Diagnosis of Hirschsprung's disease by anorectal manometry

Anorectal manometry was performed in 48 Japanese children with Hirschsprung's disease and 61 normal children. The resting pressure of the rectum and anal canal was not significantly different between these groups of subjects. The frequency of rhythmical contractions of the anal canal of patients was significantly lower than for the normal subjects, but the frequencies overlapped considerably. Therefore, the frequency is an inadequate indicator for identifying these patients. Conventional manometry elicited a distinct rectoanal relaxation reflex from 90% of the normal children, and the rate increased to 98% when indistinct reflexes were regarded as positive. Indistinct reflexes often occur in neonates, possibly because the constriction of the anal canal is weak. However, when prostaglandin F2 alpha was intravenously administered during the examination, all ambiguous reflexes became distinct. Of patients with Hirschsprung's disease, 4% had a distinct reflex and 19% an atypical one. Most of the atypical reflexes were regarded as being artifacts and were mostly attributed to distension by a balloon. In these patients, the reflex was abolished in case of examination with electric stimulation or stimulation with cold water, procedures which do not dilate the rectum. Moreover these atypical reflexes did not fit the criteria for the normal rectoanal relaxation reflex prepared by the Japan Study Group of Pediatric Intestinal Manometry. The use of electric stimulation, cold water, or intravenously administered prostaglandin F2 alpha improves reliability of the conventional anorectal manometry. A clear and accurate definition of the normal reflex should aid in excluding the atypical reflex.

Esophageal manometrical assessment after esophageal circular myotomy for wide-gap esophageal atresia

We treated 3 children with wide-gap esophageal atresia by a circular myotomy of Livaditis technique, after which no postoperative complaints, such as heartburn, vomiting or dysphagia, were seen. Esophageal manometry, performed to evaluate the postoperative esophageal motor function revealed; (1) that lower esophageal sphincter pressure (LESP) increased gradually with time, (2) esophageal contraction waves (ECW) were evident at the site of the circular myotomy with swallowing, though these contractions were simultaneous; and (3) relaxation of the LES with swallowing was evident. These findings, as determined by the esophageal manometrical assessments, indicate that there is no difference between the postoperative esophageal function after either repair with a circular myotomy or primary anastomosis for esophageal atresia.

Hypogenesis of intestinal ganglion cells: a rare cause of intestinal obstruction simulating aganglionosis

Hypogenesis of intestinal ganglion cells is a rare cause of functional intestinal obstruction showing both diminished numbers of ganglion cells per plexus and immature ganglion cells. We report a case of hypogenesis extending from anus to mid small intestine.

Isolated unilateral absence of left pulmonary artery with peribronchial arteriovenous malformation showing recurrent hemoptysis

Unilateral absence of a pulmonary artery is an uncommon condition and usually complicated by a cardiac anomaly. Our case is a rare one who showed the absence of the left pulmonary artery with left aortic arch and without cardiac anomaly. He suffered from recurrent hemoptysis and pneumonia since he was 9 months old. Angiography revealed peribronchial arteriovenous malformation of the affected lung which was supplied from subclavicular arteries and bronchial arteries. Although he was treated by operative ligation and angiographic embolotherapy of the supplying systemic arteries, the repeated the attacks of massive hemoptysis and necessiated left pneumonectomy at 10 years of age.

The use of prostaglandin F2 alpha and scopolamine-N-butylbromide in anorectal manometric diagnosis

To improve the accuracy of diagnosis of Hirschsprung's disease by means of anorectal manometry, prostaglandin F2 alpha (PGF2 alpha) and scopolamine-N-butylbromide (Buscopan) were used. Normal rectoanal reflex was facilitated by PGF2 alpha in 6 out of 7 children and was abolished or markedly inhibited in 12 out of 13, when Buscopan was given. Obscure rectoanal reflexes in 7 normal neonates were clarified following the administration of PGF2 alpha. On the other hand, atypical rectoanal reflexes observed in 7 children with Hirschsprung's disease were unchanged with either PGF2 alpha or Buscopan. Therefore the use of PGF2 alpha or Buscopan facilitates the manometric diagnosis of Hirschsprung's disease. In 9 postoperative children with Hirschsprung's disease the reflexes were obscure. Five of these 9 reflexes became clear after the administration of PGF2 alpha and 4 remained unchanged. As the normal rectoanal reflex was enhanced by PGF2 alpha, the obscure reflex seen in the postoperative period can be positive or negative, using PGF2 alpha.

