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Gonçalves AC, de Faria Oliveira IS, Hamamoto Filho PT, Ortolan EVP, Terra SA, Rodrigues MAM, de Arruda Lourenção PLT. Association between Clinical and Histopathological Findings in Intestinal Neuronal Dysplasia Type B: An Advance towards Its Definition as a Disease. Life (Basel) 2023; 13:life13051175. [PMID: 37240820 DOI: 10.3390/life13051175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/30/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Intestinal neuronal dysplasia type B (IND-B) is a controversial entity that affects the submucosal nerve plexus of the distal intestine. The lack of definition of the causal relationship between histological findings and clinical symptoms has been identified as the primary point to be elucidated in the scientific investigation related to IND-B, which is essential for it to be considered a disease. OBJECTIVE To investigate the relationship between histopathological findings and symptoms in a series of patients with IND-B. METHODS Twenty-seven patients with histopathological diagnosis of IND-B, according to the Frankfurt Consensus (1990), who underwent surgical treatment through colorectal resections were included. Data from medical records regarding the clinical picture of the patients at the time of diagnosis, including the intestinal symptom index (ISI) and a detailed histopathological analysis of the rectal specimens, were retrieved. Exploratory factor analysis was performed, applying the principal components method for clusters with Varimax rotation. RESULTS Two factors were determined: the first, determined by histopathological and clinical variables, and the second, composed of the main symptoms presented in patients with IND-B, including ISI. Factorial rotation showed the association between the two factors and, through a graph, demonstrated the proximity between ISI values and histopathological alterations. CONCLUSION There was evidence of an association between the clinical features presented by patients with IND-B and the histopathological findings of the rectal samples. These results support the understanding of IND-B as a disease.
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Affiliation(s)
| | | | | | | | - Simone Antunes Terra
- Botucatu Medical School, São Paulo State University (UNESP), Botucatu 18618-687, Brazil
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Terra SA, Gonçalves AC, Lourenção PLTDA, Rodrigues MAM. Challenges in the diagnosis of intestinal neuronal dysplasia type B: A look beyond the number of ganglion cells. World J Gastroenterol 2021; 27:7649-7660. [PMID: 34908804 PMCID: PMC8641051 DOI: 10.3748/wjg.v27.i44.7649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 11/11/2021] [Indexed: 02/06/2023] Open
Abstract
Intestinal neuronal dysplasia type B (IND-B) is a controversial condition among gastrointestinal neuromuscular disorders. Constipation is its most common clinical manifestation in patients. Despite intense scientific research, there are still knowledge gaps regarding the diagnostic criteria for IND-B in the histopathological analysis of rectal biopsies. The guidelines published in the past three decades have directed diagnostic criteria for quantifying the number of ganglion cells in the nervous plexus of the enteric nervous system. However, it is very complex to distinguish numerically what is pathological from what is normal, mainly because of the difficulty in determining a reliable control group composed of healthy children without intestinal symptoms. Thus, a series of immunohistochemical markers have been proposed to assist in the histopathological analysis of the enteric nervous system. Several of these markers facilitate the identification of other structures of the enteric nervous system, in addition to ganglion cells. These structures may be related to the etiopathogenesis of IND-B and represent new possibilities for the histopathological diagnosis of this disease, providing a view beyond the number of ganglion cells. This review critically discusses the aspects related to the disease definitions and diagnostic criteria of this organic cause of constipation.
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Affiliation(s)
- Simone Antunes Terra
- Department of Pathology, Faculty of Medicine, São Paulo State University (UNESP), Botucatu 18618687, São Paulo, Brazil
| | - Anderson Cesar Gonçalves
- Department of Surgery and Orthopedics, Botucatu Medical School - São Paulo State University (UNESP), Botucatu 18618970, São Paulo, Brazil
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Lourenção PLTDA, Ortolan EVP, Rosa LLM, Angelini MC, Cassettari VMG, Terra SA, Rodrigues MAM. What should be the treatment for intestinal neuronal dysplasia type B? A comparative long-term follow-up study. J Pediatr Surg 2021; 56:1611-1617. [PMID: 33279216 DOI: 10.1016/j.jpedsurg.2020.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To present the long-term follow-up outcomes of patients with intestinal neuronal dysplasia type B (IND-B) managed either conservatively or surgically. METHODS We conducted an ambispective, observational, longitudinal, and comparative study. Clinical data were reviewed at the start of treatment. After a minimum period of five years, the patients participated in semi-structured interviews in which the bowel function score (BFS) was applied to assess intestinal function, a proposed intestinal symptom index (ISI) to assess clinical symptoms, and a classification of clinical prognosis to assess treatment success. Comparisons between the two types of treatment were performed by evaluating pre- and post-treatment criteria. RESULTS Fifty patients diagnosed with IND-B were included in the study. Thirty-eight patients underwent surgical treatment (26 elective surgical treatment for primary colorectal resection and 12 emergency colostomies for intestinal obstruction or enterocolitis). Twelve patients were managed conservatively. With the exception of the patients who required an emergency operation (n = 12), the two groups were composed of patients with severe constipation who had similar clinical and functional characteristics at the time of IND-B diagnosis. A better clinical response was observed in patients submitted to conservative treatment, with a greater increase in the BFS (16.5 [-4/+18] versus 4 [-15/+17]; p = 0.001), indicating better bowel function and a more pronounced drop in ISI (-6 [-7/-4] versus -4 [-6/+1]; p = 0.015), suggesting fewer symptoms. The percentage of patients who had a successful treatment was higher in the group treated conservatively (72.7% versus 42.3%; p = 0.03). CONCLUSION Conservative management showed better long-term outcomes than surgical management in children with IND-B.
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Affiliation(s)
- