Enterocolitis associated with Hirschsprung's disease: a clinical histopathological correlative study

Enterocolitis complicating Hirschsprung's disease

Enterocolitis remains a relatively common complication of Hirschsprung's disease with significant morbidity and mortality. The etiology of Hirschsprung's enterocolitis (HEC) is multifactorial and remains poorly understood. Preventative measures and better treatment modalities will evolve out of a better understanding of the underlying pathophysiology. Prompt recognition of HEC allows early intervention and a potential reduction in disease severity and mortality. This review of HEC describes the epidemiology, clinical and pathological features and current best practice in management. Some of the areas of research into etiology and treatment are discussed.

Transanal one-stage endorectal pull-through for Hirschsprung's disease: a multicenter study

BACKGROUND/PURPOSE

Transanal endorectal pull-through (TEPT) is the latest development in treatment of Hirschsprung's disease (HD). This prospective study was designed to evaluate the safety and efficacy of 1 stage TEPT technique in the management of patients with HD.

METHODS

One hundred forty-nine children (116 boys and 33 girls) aged 8 days to 14 years underwent 1 stage TEPT procedure over an 18-month period at 5 Egyptian academic pediatric surgical centers and affiliated hospitals. Median follow-up was 12 months (range, 3 to 21 months). These patients were evaluated with regard to age, sex, length of the aganglionic segment, intraoperative details, and postoperative functional results or complications. An electromyogram (EMG), endorectal ultrasound scan, and lower gastrointestinal (GI) motility studies were reserved for patients with postoperative problems with bowel control.

RESULTS

Mean operating time was 120.2 +/- 27.8 minutes (range, 60 to 210 minutes). The average length of resected bowel was 26.8 +/- 12.4 cm (range, 15 to 45 cm). Thirteen patients required laparotomy because of extension of aganglionic segment beyond the sigmoid colon in 9, tear in the mesenteric vessels in 2, and difficulties in getting to the submucosal plane in 2. Three deaths (2%) occurred 3 days, 4 days, and 4 weeks postoperatively, respectively. Postoperative complications included transient perianal excoriation in 48 patients (30 were <3 months of age), enterocolitis (n = 26), anastomotic stricture (n = 7), recurrent constipation (n = 6), hypoganglionosis at distal end of pulled through segment (n = 2), cuff abscess (n = 3), anastomotic leak (n = 1), adhesive bowel obstruction (n = 1), and rectal prolapse (n = 1). Complete anorectal continence was noted in 35 of 42 (83.3%) children older than 3 years, whereas soiling and frequent accidents still occur in 7, who showed a steady improvement in their continence status.

CONCLUSIONS

One-stage TEPT technique is both feasible and safe technique in properly selected children with rectosigmoid HD in all ages. The technique is easily learned and is associated with excellent clinical results.

Reoperative surgery for Hirschsprung's disease

Most patients who undergo a pull-through procedure for Hirschsprung's disease typically do well. A small number of patients have persistent stooling problems, often manifesting with either constipation or recurrent enterocolitis. A group of these patients will not respond to conservative medical management and may need to undergo another operative procedure. Reoperative surgery for Hirschsprung's disease typically falls into 2 categories, those who require a myectomy and those who need a redo pull-through. This article reviews the workup, indications, and techniques for these procedures and discusses previously published, as well as the authors' outcome, with these 2 procedures.

MUC-2 mucin production in Hirschsprung's disease: possible association with enterocolitis development

BACKGROUND/PURPOSE

The etiology of Hirschsprung's-associated enterocolitis (HAEC) is unknown. Previous investigations have suggested that abnormal production of mucins may have an etiologic role. Recently, a series of mucin genes have been identified. MUC-2 is the predominant mucin expressed in humans. The authors have shown previously in vitro that use of MUC-2 can prevent bacterial translocation. Based on this, it was hypothesized that those patients with Hirschsprung's disease (HD) would have an abnormal production of MUC-2 compared with normal patients.

METHODS

Fresh stool specimens were collected from children with a diagnosis of HD (with or without HAEC) and from age-matched control patients. Protein was extracted, and MUC-2 was detected with Western blot analysis. MUC-2 protein expression was quantified by densitometry measurements. Results are expressed as mean density +/- SD. Statistical comparison was done with unpaired t tests, with P less than.05 being considered significant.

RESULTS

MUC-2 expression was detected in all control patients (mean density, 121 +/- 47). MUC-2 level was lowest in one child with a viral-induced diarrhea (density = 71). In those patients with HD, levels of MUC-2 protein expression were significantly lower (P <.05) than controls (12 +/- 15 for all HD patients). Levels of MUC-2 were lowest (nondetectable) in 2 HD patients who had clinical evidence of HAEC.