Lymphoid cell subsets in normal human small intestine

Nineteen specimens of normal tissue were obtained from the duodenum, upper jejunum and terminal ileum. Specimens were fixed with periodate-lysine-paraformaldehyde and then frozen sections were made. Lymphoid cell subsets were identified by indirect immunoperoxidase staining using mouse anti-human monoclonal antibodies.

RESULTS

There was a remarkable variation in the distribution of positive cells among individuals and even within single sections. Lymphoid cell subsets of the three parts of the small intestine were almost identical except for the difference in IgA subclasses of IgA-containing cells. IgA1 predominated over IgA2 in the jejunum while IgA2 predominated over IgA1 in the ileum. The subsets in the lamina propria (LP) and in the epithelium were clearly distinct; Leu 3+ (helper/inducer T) predominated in LP while Leu 2+ (suppressor/cytotoxic T) predominated in the epithelium and no Ig-containing cells were found in the epithelium. In LP the mean ratio of Leu 1+ (pan T):IgA (IgA1 + IgA2) containing cells: IgM: IgG: IgD: IgE: HNK-1+ was 48.9: 36.6: 9.0: 1.8: 1.0: 0.3: 2.4. The staining patterns of HLA-DR+ and Leu 10+ were similar; dense in the top in LP of the villi. In some individuals the apical portion of epithelial cells was stained by anti-HLA-DR. A few positive cells were observed in only two out of 19 cases by anti IL-2R.

The effect of autonomic drugs and prostaglandinF2 alpha on the rectoanal inhibitory reflex

Anorectal manometry was performed on mongrel dogs given various drugs in attempts to determine the effect of the drugs on rectoanal inhibitory reflex. Anal canal pressure was significantly increased by the administration of neostigmine and noradrenaline and significantly lowered by isoproterenol. The amplitude of the rectoanal inhibitory reflex was increased by the administration of neostigmine and prostaglandinF2 alpha (PGF2 alpha), decreased by atropine but was little affected by either noradrenaline or isoproterenol. These results suggested that cholinergic neurons have an excitatory effect both on the anal canal pressure and the rectoanal inhibitory reflex, while adrenergic alpha and beta receptors have little effect on the rectoanal inhibitory reflex. PGF2 alpha was though to increase the motor activity of the anal sphincter and facilitate the rectoanal inhibitory reflex. Neostigmine and PGF2 alpha may aid in clarifying rectoanal inhibitory reflexes in neonates or postoperative children with rectoanal diseases.

[Bowel control after surgery for Hirschsprung's disease]

Bowel control was studied in 66 children operated by Ikeda's Z-shaped anastomosis for Hirschsprung's disease. At the age of 2 or 3 years, mild constipation was recognized in 16% of the children, incontinence in 12% and soiling in 28%. However, these disorders reduced as the patients grew up and finally over 7 years, constipation was seen in 8% of the patients, incontinence in 8% and soiling in 19%. According to barium enema, megarectum was seen in all constipated children but one, though slight megarectum was sometimes seen even in normal or incontinent children. Frequently, anal canal was wide and leakage of barium through the anus was seen in incontinent or soiling children. Anal canal pressure was high in constipated group, low in soiling group and the lowest in incontinent group. The appearance rate of rhythmical wave of anal canal and recto-anal reflex was the same among all groups. Our treatment of the constipation and incontinence is daily bowel movement using laxative, suppository or enema. For the incontinent patients without rectal sensation, biofeedback method or electrical stimulation is applied.

