Expression of beta-1 integrins in ganglionic and aganglionic segments of patients with Hirschsprung's disease

An immunocytochemical study was performed to assess the role of beta-1 integrins in the pathogenesis of Hirschsprung's disease. Fresh tissue samples from both aganglionic and ganglionic segments of five patients who were undergoing surgery for Hirschsprung's disease were obtained. Samples were rapidly frozen in liquid nitrogen. Sections were cut and stained using anti alpha-1, 2, 3, 4, 5, 6 and beta-1 monoclonals according to the indirect immunoperoxidase method. The evaluation did not reveal any significant change of pattern in the distribution of beta-1 integrins in the non-neural elements of both aganglionic and ganglionic segments of colon, such as the epithelium, muscularis mucosa, muscularis externa, connective tissues and blood vessels. Nerve fibres in both aganglionic and ganglionic segments strongly expressed the alpha-6 chain of very late activation antigen which led to their increase in the aganglionic segment. In addition to revealing the increase, alpha-6 monoclonals also had in situ positive control due to their presence in non-neural elements. Hence, immunostaining of the suction biopsies with anti alpha-6 monoclonals may be employed as a new and simple method in the diagnosis of Hirschsprung's disease. On the other hand, beta-1 integrins do not seem to play a role in the defective migration of ganglion cells occurring in Hirschsprung's disease.

Neuronal intestinal and fibromuscular arterial dysplasias associated with intraluminal mucosal web

A two-year-old boy presenting with the signs and symptoms of partial intestinal obstruction caused by a mucosal web in the ileum is presented. Histopathological evaluation following resection and primary anastomosis revealed neuronal intestinal dysplasia associated with fibromuscular arterial dysplasia limited to the segment proximal to the web and normal findings in the distal part. These findings and a brief review of the literature support the hypothesis that neuronal and fibromuscular dysplasias may develop on the basis of congenital obstructive lesions of the bowel.

A form of juvenile Batten disease with granular osmiophilic deposits

The clinical, neurophysiological and pathological features of a patient who presented with the clinical features of juvenile Batten disease, yet who had storage of granular osmiophilic deposits (GROD) on ultrastructural examination of biopsy and postmortem tissues is described. The ultrastructural features are those usually found in the infantile form of Batten disease. The postmortem study showed marked neuronal storage of a lipofuscin-like material in an atrophic brain without loss of myelin. The cerebellum showed almost complete loss of Purkinje cells and loss of the granule cells. No accumulation of subunit c of mitochondrial ATP synthase was found. The clinical and neurophysiological findings are compared with those of the classical juvenile form and with those of the few reported cases of juvenile Batten disease with GROD. The importance of correct classification of patients with Batten disease and its impact on the molecular genetic studies is emphasised. The pathogenesis of this form of the disease is considered to be similar to that for infantile Batten disease.

Ultrastructural aspects of the neuroendocrine complex in the stomach in patients with either pernicious anemia or the Zollinger-Ellison syndrome

The neuroendocrine complex of the gastrointestinal tract is defined as the presence of neuroendocrine cells in the lamina propria and in direct contact with nerve fibres of Meissner's plexus. The entire complex is separated from the interstitium by a basement membrane. To date, only a few studies have been published on the neuroendocrine complex. In this prospective electron microscopic study, we investigated the neuroendocrine complex of the stomach in 21 patients with pernicious anemia, and in eight patients with the Zollinger-Ellison syndrome. For each patient, six step biopsies obtained from the stomach at endoscopy were investigated. 16 out of the 21 patients with pernicious anemia, and four of the eight patients with the Zollinger-Ellison syndrome were found to have neuroendocrine complexes in the gastric mucosa. In patients with pernicious anemia who had neuroendocrine complexes more neuroendocrine complex-positive biopsies were found, on average, per patient, and more and larger neuroendocrine complexes, on average, per biopsy, than was the case in patients with the Zollinger-Ellison syndrome. These results show that in the gastric mucosa of patients with pernicious anemia, more marked proliferation of neuroendocrine complexes occur than in patients with Zollinger-Ellison syndrome.