CONCLUSIONS

MUC-2 production is markedly depressed in patients with Hirschsprung's disease and is absent with enterocolitis. This decline in protein expression may result in a decrease in epithelial barrier function and be a predisposing factor in the development of HAEC.

Hirschsprung's disease: diagnosis and management in children

Hirschsprung's disease is a congenital abnormality of the bowel that results in loss of peristalsis, and is one of the main reasons why an infant may require a stoma soon after birth. Various stages of surgery may be required to resect the affected part of the bowel, including formation and closure of the stoma. Following surgery, the perception of many families is that their child is now "normal" and that all previous problems of managing their child are now resolved. However, there are a variety of postoperative complications and issues relating to bowel control which can affect the child in the long term. This article looks at how potential postoperative long-term problems can be identified early, and thus minimized, by healthcare staff being aware of possible problems, taking a proactive approach to management and advising families about the issues involved.

Recent advances in the management of Hirschsprung's disease

BACKGROUND

Major advances have occurred in the management of Hirschsprung's disease since Swenson described his definitive operation in 1948. These advances have occurred in the following areas: genetics, neurophysiology, definitive management in the newborn, total colonic aganglionosis (TCA), Hirschsprung's-associated enterocolitis (HAEC), intestinal neuronal dysplasia (IND), and laparoscopic and perineal approaches for definitive pull-through and redo pull-through operations.

METHODS

This paper will focus on the definitive management of the newborn, TCA, and HAEC, areas in which we have had considerable experience at our institution.

RESULTS

We have treated almost 90 newborns with the definitive pull-through with minimum morbidity. We have managed 25 patients with TCA, of whom 5 had total intestinal involvement and died. The remaining 20 have undergone a total colectomy and endorectal pull-through (ERPT), with zero mortality and a very acceptable stooling pattern and continence rate. Our experience with more than 350 patients with Hirschsprung's disease over the past 25 years has demonstrated an incidence of HAEC of between 20% and 30%. During this period, we have performed 19 redo pull-through operations, the majority of which were ERPTs, with results comparable with those seen with a primary pull-through operation.

CONCLUSIONS

The major advances that have occurred in the management of Hirschsprung's disease include the definitive management of the newborn, our understanding of Hirschsprung's-associated enterocolitis and the treatment of this entity, and the recent successful management of the very complex form of this disease, total colonic aganglionosis.

Transanal mucosectomy in the treatment of Hirschsprung's disease

BACKGROUND/PURPOSE

Transanal mucosectomy of the aganglionic segment of colon is a critical step in minimally invasive surgery for Hirschsprung's disease. The purpose of this study was to examine the outcome of patients undergoing transanal mucosectomy.

METHODS

From January 1979 to November 1998, 26 patients (ages 25 days to 17 years) underwent transanal mucosectomy for Hirschsprung's disease. Seventeen (65%) had partial transanal mucosectomy (PTM; 1979 to 1998) and 9 (35%) complete transanal mucosectomy (CTM; 1995 to 1998). In PTM, a 2- to 3-cm mucosal dissection was begun 1 cm above the dentate line in conjunction with transabdominal endorectal dissection (modified Soave). In CTM, the entire mucosal dissection was performed transanally as part of a laparoscopically assisted Soave procedure. Results were obtained by chart review and personal communication. Patients were assessed clinically for continence where age appropriate (>3 years) and for development of constipation, postoperative enterocolitis, and anal stricture.

RESULTS

One of 16 (6.2%) of the PTM group was incontinent versus none (4 patients) in the CTM group. Five of 17 (29.4%) of the PTM group were constipated versus 4 of 9 (44.4%) in the CTM group (t test, P = not significant). Postoperative enterocolitis developed in 4 of 17 (23.5%) of the PTM group versus 6 of 9 (66.6%) in the CTM group (t test, P<.05). Three of 6 (50%) of the CTM group versus none in the PTM group required hospitalization for bowel rest, rectal washouts, and antibiotics. All patients were well at the time of the report. Anal stricture was not seen in either group.

CONCLUSIONS

Constipation and postoperative enterocolitis are a significant feature of transanal mucosectomy for Hirschsprung's disease deserving close surveillance, especially in patients in whom the entire mucosal dissection was performed transanally. Continence appears to be satisfactorily preserved from these preliminary results.

Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition

BACKGROUND

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers.

METHODS

The Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method.

RESULTS

The Subcommittee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Subcommittee also provided recommendations for management by the pediatric gastroenterologist.