An immunohistochemical study of serotoninergic nerves in the colon and rectum of children with Hirschsprung's disease

Serotonin (5-HT)-like immunoreactive nerve fibers were investigated in gut tissue obtained from seven Japanese children with Hirschsprung's disease. In the control untreated tissues, 5-HT-like immunoreactive fibers were observed neither in the normoganglionic nor in the aganglionic regions. After pargyline treatment, 5-HT-positive neuropils were consistently detected in association with the myenteric plexus in the normoganglionic segment, while in the aganglionic segment immunoreactive fibers could not be demonstrated through the entire layer of the bowel tissue. The occurrence of 5-HT-like immunoreactive neuropils by pargyline treatment strongly suggests that the infant bowel is innervated with serotoninergic elements. After treatment with 5-hydroxy-L-tryptophan (5-HTP), the immunoreactive neuropils were localized in the myenteric and submucous plexuses of the normoganglionic segment. On the other hand, another type of 5-HT-positive fibers was characteristically demonstrated in aganglionic segments following the drug treatment; moderate numbers of 5-HT-like immunoreactive fibers appeared in the intermuscular zone and within the circular and longitudinal muscle layers. Several 5-HT-positive fibers were present in the hypertrophic nerve bundles seen in a diseased bowel. A possible origin of this type of 5-HT-positive nerve fibers was discussed.

[Japan Study Group of Manometry of Digestive Tract in Childhood]

The Japan Study Group of Manometry of the Digestive Tract in Childhood was organized in 1975. The 14th meeting was held in February 1984. During the meeting, the technique of anorectal manometry was established and the criteria of positive recto-anal reflex was defined. The mechanism of recto-anal reflex has been studied, but the details of it remain obscure. The relationship between postoperative fecal continence and the findings of anorectal manometry of patients with anorectal disorders are currently being investigated. It is in dispute whether the recto-anal reflex is present or absent in patients with pseudo-Hirschsprung's disease. Study of esophageal manometry in children was added to the work of the group in 1978, and gastroesophageal reflux has been studied using manometry and/or pH measurement.

Induction of the rectoanal reflex by electric stimulation. A diagnostic aid for Hirschsprung's disease

We induced the rectoanal reflex electrically in three groups of children, following rectal dilatation with a balloon. In normal children, and in children with constipation or ileus due to causes other than Hirschsprung's disease, the rectoanal reflex was induced by electric stimulation as well as by dilatation of the rectum with a balloon. In children with Hirschsprung's disease, however, no typical reflex was obtained by either of these stimuli. Since electric stimulation does not dilate the rectum, passive dilatation of the anus or shift of the probe along with balloon expansion does not take place, so no false-positive reflex is elicited. Electric current, moreover, is capable of providing a constant quantifiable stimulus. We have demonstrated the induction of the rectoanal reflex by electric stimulation alone; distention of the circular muscle of the rectum does not appear necessary for the induction of this reflex.

Histochemical acetylcholinesterase reactions in total colonic aganglionosis

Reliability of the histochemical diagnosis in total colonic aganglionosis is controversial. We studied histochemical acetylcholinesterase (AChE) reactions in three children with total colonic aganglionosis. In all three, there was an increase in AChE positive nerve fibers in the rectal mucosa, obtained when the patients were over the neonatal period. However, a proximal extension of the increase in AChE positive nerve fibers was noted in the distal end of the resected bowel obtained at the definitive operation in two cases out of three. In one, there was no proximal extension in the resected bowel, and in another, there was an increase in AChE positive nerve fibers in the mucosa of the ganglionic ileum. Our findings indicate that the histochemical study of AChE activity in rectal suction biopsy is useful, even in cases of total colonic aganglionosis.

Hirschsprung's disease in an adult. Special reference to histochemical determination of the acetylcholinesterase activity

A 24-year-old Japanese woman with Hirschsprung's disease was subjected to the combination of barium enema, anorectal manometry, and a histochemical study of acetylcholinesterase (AChE) activity in rectal suction biopsy. The histochemistry revealed a marked increase of AChE positive nerve fibers. The importance of such a study is stressed in order to diagnose Hirschsprung's disease correctly, even in adults. A Z-shaped anastomosis as a modification of Duhamel's method was carried out. The postoperative course was uneventful and she now has normal bowel evacuation.

Assessment of bowel control with anorectal manometry after surgery for anorectal malformation

Bowel function after surgery for anorectal malformation was assessed by Kelly's score in 101 children over 3 years of age. Seventy-two were examined using anorectal manometry. In the "good" group, resting pressure of the anal canal was as high as in the normal children, and the frequency of contraction waves in the anal canal was the same as in the normal children. Recto-anal reflex was recognized in about three fourths of the "good" group. On the other hand, in the "poor" group resting pressure was low, in only one were contraction waves evident and in none was there a recto-anal reflex. The findings of the anorectal manometry placed the "fair" group between the "good" and the "poor" groups. The clear contraction waves of the anal canal or the clear recto-anal reflex related to a resting pressure in the anal canal of over 20 cmH2O. This high pressure in the anal canal is important for good and continence, and depends on a precise pull-through of the rectum into the puborectalis muscle.

