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Yoon J, Jung KW, Ham NS, Kim J, Do YS, Kim SO, Choi SH, Kim DW, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, Yoon YS, Kim CW, Yu CS, Jung HY, Yang SK, Martin JE, Knowles CH, Myung SJ. Adult-onset megacolon with focal hypoganglionosis: A detailed phenotyping and prospective cohort study. Neurogastroenterol Motil 2023; 35:e14630. [PMID: 37392417 DOI: 10.1111/nmo.14630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 05/15/2023] [Accepted: 06/05/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND In this prospective cohort study, we evaluated features of "adult-onset megacolon with focal hypoganglionosis." METHODS We assessed the radiologic, endoscopic, and histopathologic phenotyping and treatment outcomes of 29 patients between 2017 and 2020. Data from community controls, consisting of 19,948 adults undergoing health screenings, were analyzed to identify risk factors. Experts reviewed clinical features and pathological specimens according to the London Classification for gastrointestinal neuromuscular pathology. KEY RESULTS The median age of the patients with adult-onset megacolon with focal hypoganglionosis at symptom onset was 59 years (range, 32.0-74.9 years), with mean symptom onset only 1 year before diagnosis. All patients had focal stenotic regions with proximal bowel dilatation (mean diameter, 78.8 mm; 95% confidence interval [CI], 72-86). The comparison with community controls showed no obvious risk factors. Ten patients underwent surgery, and all exhibited significant hypoganglionosis: 5.4 myenteric ganglion cells/cm (interquartile range [IQR], 3.7-16.4) in the stenotic regions compared to 278 cells/cm (IQR, 190-338) in the proximal and 95 cells/cm (IQR, 45-213) in the distal colon. Hypoganglionosis was associated with CD3+ T cells along the myenteric plexus. Colectomy was associated with significant symptom improvement compared to medical treatment [change in the Global Bowel Satisfaction score, -5.4 points (surgery) vs. -0.3 points (medical treatment); p < 0.001]. CONCLUSIONS AND INFERENCES Adult-onset megacolon with focal hypoganglionosis has distinct features characterized by hypoganglionosis due to inflammation. Bowel resection appears to benefit these patients.
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Affiliation(s)
- Jiyoung Yoon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- Department of Gastroenterology, Eulji University School of Medicine, Uijeongbu Eulji Medical Center, Uijeoungbu, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Nam Seok Ham
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yoon Suh Do
- Health Screening and Promotion Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seon Ok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Sang Hyun Choi
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wook Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- Digestive Diseases Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- Digestive Diseases Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joanne E Martin
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Charles H Knowles
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Seung-Jae Myung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- Digestive Diseases Research Center, University of Ulsan College of Medicine, Seoul, Korea
- Edis Biotech, Seoul, Korea
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Li H, Shu H, Xie Y, Zhang H, Cui M, Gao Y, Tian F. Multisegmental Hypoganglionosis: A Rare Cause of Recurrent Bowel Obstruction and Intestinal Ulcers. Inflamm Bowel Dis 2022; 28:e104-e105. [PMID: 35166345 DOI: 10.1093/ibd/izac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Hui Li
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hong Shu
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ying Xie
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hong Zhang
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mingming Cui
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuying Gao
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Feng Tian
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
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Song EM, Kim JW, Lee SH, Chang K, Hwang SW, Park SH, Yang DH, Jung KW, Ye BD, Byeon JS, Yang SK, Lee HJ, Yu CS, Kim CW, Park SH, Kim J, Myung SJ. Colonic Pseudo-obstruction With Transition Zone: A Peculiar Eastern Severe Dysmotility. J Neurogastroenterol Motil 2019; 25:137-147. [PMID: 30646485 PMCID: PMC6326194 DOI: 10.5056/jnm18121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/19/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Previous studies from Korea have described chronic intestinal pseudo-obstruction (CIPO) patients with transition zone (TZ) in the colon. In this study, we evaluated the pathological characteristics and their association with long-term outcomes in Korean colonic pseudo-obstruction (CPO) patients with TZ. Methods We enrolled 39 CPO patients who were refractory to medical treatment and underwent colectomy between November 1989 and April 2016 (median age at symptoms onset: 45 [interquartile range, 29–57] years, males 46.2%). The TZ was defined as a colonic segment connecting a proximally dilated and distally non-dilated segment. Detailed pathologic analysis was performed. Results Among the 39 patients, 37 (94.9%) presented with TZ and 2 (5.1%) showed no definitive TZ. Median ganglion cell density in the TZ adjusted for the colonic circumference was significantly decreased compared to that in proximal dilated and distal non-dilated segments in TZ (+) patients (9.2 vs 254.3 and 150.5, P < 0.001). Among the TZ (+) patients, 6 showed additional pathologic findings including eosinophilic ganglionitis (n = 2), ulcers with combined cytomegalovirus infection (n = 2), diffuse ischemic changes (n = 1), and heterotropic myenteric plexus (n = 1). During follow-up (median, 61 months), 32 (82.1%) TZ (+) patients recovered without symptom recurrence after surgery. The presence of pathological features other than hypoganglionosis was an independent predictor of symptom recurrence after surgery (P = 0.046). Conclusions Hypoganglionosis can be identified in the TZ of most Korean CPO patients. Detection of other pathological features in addition to TZ-associated hypoganglionosis was associated with poor post-operative outcomes.