CONCLUSIONS

This report, which has been endorsed by the Executive Council of the North American Society for Pediatric Gastroenterology and Nutrition, has been prepared as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. It is not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Aganglionosis of the small intestine: a rare form of Hirschsprung's disease

Absence of ganglion cells in the small intestine, a rare form of Hirschsprung's disease, is a condition found in newborns and associated with increased morbidity and mortality. Families are faced with numerous challenges, including maintenance of nutrition, the need for surgical interventions, and the potential for complications associated with the medical technologies necessary to maintain children with aganglionosis. Home care needs are not unlike those of other children with severe intestinal dysfunction such as short bowel syndrome. This article gives an overview of Hirschsprung's disease and presents three case studies of small bowel Hirschsprung's. One center's experience with Hirschsprung's disease supports the need for a multidisciplinary approach to long-term management and home care.

Reoperation for Hirschsprung's disease

BACKGROUND/PURPOSE

Reoperation for Hirschsprung's disease traditionally has been used for patients with anastomotic leaks or stricture or with severe constipation from retained aganglionic segment or neuronal dysplasia, but there is little information regarding its use for other complications and the long-term outcome in these patients.

METHODS

In a 23-year period, 107 infants and children underwent Soave (68 patients) or Duhamel (39 patients) pull-through procedures. The age at operation was newborn to 6 years (mean, 10 months). Eighty percent had aganglionosis limited to the rectosigmoid colon. Follow-up was by office visit or telephone (mean, 8.5 years).

RESULTS

Twenty-three of the 68 patients with Soave pull-through (34%) underwent reoperation for intractable enterocolitis (10 patients, all 10 cured); anastomotic stenosis (four patients, three cured, one continued diversion); anastomotic leak (four patients, four cured); retained aganglionic segment (three patients, three cured); one necrosis of pull-through converted to Duhamel and cured; and one rectal prolapse that was diverted. Fifteen of the 39 patients with Duhamel procedure (38%) underwent reoperation for severe constipation (seven patients, six cured, one diverted); persistent rectal septum (four patients, 4 cured); and intractable enterocolitis (four patients, three cured, one diverted). Overall, 21 of 23 patients (91%) with reoperation after Soave procedures were cured, whereas 13 of 15 patients (87%) who underwent reoperation after Duhamel procedure were cured, and four patients remain diverted.

CONCLUSIONS

These data show that aggressive reoperation can result in a high cure rate in Hirschsprung's disease. Although there is no significant difference in the rate of reoperation after Duhamel and Soave procedures, the patients with Soave pull-through required more complex reoperations, with several requiring more than one procedure. An aggressive approach to reoperation in patients with Hirschsprung's disease clearly is justified.

The approach to common abdominal diagnoses in infants and children. Part II

Part I (August 1998 issue, Pediatric Clinics), discussed appendicitis and common abdominal diagnoses in infants and in children associated with vomiting, as well as special considerations in the evaluation of immunologically suppressed and neurologically impaired pediatric patients. In this article, the authors continue to discuss the evaluation of constipation, gastrointestinal bleeding, common abdominal masses, and recurrent abdominal pain.

Enterocolitis

Enterocolitis continues to be the major cause of morbidity and mortality in patients with Hirschsprung's disease. The exact etiology of Hirschsprung's-associated enterocolitis is not known. This review focuses on the clinical aspects, etiology, and therapy of Hirschsprung's-associated enterocolitis.

Enterocolitis after the surgical treatment of Hirschsprung's disease: risk factors and financial impact

BACKGROUND/PURPOSE

Enterocolitis (EC) represents a serious complication after the surgical correction of Hirschsprung's disease (HD). Although previous studies have identified risk factors associated with the development of this complication before definitive repair, the factors leading to EC after pull-through have not been examined. This study was therefore designed to determine risk factors for the development of post-pull-through EC.

METHODS

Patients with HD treated from 1991 through 1996 at the Hospital for Sick Children in Toronto, Canada were assessed. Risk factors were examined in three areas: patient factors (gender, age at diagnosis, age and weight at pull-through), technical factors (type of repair, number of stages, location of transition zone, previous EC), and mechanical factors.

RESULTS

In 105 consecutive patients, the incidence of postoperative EC was 32%. There was no mortality. The risk of postoperative EC was significantly increased by mechanical factors related to anastomotic complications (relative risk, 2.8) and intestinal obstruction (relative risk, 3.5). This finding was not attributable to the general occurrence of any postoperative complication because the incidence of postoperative complications was equally distributed in patients with and without EC. The presence of EC significantly increased the number of hospital admissions, mean length of stay, and total treatment cost.

CONCLUSION

These findings suggest the use of measures to decrease mechanical obstruction so as to decrease the incidence and impact of this potentially devastating complication.

Turnover of radioactive mucin precursors in the colon of patients with Hirschsprung's disease correlates with the development of enterocolitis

BACKGROUND/PURPOSE

Mucin glycoproteins (mucins) in the colonic mucus gel layer interact with pathogens performing protective functions by a variety of mechanisms. It is recognised that patients with Hirschsprung's disease (HD) are prone to episodes of enterocolitis even after corrective surgery, the aetiology of which is poorly understood. The authors correlated the turnover of radioactive mucin precursors in organ culture of the proximal ganglionated colon at the time of pull-through with the development of postoperative enterocolitis.

