Short segment Hirschsprung's disease as a cause of discrepancy between histologic, histochemical, and clinical features

Calretinin immunohistochemistry versus acetylcholinesterase histochemistry in the evaluation of suction rectal biopsies for Hirschsprung Disease

Diagnosis of Hirschsprung disease (HSCR) relies on histologic and/or histochemical staining of sections from suction rectal biopsies. Acetylcholinesterase histochemistry (AChE) facilitates diagnosis but is not universally employed, in part because it requires special tissue handling. Calretinin immunohistochemistry (IHC) may be a useful alternative, because loss of calretinin immunoreactive nerves reportedly correlates spatially with aganglionosis. We investigated the patterns of calretinin IHC in suction rectal biopsies from HSCR and non-HSCR patients and compared the diagnostic value of calretinin IHC with a widely used rapid AChE method. In suction rectal biopsies that contain ganglion cells, small nerves in the lamina propria, muscularis mucosae, and superficial submucosa contain granular aggregates of calretinin immunoreactivity. Immunolabeling of these nerves is completely absent in the aganglionic biopsies of HSCR patients. Multiple observers independently reviewed calretinin IHC and AChE sections of suction rectal biopsies from 14 HSCR patients and 17 non-HSCR controls. Five observers, blinded to the correct diagnosis, scored each patient's calretinin IHC and AChE slides as HSCR, not HSCR, or equivocal. The frequencies of major and minor discrepant diagnoses were compared. Calretinin IHC yielded no misdiagnoses or major discrepancies between observers. In contrast, 2 misdiagnoses and significantly more interobserver disagreement resulted from the AChE-stained sections. Calretinin IHC appears to be a reasonable, and potentially superior, alternative to AChE as an adjunctive diagnostic method for evaluating suction rectal biopsies for HSCR.

Hirschsprung's disease in Zaria, Nigeria: comparison of 2 consecutive decades

This is a retrospective study of 136 histologically confirmed cases of Hirschsprung's disease (HD) seen and treated in a single centre over 2 consecutive decades spanning the years from 1972 to 1991. Forty-six cases were seen in the 1st 10 years and 90 in the 2nd. Certain factors were considered to be responsible for the observed improvement during the 2nd decade; these included improvements in the mode of bowel preparation, the use of more effective antimicrobial agents with a wider spectrum of activity for prevention and treatment of established infections, and improvements in the pre-operative nutritional status of the patients and in the staging of the operations. Morbidity was minimal. Mortality dropped from 28.3% in the 1st decade to 5.6% in the 2nd. Causes of mortality in the 1st decade were pneumonia (8), aspiration of gastric contents (2), undernutrition (2) and haemorrhage from a dislodged clamp several days following a Duhamel procedure (1). In the early part of the 2nd decade, three patients died from anastomotic dehiscence following the Swenson procedure and two from aspiration pneumonia.

Hirschsprung disease: paternal transmission to a son

Hirschsprung disease (HD) is genetically heterogeneous with approximately 4% familial occurrence. The recurrence risk is higher in patients with severe involvement. We describe the transmission of histotopochemically proven HD from a father with long aganglionic segment disease to a son with ultrashort segment disease. This observation suggests that the length of involvement in HD is related to the variable expression of the gene defect. It also suggests autosomal dominant inheritance of HD.

Ultrashort Hirschsprung's disease: myth or reality

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

Problems and pitfalls in the management of Hirschsprung's disease

A study of 126 patients with histologically proven Hirschsprung's disease revealed various problems associated with the surgical management of these cases. Complications such as prolapse, stricture, and cuff abscess were noted in patients undergoing endorectal pull-through (ERPT). These complications were not always obvious, and in some cases, the diagnosis became apparent only several years after definitive surgery. Specific technical aspects of the procedure probably play an important role in the pathogenesis of these problems. Ultrashort-segment Hirschsprung's disease remains a problem in treatment. Rectal myectomy gives good results in some cases and unsatisfactory results in others.

Cholinesterase activities in resected bowel specimens from children with Hirschsprung's disease

We have measured acetylcholinesterase (AChE) and the butyrylcholinesterase (BChE) activities along strips of resected bowel specimens from thirteen children with Hirschsprung's disease. The AChE activity was variable along the length of the resected bowel, while the BChE activity remained constant. By contrast, the AChE/BChE ratio decreased rapidly to low levels when ganglion cells were present. We suggest that this ratio can be used to determine the normal segments of the bowel, to specify the anatomic forms (i.e. rectal or rectosigmoid) and may be useful in determining the anastomotic level.