AchE distribution in the bowel itself without any
extraneous staining and can be used for diagnosing HD and allied
disorders as well as establishing the exact level of innervation for
pull-through resection.
Hirschsprung's
disease in a young adult: report of a case and review of the
literature.
Ann Diagn
Pathol. 2006 Dec;10(6):347-51.
Hirschsprung's disease (HD) in adults is rare and often undiagnosed or
misdiagnosed. We report a case of HD in a 26-year-old woman who had a
history of chronic constipation that required laxatives and enemas
since early childhood. She developed severe intestinal obstruction and
presented to the emergency department with significant abdominal
distension. A computed tomographic scan confirmed significant fecal
loading of the entire colon and rectum. An anal manometry revealed
lack of normal rectoanal inhibitory reflex. A rectal biopsy showed
hypoganglionic anorectum, suspicious for HD. Because of the severe
fecal retention that was refractory to conservative management, total
proctocolectomy with ileal pouch-anal anastomosis was performed. The
entire colon showed massive dilatation and marked wall thickening.
Histologic examination showed absence of ganglion cells in submucosal
(Meissner's) and myenteric (Auerbach's) plexuses in the distal rectum.
A diagnosis of adult HD was made. Her postoperative course was
uneventful with complete resolution of the symptoms. Hirschsprung's
disease should be considered in adults who have long-standing and
refractory constipation.
Hirschsprung's
disease: diagnosis and management.Am
Fam Physician. 2006 Oct 15;74(8):1319-22.
Hirschsprung's
disease (congenital megacolon) is caused by the failed migration of
colonic ganglion cells during gestation. Varying lengths of the distal
colon are unable to relax, causing functional colonic obstruction.
Hirschsprung's disease most commonly involves the rectosigmoid region
of the colon but can affect the entire colon and, rarely, the small
intestine. The disease usually presents in infancy, although some
patients present with persistent, severe constipation later in life.
Symptoms in infants include difficult bowel movements, poor feeding,
poor weight gain, and progressive abdominal distention. Early
diagnosis is important to prevent complications (e.g., enterocolitis,
colonic rupture). A rectal suction biopsy can detect hypertrophic
nerve trunks and the absence of ganglion cells in the colonic
submucosa, confirming the diagnosis. Up to one third of patients
develop Hirschsprung's-associated enterocolitis, a significant cause
of mortality. Patients should be monitored closely for enterocolitis
for years after surgical treatment of Hirschsprung's disease. With
proper treatment, most patients will not have long-term adverse
effects and can live normally.
Clinicopathological features in 102 cases of Hirschsprung disease.Ann
Saudi Med. 2006 May-Jun;26(3):200-4.
BACKGROUND:
Hirschsprung disease [HD] is a predominantly childhood disorder of
intestinal motility with a multifactorial and polygenic etiology. The
objective of this study was to document the clinical and pathological
features of HD in Kuwait, which has an estimated consanguinity rate of
54%. METHODS: We analyzed all rectal and colonic biopsies (n=268) for
suspected HD identified from the records in the Pathology Department
of Al-Sabah Hospital for the period between 1994 and 2004. RESULTS:
One hundred and two patients (87 males and 15 females) had
histologically confirmed HD. Fifty-eight (57%) were neonates (<1 month
of age), while 21% were more than 4 months old. The diagnosis was
based on open biopsy in 11 cases and rectal biopsies in 91 cases. Nine
patients with open biopsies presented as intestinal obstruction,
necrotizing enterocolitis, or perforation. The extent of the disease
was unknown in 13 patients. There were 67 males and 3 females with
short segment HD. Nine had long segment, two ultra-short segment and
eight total colonic aganglionosis (TCA). Five TCA cases involved the
small intestine. A skip area was observed in two cases. Six patients
had other anomalies. A positive family history for HD was established
in three patients. Two of these were male siblings from a
consanguineous marriage and had Waardenburg syndrome. CONCLUSION: This
study has highlighted an exceptionally strong male predominance of
short segment and a relatively high frequency (5.6%) of small
intestinal involvement in HD in Kuwait. These data call for a more
detailed epidemiological study with special emphasis on genetics.
Rectal biopsy: what is the
optimal procedure?Pediatr
Surg Int. 2002 Dec;18(8):753-6.
Rectal suction
biopsy (RSB) is a well-known diagnostic procedure for disorders of
bowel motility such as Hirschsprung's disease (HD). However, there are
few reports about the optimal method of obtaining rectal tissue. We
introduce a new technique using Gruenwald's nasal cutting forceps (NCF).