METHODS

The colonic mucins in the retained proximal ganglionated colon of nine HD patients at the time of pull-through were studied. Organ culture of intact mucosa was performed with radioactive mucin precursors 35S-sulphate and 3H-glucosamine. Mucins in the secretions and epithelial cells were then purified by gel filtration. Turnover of the isotopes was determined by relating radioactivity to tissue DNA content. These patients were followed up prospectively for a mean duration of 30.8 months. The patients were assigned to one of two groups according to the criteria of requiring hospital admission for enterocolitis during this period. There were five patients in the group that remained well after corrective surgery and four in the group that developed entercolitis. The turnover values of both radioisotopes were analysed for differences in the two groups of patients.

RESULTS

Patients in the enterocolitis group had a median value for turnover of 331 dpm/microg DNA, and the group that was well had a median value of 2044 dpm/microg DNA. These differences were statistically significant (Mann-Whitney, P = .037).

CONCLUSIONS

A reduced turnover of mucins as shown by incorporation of radioactive precursors will give rise to a defective colonic mucus-defensive barrier. It can be inferred that the lower the turnover, the more prone a patient is to postoperative enterocolitis. It is therefore possible that organ culture with radioactive mucin precursors of the proximal ganglionated mucosa performed at the time of pull-through has a predictive value in the development of postoperative enterocolitis.

Children with Hirschsprung's disease have an abnormal colonic mucus defensive barrier independent of the bowel innervation status

The mucus gel layer in the colon plays an important role in the defensive mechanisms against pathogenic organisms. Mucin glycoproteins or mucins are the major component of this gel. We studied the mucins in patients who had Hirschsprung's disease (HD) by colonic mucosal organ culture with radioactive mucin precursors [35S]-sulphate and [3H]-glucosamine. The secreted and cellular mucus fractions were collected after 24-hour incubation, and mucins were purified by gel filtration. The ratio of incorporation of the precursors and their turnover were quantified. Purified mucins were tested against wheat germ agglutinin for total mucin turnover. We used nine aganglionic bowel samples, 10 ganglionic bowel samples from HD patients, and 13 age-matched normal controls. There were no significant differences in the three groups in ratio of incorporation. The turnover with both radioactive precursors was reduced in both aganglionic and ganglionic bowel of HD, these differences were significant in [35S]-sulphate incorporation in the cellular fraction, ganglionic bowel being most affected. Total mucin turnover, as assessed by reactivity with wheat germ aggultinin, was reduced in both HD groups, being significant in the cellular fraction, aganglionic bowel being the most affected. These results signify an abnormal mucus defensive barrier in the colon of HD patients, even in the ganglionic bowel, which is thought to be normal and is retained at the definitive pull-through operation. This abnormality may be an etiological factor in the pathogenesis of enterocolitis of HD.

Clinical outcome and long-term quality of life after surgical correction of Hirschsprung's disease

One hundred seventy-eight of 330 patients were recalled after undergoing surgery for histologically proven Hirschsprung's disease (HD). One hundred fifteen were older than 4 years at interview (Mean age, 10 years). This sample appeared to be representative of the whole in terms of demographic features such as ethnic group, sex, length of aganglionic segment, timing of presentation and surgery performed. Anthropomorphic indices for weight and height were comparable to norms, but many younger patients were below expected weight for age. In general, weight and height for age was regained with time. Nine patients had delayed developmental milestones, which were owing to specific causes in four. Nine patients had a poor functional outcome, of which two had neurological impairment. Satisfactory school performance was achieved in all but 19 (26%) of the remaining patients. Long-term functional results were comparable for the Soave and Duhamel procedures with less favorable results noted following the Swenson procedure. Assessment of complications demonstrated a significantly (P < .01) lower incidence of constipation, sexual dysfunction, and micturition disturbance following the Soave procedure when compared with the Duhamel and Swenson procedures. Neurological impairment and length of aganglionic segment beyond the rectosigmoid area appeared to influence functional outcome, as did persisting enterocolitis. Enterocolitis was observed in 16.6% of patients on presentation, but continued in only 6%. Constipation was particularly associated with the Duhamel procedure, and a higher incidence of micturition disturbance, abdominal distension, and cuff stricture was noted following the Swenson procedure. Functional assessment by three different scoring methods showed that 86 (74.7%) of the 115 patients over the age of 4 had excellent anorectal function and appeared to be well adjusted. Twenty-two patients (19.2%) had relatively minor long-term problems but seven (6.1%) had persistent fecal soiling with resulting psychosocial maladjustment.