Radiologic diagnosis of Hirschsprung's disease utilizing rectosphincteric reflex

Artificial balloon distension of the rectum caused a reflex opening of the anal canal as seen during barium enema in 10 out of 10 normal children and in 7 of 7 children with idiopathic constipation. Reflex opening of the anal canal was not observed in any of 15 children with proven Hirschsprung's disease. This lack of response was independent of the length of aganglionosis or previous diverting colostomy and corresponded to the fact that on manometric study the intraluminal pressure of the anal canal fell in normal children but not in the children with Hirschsprung's disease. This finding greatly improves the reliability of barium enema in the diagnosis of Hirschsprung's disease.

Diurnal profile of gallbladder size in diabetic patients: ultrasonographic evaluation of diabetic neurogenic gallbladder

The diurnal change of gallbladder size was clearly measured with a real time ultrasonography. To visualize the gallbladder, 21 diabetic patients and 11 healthy subjects were scanned right subcostally in the supine position nine times between 8:00 a.m. and 8:00 p.m. Photographs of the images were produced on Polaroid film, and the area of gallbladder was calculated. The diurnal changes of the gallbladder size were expressed as the percentage of the size measured at 8:00 a.m. after an overnight fast. The gallbladder in normal control started contracting immediately after breakfast and reached 57.2 +/- 7.6% at 9:00 a.m. In the diabetic patients with and without autonomic neuropathy the gallbladder contracted to 80.9 +/- 14.5% and 72.4 +/- 14.8%, respectively, at 9:00 a.m. while the nadir of the diurnal profile curve in healthy subjects was 24.5 +/- 3.6% at 3:00 p.m., in the diabetic patients with and without autonomic neuropathy those were 57.7 +/- 6.1% at 6:00 p.m. and 41.3 +/- 8.3% at 8:00 p.m., respectively. This implies that the gallbladder contraction was delayed and poor in diabetic patients. In this paper, the gallbladder tonicity index is proposed, which is useful for the easy evaluation of autonomic state of gallbladder in diabetes mellitus.

Follow-up studies of children treated with a long-term intravenous nutrition (IVN) during the neonatal period

The outcome of the 28 children treated with intravenous nutrition (IVN) for more than 4 wk during the neonatal period was investigated. Ten of the 28 children had a normal length of small bowel (group 1) and the other 18 children had a short bowel (group 2). Eight of these 28 children (4 in group 1 and 4 in group 2) died during or after cessation of IVN; three died from complication of IVN and 5 died from their initial disease. On physical examination, delay in catch-up growth was observed in the early postoperative period, particularly in children in group 2, but this diminished with time. Mental and emotional development showed both groups to be within the normal range, except for two children. Intellectual function was also normal in five children over the age of 4 yr who were examined. Hepatic dysfunction was noticed during IVN in 30.0% in group 1 and 66.7% in group 2, indicating that the longer the duration of IVN, the higher the incidence of liver damage. Furthermore, histologic abnormalities in these neonates lasted for a longer time. These results imply that long-term IVN during the neonatal period in surgical patients does not interfere with physical and developmental growth. However, careful and long-term follow-up of liver function after IVN is necessary.

Effects of a glucoside-hydrolase inhibitor (Bay g 5421) on serum lipids, lipoproteins and bile acids, fecal fat and bacterial flora, and intestinal gas production in hyperlipidemic patients

Significant decrease in serum very low density lipoproteins and low density lipoproteins was observed after Bay g 5421 trial (300 mg/day for 6 weeks) in 14 hyperlipidemic patients. Although no significant changes were demonstrated in serum fractions of bile acids, the alteration in the patterns of fecal bacterial flora including the increase in obligate anaerobes was observed after the trial and this was accompanied by the increase in fecal fat excretion. Thus, the possible change in the intestinal bile acid metabolism with the altered flora may lead to an increased catabolism of cholesterol and to the reduction of serum low density lipoproteins. The meteorism developed in several patients but its etiology was shown to be independent of the patterns of the pre-trial bacterial flora and diet composition.