Anorectal electromanometry in the diagnosis of neuronal intestinal dysplasia in childhood

Quality of life for families with spina bifida in Kenya

Spina bifida (SB) affects children worldwide. Studies from developed nations have explored the impact of SB on the quality of life of children and their parents. However, there are no such studies available from developing countries. We have therefore undertaken to document the impact of the disability on the families of affected children in Kenya. A questionnaire was administered to 40 mothers and their children, who were receiving treatment for SB at our institution. The results of this study should indicate where community and governmental resources and educational efforts for the disabled should be directed.

Rectal mucosal biopsy compared with laparoscopic seromuscular biopsy in the diagnosis of intestinal neuronal dysplasia in children with slow-transit constipation

BACKGROUND/PURPOSE

Intestinal neuronal dysplasia (IND) as a cause for severe chronic constipation remains controversial. The aim of this study is to examine the correlation between a deficiency of substance P (SP) immunoreactive nerve fibers in the colon and enzyme histochemistry of rectal biopsies in children with slow-transit constipation.

METHODS

Fifty children with intractable constipation have been assessed by rectal biopsies examined with histochemical staining for lactate dehydrogenase, and 32 children among those 50 have been studied by laparoscopic seromuscular biopsy of the colon labelled with antibodies to SP using immunofluorescence methods.

RESULTS

Four children have evidence of IND. Fifteen children, including all 4 IND cases, showed a deficiency of SP immunoreactivity. There is a significant correlation between giant ganglia and SP deficiency (P <.01).

CONCLUSION

This study is attempting to propose that a deficiency of SP immunoreactivity in colonic circular muscle nerves may be used as a histologic marker for slow-transit constipation and that IND may be a small subset of patients with SP deficiency.

Ileocolic intussusception: an unusual complication in a newborn with intestinal neuronal dysplasia

Intestinal neuronal dysplasia type B (IND B) represents a congenital malformation of the enteric nervous system causing disorders of intestinal motility, e. g., chronic constipation. We report a newborn who primarily suffered from intussusception and peritonitis. He required a subtotal colectomy for gangrene, but since IND B had not been expected at this time, no specific immunhistochemical workup for IND was initiated. Following recurrent episodes of ileus and subileus within the next years, colonic biopsies were taken and histotopochemical staining revealed IND B. The remaining colon required resection; an ileorectostomy was performed and the patient is now asymptomatic. This case report discusses the causality of IND B for intussusception and stresses that in newborn patients the clinical presentation may be misleading, and adequate histochemical evaluation is essential for early detection.

Surgical evaluation and management of refractory constipation in older children

Chronic constipation is a common childhood problem that accounts for 3% to 5% of pediatric visits and 10% to 25% of referrals to pediatric gastroenterologists. The etiology of constipation can be elusive, and extensive investigation often fails to identify a specific cause. The authors conducted a 5-year retrospective review of the patients referred for deep transanal rectal biopsy to determine the usefulness of this procedure in the evaluation and subsequent surgical management of refractory constipation. Specimens obtained by transanal rectal biopsy established a diagnosis for 30 of the 70 patients, and 17 of these 30 had subsequent procedures in the treatment of their constipation. The authors conclude that transanal rectal biopsy identifies a significant number of patients with previously unidentified neuroenteric disorders who may benefit from additional surgery in the treatment of constipation refractory to medical management.

Intestinal neuronal dysplasia in twins

Intestinal neuronal dysplasia (IND) has been described proximal to the aganglionic segment in Hirschsprung's disease and less frequently as an isolated condition. Familial occurrence of IND is rare. We report a case of monozygotic twins affected with IND. One-year-old male monozygotic twins presented with a history of chronic constipation and abdominal distension since birth. At presentation, both twins had fecal impaction with palpable fecal-filled loops of bowel. Barium enema in both patients showed gross fecal loading of the sigmoid colon and rectum. Delayed films taken at 48 h showed marked barium retention. Suction rectal biopsy specimens examined by acetylcholinesterase (AChE) histochemistry in both patients showed moderately increased AChE-positive nerve fibers in the lamina propria, muscularis mucosae, and around submucosal blood vessels, as well as hyperplasia of submucous plexus with formation of giant ganglia. Both children underwent extended internal sphincter myectomy. Six months later, both patients had normal bowel function. The occurrence of IND in twins suggests that genetic factors are involved in the etiology of this disease.

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.