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Affiliation(s)
- Eun Mi Song
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi-do, Korea
| | - Sun-Ho Lee
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kiju Chang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Wook Hwang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Hyoung Park
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Hoon Yang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Wook Jung
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byong Duk Ye
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong-Sik Byeon
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Suk-Kyun Yang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyo Jeong Lee
- Health Screening and Promotion Center, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan Wook Kim
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seong Ho Park
- Departments of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jihun Kim
- Departments of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Jae Myung
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Do YS, Myung SJ, Kwak SY, Cho S, Lee E, Song MJ, Yu CS, Yoon YS, Lee HK. Molecular and Cellular Characteristics of the Colonic Pseudo-obstruction in Patients With Intractable Constipation. J Neurogastroenterol Motil 2015; 21:560-70. [PMID: 26424041 PMCID: PMC4622139 DOI: 10.5056/jnm15048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/11/2015] [Accepted: 07/06/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Chronic intestinal pseudo-obstruction (CIPO) is a disorder characterized by recurrent symptoms suggestive of obstruction such as abdominal pain, proximal distension with extremely suppressed motility in the absence of lumen-occluding lesion, whose etiology/ pathophysiology is poorly understood. In this study we investigated a functionally obstructive lesion that could underlie symptoms of CIPO. METHODS We studied colons surgically removed from 13 patients exhibiting clinical/pathological features of pseudo-obstruction but were unresponsive to standard medical treatments. The colons were characterized morphologically, functionally and molecularly, which were compared between regions and to 28 region-matched controls obtained from colon cancer patients. RESULTS The colons with pseudo-obstruction exhibited persistent luminal distension proximally, where the smooth muscle was hypertrophied with changes in the cell phenotypes. Distinct luminal narrowing was observed near the distal end of the dilated region, close to the splenic flexure, previously referred to as the "transition zone (TZ)" between the dilated and non-dilated loops. Circular muscles from the TZ responded less to depolarization and cholinergic stimulation, which was associated with downregulation of L-type calcium channel expression. Smooth muscle contractile protein was also downregulated. Myenteric ganglia and neuronal nitric oxide synthase (nNOS) positive cells were deficient, more severely in the TZ region. Interstitial cells of Cajal was relatively less affected. CONCLUSIONS The TZ may be the principal site of functional obstruction, leading to proximal distension and smooth muscle hypertrophy, in which partial nNOS depletion could play a key role. The neuromuscular abnormalities probably synergistically contributed to the extremely suppressed motility observed in the colonic pseudo-obstruction.
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Affiliation(s)
- Yoon Suh Do
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Sun-Young Kwak
- Department of Pharmacology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Soohan Cho
- Department of Pharmacology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Enoch Lee
- Department of Pharmacology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Min Jeong Song
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hye Kyung Lee
- Department of Pharmacology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Kim JS, Lee BI, Kim BW, Choi H, Lee YS, Maeng L. Repetitive Colonoscopic Decompression as a Bridge Therapy before Surgery in a Pregnant Patient with Chronic Intestinal Pseudo-Obstruction. Clin Endosc 2013; 46:591-4. [PMID: 24143328 PMCID: PMC3797951 DOI: 10.5946/ce.2013.46.5.591] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 12/06/2012] [Accepted: 02/12/2013] [Indexed: 12/23/2022] Open
Abstract
Chronic intestinal pseudo-obstruction is a rare clinical syndrome which is characterized by intestinal obstruction without occluding lesions in the intestinal lumen and pregnancy is one of the important aggravating factors. Here, we report a case of a woman with intractable intestinal pseudo-obstruction that was precipitated by pregnancy. She could not make any stool passage for more than 4 weeks until a fetal gestational age of 17 weeks was reached. However, the patient could be maintained by repetitive colonoscopic decompressions and finally total colectomy could be performed successfully at a fetal gestational age of 21 weeks.
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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