Cystic fibrosis associated with neuronal intestinal dysplasia type B: a case report

The authors present the case of a newborn girl who had cystic fibrosis associated with neuronal intestinal dysplasia type B (NID-B). The association is rare but must be considered in the differential diagnosis of gastrointestinal problems in patients with cystic fibrosis. The present case elucidates the intestinal problems that can arise with this combination of diseases. Although the unusual association found in this patient could have been a random occurrence, the possibility of an NID-B determining gene localized on chromosome 7q should be considered.

Is intestinal neuronal dysplasia a disorder of the neuromuscular junction?

Intestinal neuronal dysplasia (IND) is a malformation of the enteric plexus and clinically resembles Hirschsprung's disease. The pathogenesis of IND is not known. There is no information available regarding the nature of the neuromuscular junction in this disease. The authors examined immunohistochemically full-thickness biopsy specimens from 14 patients (aged 3 weeks to 26 months) with IND and 10 age-matched controls, using monoclonal antibodies to growth associated protein-43 (GAP-43), synaptophysin, and neural-cell adhesion molecule (NCAM) as neuromuscular junction markers. In the normal bowel, GAP-43, synaptophysin, and NCAM immunoreactivity was abundant in the submucous and myenteric plexuses as well as in the muscularis mucosae and circular and longitudinal muscle layers. However, of the biopsy specimens from patients with IND, five had absence of GAP-43, synaptophysin, and NCAM immunoreactivity in muscularis muscosae and the circular and longitudinal muscle layers; five had no immunoreactivity in the longitudinal muscle; and four had no immunoreactivity in the muscularis mucosae. The submucous and myenteric plexuses of all patients with IND displayed strong immunoreactivity for GAP-43, synaptophysin, and NCAM. The findings demonstrate that patients with IND have defective innervation of the neuromuscular junction of the affected bowel.

[Quantitative and qualitative studies of the Auerbach and Meissner plexuses of the esophagus in dogs inoculated with Trypanosoma cruzi]

A quantitative and qualitative study was conducted on the Auerbach and Meissner plexuses of the esophagus of four chagasic dogs sacrificed during the acute phase of infection. Ganglionitis and periganglionitis of the Auerbach plexus ranged from mild to moderate and induced significant neuronal lesions, especially in two animals. The ganglions of the Meissner plexus were observed in small number which did not permit any analysis. Mild or moderate myositis was observed mainly in the lower third of the esophagus and was rarely associated with amastigote nests. Ganglion and neuron counts did not demonstrate denervation. Although the formation of megaesophagus was not induced in any dog, lesions of the Auerbach plexus and myocells of the esophagus were observed during the acute phase of chagasic infection. To our knowledge, this is the first systematic quantitative and qualitative study of the Auerbach and Meissner plexuses of the esophagus in experimental trypanosomiasis cruzi.

Overexpression of intercellular adhesion molecule-1 (ICAM-1) and MHC class II antigen on hypertrophic nerve trunks suggests an immunopathologic response in Hirschsprung's disease

The pathogenesis of Hirschsprung's disease (HD) is not fully understood. The authors studied expression of intercellular adhesion molecule-1 (ICAM-1) and major histocompatibility complex (MHC) class II antigen in the resected bowel specimens of 18 patients with HD who had no evidence of enterocolitis and in eight age- and site-matched controls, using indirect immunohistochemistry. There was strong expression of ICAM-1 and MHC class II antigen on hypertrophic nerve trunks, in both the submucous and myenteric plexuses of the aganglionic colon. The transition zone showed strong expression of ICAM-1 and MHC class II antigen on small ganglia in the myenteric and submucous plexuses. However, no staining of ganglia or nerve fibers was found in the submucous and myenteric plexuses of the colon from controls or in the ganglionic colon from patients with HD. The expression of both antigens on hypertrophic nerve trunks suggests the presence of an immunologic response in the pathogenesis of HD.

[Nerve-neuroendocrine complexes in stomach mucosa in Zollinger-Ellison syndrome]

Nerve fibre-neuroendocrine cell complexes (NF-NEC-C's) are neuroendocrine cells located in the lamina propria of the gastro-intestinal tract directly connected with nerve fibres of Meissner's plexus. We report on a patient with sporadic Zollinger-Ellison syndrome (ZES) with electron microscopically demonstrated multiple NF-NEC-C's in non-antral gastric mucosa. It is suspected that in ZES the hypergastrinaemia may represent a trophic stimulus for the proliferation of NF-NEC-C's in the gastric mucosa.