From 1986 to 1999, we performed 130 sets of rectal biopsies in
patients suspected of having HD. In group I (1986 to 1994), 68 sets of
three-site biopsies (2, 3, and 5 cm above the dentate line) were
performed using a conventional blind RSB technique. In group II (1995
to 1999), 62 sets of one-site biopsies (2 cm above the dentate line)
were performed using Gruenwald's NCF after anal dilatation during
general anesthesia. Hematoxylin-eosin staining and
acetylcholinesterase histochemistry were used to examine all
specimens. Biopsy specimens in group II (4.39 +/- 1.07 mm(2)) were
larger than in group I (1.59 +/- 0.39 mm(2)) ( P < 0.01). In 18 cases
(26 %) in group I, normal and HD bowel could not be differentiated
because the specimens were too small to detect ganglion cells (i.e.,
only lamina propria [9 cases] or a small area of submucosa [9 cases]
was present). These cases required repeat biopsy. All cases of HD
diagnosed in group I (n = 20) were based on the findings of biopsies
taken at 2 cm; biopsies from 3 and 5 cm did not provide additional
information. There were 2 cases of post-biopsy hemorrhage in group I.
In group II, 18 subjects were diagnosed with HD and 39 were confirmed
to have normal bowel. There were no complications and repeating the
biopsy was unnecessary. Three cases of hypoganglionosis (1 in group I
and 2 in group II) were missed because the myenteric plexus
abnormalities could not be detected by RSB. Intestinal neuronal
dysplasia (IND) was diagnosed in 5 cases (2 in group I by repeat
full-thickness biopsy and 3 in group II by rectal biopsy). We conclude
that our new technique is advantageous and safe to differentiate
between normal bowel, HD, and even IND on the basis of a single biopsy
taken 2 cm above the dentate line. The biopsy can be taken under
direct vision and is histopathologically accurate.
Altered
distribution of interstitial cells of Cajal in Hirschsprung disease.
Arch Pathol Lab Med. 2002
Aug;126(8):928-33.
CONTEXT:
Constipation or recurrent intestinal dysmotility problems are common
after definitive surgical treatment in Hirschsprung disease (HD).
c-Kit-positive interstitial cells of Cajal (ICCs) play a key role in
the motility function and development of the gastrointestinal tract.
Interstitial cells of Cajal that carry the tyrosine kinase receptor
(c-Kit) develop as either myenteric ICCs or muscular ICCs under the
influence of the kit ligand, which can be provided by neuronal and
nonneuronal cells, for example, smooth muscle cells. OBJECTIVE: To
investigate the distribution of myenteric and muscular ICCs in
different parts of the colon in HD. METHODS: Resected bowel specimens
from 8 patients with rectosigmoid HD were investigated using combined
staining with c-Kit enzyme and fluorescence immunohistochemistry and
acetylcholinesterase and nicotinamide adenine dinucleotide phosphate (NADPH)
histochemistry in whole-mount preparations and conventional frozen
sections. RESULTS: In the normal bowel, ICCs formed a dense network
surrounding the myenteric plexus and at the innermost part of the
circular muscle. Myenteric ICCs were absent or sparse in the
aganglionic bowel and sparse in the transitional zone. The expression
of myenteric ICCs in the ganglionic bowel in HD was reduced compared
to that in the normal bowel, and they formed only sparse networks.
Muscular ICCs were found in the aganglionic bowel, transitional zone,
and normoganglionic bowel of HD in a reduced density compared to the
normal bowel. CONCLUSION: This study demonstrates altered distribution
of ICCs in the entire resected bowel of HD patients. This finding
suggests that persistent dysmotility problems after pull-through
operation in HD may be due to altered distribution and impaired
function of ICCs.
Colonic atresia and
Hirschsprung's disease: importance of histologic examination of the
distal bowel.J Pediatr
Surg. 2002 Aug;37(8):E19.
Hirschsprung's
disease associated with colonic atresia is rare. A boy with colonic
atresia at the hepatic flexure who had a colostomy in the neonatal
period suffered from severe constipation after definitive
colocolostomy. Hirschsprung's disease was diagnosed with anorectal
manometry and rectal mucosal biopsy, and a Duhamel-Ikeda's
pull-through procedure was performed. Aganglionosis of the entire
distal colon was seen, and intrauterine torsion of the dilated
proximal colon followed by necrosis and absorption was suspected as
the cause of colonic atresia. Colonic atresia should be generally
screened for Hirschsprung's disease with a rectal biopsy.
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