Histopathological criteria for intestinal neuronal dysplasia of the submucosal plexus (type B)

The aim of this study was to review critically the diagnostic features of intestinal neuronal dysplasia type B (IND B). Over a period of 5 years colonic mucosal biopsies of 773 children with symptoms of chronic constipation were examined. Four biopsies taken 2-10 cm above the pectinate line were cut in serial sections and histochemical lactate dehydrogenase, succinate dehydrogenase, (SDH) and acetylcholinesterase (AChE) reactions performed. Presence of giant ganglia of the submucosal plexus, being characterized by more than seven nerve cells, established the diagnosis of IND B. Giant ganglia were found to be age-independent changes, while hyperplasia of the submucosal plexus, increase of AChE activity in nerve fibres of the lamina propria and low SDH activity in nerve cells proved to be age-dependent findings which disappear during the maturation of the enteric nervous system. Using these criteria IND B was diagnosed in 209 children. In 64 of these patients a combination of IND B and aganglionosis (Hirschsprung's disease) was found. IND B seems to be related to premature expression of laminin A during embryogenesis, resulting in premature nerve cell differentiation in the myenteric and submucosal plexus, which in turn blocks neuroblast colonization of the rectum. IND B, hypoganglionosis and aganglionosis, which are often combined, may therefore be considered to be different manifestations of the same developmental abnormality.

Small ileal neurofibroma causing intussusception in a non-neurofibromatosis patient

Neurofibromas in the small intestine are usually accompanied by von Recklinghausen's disease (neurofibromatosis), and usually originate in the intramuscular plexus of Auerbach. We present here a solitary neurofibroma, which caused an ileocolic intussusception, originating in the submucosal plexus of Meissner in a non-neurofibromatosis patient. To our knowledge, there is no previous report of a neurofibroma originating in the plexus of Meissner. This condition was clearly confirmed by macroscopic and microscopic evaluation.

Histopathological features of neuronal intestinal dysplasia of the plexus submucosus in whole mounts revealed by immunohistochemistry for PGP 9.5

Neuronal intestinal dysplasia (NID) is wellknown, but its definition is a topic of debate. The histopathological diagnosis of NID is based on traditional enzyme-histochemical methods such as the acetylcholinesterase and dehydrogenase reaction on native cryosections. In this study, we have investigated the enteric nervous system in whole mount preparations of resected intestinal segments affected by NID of the plexus submucosus (type B). The plexuses of the tunica mucosa and tunica submucosa were visualized by immunohistochemical methods using a polyclonal antibody to protein gene produce 9.5 (PGP 9.5). PGP 9.5 is a novel general cytoplasmatic marker specific for the nervous system. The morphology of the plexuses is revealed in full, making possible changes easily discernible. Known pathological findings of the NID can be identified and judged more precisely with this method. Numerous enlarged nerve trunks run within the tunica submucosa and tunica mucosa. Hyperplastic ganglia with an unusually high nerve cell number in the tunica submucosa can be demonstrated as well as heterotopic nerve cells in the tunica mucosa.

Neuronal intestinal malformations: a retro- and prospective study on 203 patients

A total of 203 patients with neuronal intestinal malformations were analyzed. A retrospective study was performed on 122 patients who had been treated from 1963-1988 and 119 (97.5%) of these patients underwent follow-up examination after a mean of 11.5 years. Subsequently 81 patients treated from 1989-1993 were included in a prospective trial. These patients were investigated preoperatively by standardized questionnaires, x-ray examination, electromanometry, transit time studies, and underwent follow-up after a mean of 3.2 years. All biopsy specimens of the prospective trial were analyzed by the Institute for Pathology of the University of Basel. Before 1989 the incidence of neuronal intestinal malformations was 4.9 per year as compared to 18 per year from 1989-1993. The percentage of classical aganglionosis decreased from 77.9% to 35.8% and aganglionosis associated with NID B was increased from 9% to 29.6% (p < 0.001). The prospective trial showed that only 54.7% of 53 children with aganglionosis had classical Hirschsprung's disease, 45.3% were combined with NID B. Out of 37 patients with NID 64.9% had associated aganglionosis. Preoperative symptoms showed no pathognomonic criteria for any specific neuronal intestinal disorder. However, 75% of the patients with aganglionosis combined with NID suffered from ileus as compared to 41.1% of the patients with classical aganglionosis and 23.1% of patients with isolated NID (p < 0.05). This indicates an additive effect of both lesions. X-ray examinations, electromanometry, and transit time studies did not show pathognomonic criteria for specific neuronal intestinal malformations.(ABSTRACT TRUNCATED AT 250 WORDS)

Results in the treatment of anorectal malformations with special regard to the histology of the rectal pouch

The results of surgery for anorectal malformation (ARM) in 536 children treated between 1962 and 1993 are presented. Before 1985, patients underwent an abdominoperineal pullthrough for high and intermediate type of ARM, whereas cut-back procedures or perineoproctoplasty were performed in low type. Since 1985, we have changed our policy and performed a modified posterior sagittal anorectoplasty (PSARP) for intermediate type of ARM, eventually combined with an abdominal mobilization for high type. Perineoproctoplasty was reserved for low type of ARM. Data of 143 patients of Group 1 and 85 patients of Group 2 were available for follow-up. Continence was compared using a clinical score. Good or fair continence was found in 82% of patients operated on before 1985 (low type 85% good, 15% fair, intermediate type 17% good, 50% fair, high type 12% good, 37% fair), comparing to 93% in children treated after 1985 according to the new regimen (low type 88% good, 6% fair, intermediate type 59% good, 35% fair, high type 43% good, 47% fair). Liquid stools and inability to retain bowel contents were the main problem in the older series, whereas incontinence could often be attributed to constipation with overflow incontinence in the recently treated group of patients. Analysis of the innervation of fistula and distal rectal pouch in a prospective study comprising 40 of our most recent patients showed normal innervation in only 5% of patients, whereas 66% had neuronal intestinal malformations (NIM) including aganglionosis, NID and hypoganglionosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuronal intestinal dysplasia: clinical experience in Italian patients

The authors present a review of 431 children biopsied and studied with the following histochemical and immunohistochemical techniques: 1) acetylcholinesterase activity; 2) alphanaphthylesterase activity; 3) S-100 protein immunohistochemical technique; 4) glyoxylic acid method. Two hundred forty-eight patients of our series presented different forms of dysganglionosis, 12 of them (4.8%) presenting neuronal intestinal dysplasia type B. In 7 cases, NID type B was diffuse, whereas in 5 recto-colonic NID type B was confined to the splenic flexure. Male:female ratio was 9:3. Familial recurrence was present in 2 of the 12 cases of our series, affected by severe neuronal intestinal dysplasia extended to the small intestine, associated with intestinal malrotation and short bowel syndrome. Four of the 7 cases of diffuse NID type B and 2 of the 5 cases of rectocolonic NID type B were surgically treated. Three patients with diffuse NID died from sepsis within the 2nd year of life. This study confirms that NID type B is a form of dysganglionosis which can be diagnosed in a Mediterranean country if histochemical techniques are applied in the study of a large series of constipated and pseudo-Hirschsprung patients. From a pathogenetic point of view, the authors compared the histochemical findings of biopsies from their series of NID patients with those of recto-colonic biopsies from patients with MEN II B syndrome. The similarity of GI symptoms in MEN II B and NID pediatric patients suggests that the two disorders could be the result of mutations affecting the same domain of the RET proto-oncogene.

Value of a score in the electromanometrical diagnosis of neuronal intestinal dysplasia

Anorectal manometry was performed in a series of 8 children where NID was histochemically confirmed or suspected. The results were transferred to a electromanometric score theoretically worked out previously. Clinical symptoms as well as histological and manometric findings have been compared concerning the meaningfulness of the electromanometric score in the diagnosis of NID. It was impossible to make a statistical statement due to the small number of patients we examined. It seems, however, that certain electromanometric parameters in NID appear regularly which, when combined in a score, make manometric diagnosis of NID sufficiently reliable.

Immunohistochemistry of markers of the enteric nervous system in whole-mount preparations of the human colon

In this study we tested the immunohistochemical reactions of various markers for the enteric nervous system in whole-mount preparations of the human colon. For that purpose we used polyclonal antibodies against the neuronal markers--protein gene product 9.5 (PGP), neuron-specific enolase (NSE), neurofilament protein 200 (NFP), microtubule-associated proteins (MAPs); and the glial markers--S-100 protein and glial fibrillary acidic protein (GFAP) for the immunoperoxidase reaction. Whole-mount preparations are more suitable for histopathological evaluation and interpretation than sections, because the enteric nervous system consists of three-dimensional plexuses lying within the layers of the intestinal wall. Sections show only a part of the plexuses, neurons and glial cells. On the other hand, whole-mount preparations reveal the morphology of the plexuses as a whole. Among the neuronal and glial markers used, S-100 protein, the neurofilament protein, and the protein gene product 9.5 (PGP) produced the best results. Furthermore, this developing method provides new possibilities for the histopathological analysis of defects in the enteric nervous system, such as neuronal intestinal dysplasia (NID).

A histological grading system for the evaluation of co-existing NID with Hirschsprung's disease

The significance of dysplastic features in the surgical pullthrough segment of bowel in patients with Hirschsprung's disease (HD) has not yet been clarified. The aim of this study was to evaluate prospectively the ganglionated proximal bowel in 26 patients with HD (January 1988 through January 1991). The significance of dysplastic features and their influence on post operative outcome were evaluated by means of a newly devised histological scoring system based on the morphological features. Functional outcome was assessed clinically at follow-up interview. Comparison was with control specimens from 22 patients undergoing unrelated bowel surgery and a further 5 patients with neuronal intestinal dysplasia (NID). Results indicated a wide spectrum of histologically identified dysplastic features in patients with NID, the ganglionated bowel of HD and controls. Although individual abnormal features were noted in the control group, significant degrees of dysplasia were absent. The overall degree of dysplasia was less striking than that observed in NID and in the 5 patients in whom NID co-existed with HD. Dysplasia of the ENS in residual bowel could be correlated with postoperative dysfunction in 4 out of 5 patients (80%) with HD and features of co-existing NID. In addition, milder symptoms were noted in 50% of patients having a borderline score (5-6/12). This study emphasizes the relationship between clinical obstructive symptoms and a high degree of dysplasia within the ENS. A histological grading system is of value in evaluating the spectrum of abnormal findings and prospectively identifying those with functional significance in patients with NID co-existing with HD.

Electromanometrical investigations in patients with isolated neuronal intestinal dysplasia (NID)

In a retrospective study the manometrical findings of 27 patients with histochemically confirmed isolated NID were compared with the findings of 14 patients with habitual constipation. In a second group NID or other neuronal disorders of the distal colon were excluded by histology/histochemistry. Significant differences were found only for the amplitude and frequency of anorectal fluctuations and for presence or absence of rectoanal inhibitory reflexes (RAIR). All other investigated parameters were not significant. In conclusion a reliable diagnosis of isolated NID is only possibly by combined use of anorectal manometry and histochemistry. Nevertheless anorectal manometry remains an important tool for screening in constipative disorders and should be performed prior to other investigations i.e. radiology or biopsy.

Experience with neuronal intestinal dysplasia (NID) in adults

In paediatrics neuronal intestinal dysplasia (NID) has frequently been described, but in adults the clinical picture was not recognised. NID has been diagnosed in adults as well as children with impaired colonic motility since enzymehistochemical methods became available. Patients with primary chronic constipation (n = 41) and with diverticulosis of the sigmoid colon (n = 23) showed neuronal colonic dysplasia, whereas healthy controls (n = 15) had a normal innervation of the intestinal wall (p < 0.001). The results of this clinical study make a worthwile contribution to the understanding of the aetiology and pathogenesis of primary chronic constipation and diverticulosis of the colon in adults. Conservative treatment is usually unavailing and surgical intervention is needed. Hence, where strictly indicated, resection of the pathologically disturbed colon segment is often the only successful therapeutic procedure.

Hirschsprung's disease and allied disorders--a review

Despite scepticism in the English speaking literature today there is international agreement on the existence of neuronal intestinal dysplasia and other intestinal malformations which may well be differentiated from classical aganglionosis. In large series of patients with neuronal intestinal malformations it was found that only one fourth suffers from Hirschsprung's disease. Therefore this article presents the state of our recent knowledge of classical aganglionosis and allied disorders which include hypoganglionosis, neuronal intestinal dysplasia type A and B, immaturity of ganglion cells and not classifiable dysganglionosis. We want to emphasize the morphological differentiation of these neuronal intestinal malformations. However, the relationship between morphological findings, clinical symptoms and bowel motility remain to be clarified by further studies.

The neuropathological diagnosis of neuronal intestinal dysplasia (NID B)

Between 1986 and 1991 773 infants were investigated by biopsy. 209 children suffered from a neuronal dysplasia of the submucous plexus (NID B). 64 of these 209 cases had concomitant Hirschsprung's disease with NID. The combination of Hirschsprung's disease with NID was established at biopsy not earlier than at 12 +/- 6 months of age. The classical form of an isolated aganglionosis had a median age at diagnosis of 4 +/- 2 months. The preconditions for a reliable diagnosis of NID are mucosal biopsies with submucosa taken 1, 3 and 9 cm above the pectinate line, the preparation of 15 microns thick serial sections, a acetylcholinesterase- and lactate-reaction and a systematic examination of all serial sections. Giant ganglia, which are 2-3 times as large as normal ganglia and having more than 7 LDH-positive nerve cells (10 +/- 3 nerve cells in the mean), are the most relevant parameters in the diagnosis of NID. They can be observed in infants as well as in adults. The NID proximal to aganglionosis is in principle not different from an isolated form of NID. Increase of acetylcholinesterase-activity in muscularis mucosae and lamina propria mucosae and a "hyperplasia" of the submucous plexus in early infancy disappears with advancing age and are very seldom observed at 2 years of age or in adulthood. NID B is the mildest form of a developmental abnormality of the autonomic nervous system, which shows in most cases a spontaneous normalization of gut motility.(ABSTRACT TRUNCATED AT 250 WORDS)

Nerve growth factor receptor staining of suction biopsies in the diagnosis of Hirschsprung's disease

The authors studied rectal suction biopsy material in 60 consecutively treated patients suspected of having Hirschsprung's disease (HD) (age range, 3 days to 12 years). According to acetylcholinesterase (AChE) staining, 10 patients had HD, three had neuronal intestinal dysplasia (NID), and 47 were normal. The diagnoses were confirmed by H&E staining of biopsy material and by examination of surgically resected material in the HD and NID cases. The 60 cases were stained with a monoclonal antibody to the nerve growth factor receptor (NGFR) using immunohistochemistry on fresh frozen biopsy tissue. In the 47 normal biopsy specimens, there was a large number of immunoreactive fibers in the lamina propria, and staining of the muscularis mucosae and submucous ganglia. In contrast, there were no immunoreactive fibers in the lamina propria in patients with HD and NID. A striking finding was the strong expression of immunoreactivity on the perineurium of submucosal hypertrophic nerve trunks in cases of HD. The results indicate that NGFR immunoreactivity is similar in specificity and sensitivity to AChE in the diagnosis of HD. Because the technique uses an immunocytochemical rather than a histochemical technique and the results were easier to interpret, NGFR staining may be an important additional technique to diagnose HD.

Severe constipation with diffuse intestinal myenteric hyperganglionosis

The authors report a case of neuronal intestinal dysplasia in a 6-year-old girl. The disease is characterized by hyperplastic ganglia throughout the large and small intestine, associated with severe constipation. To better understand the pathophysiology of this disease the authors investigated the histopathologic, ultrastructural, and immunohistochemical characteristics of the intestinal tissue in this case. The hyperganglionosis was associated with immunohistochemical findings of intact expression of the neuropeptides controlling the peristaltic reflex, through lower expression of calcitonin-gene related peptide. With the recent progress in our understanding of the neural regulation of gastrointestinal function, it may now be possible to begin to understand the complex pathophysiological mechanisms underlying gastrointestinal motility disorders.

Intestinal pseudo-obstruction, type 1 anti-neuronal nuclear antibodies and small-cell carcinoma of the lung

Intestinal pseudo-obstruction is a rare paraneoplastic manifestation of small-cell carcinoma of the lung. This report documents a further case associated with neuronal degeneration of enteric neural plexuses and a high serum titre of immunoglobulin G (IgG) type 1 anti-neuronal nuclear antibodies (ANNA-1).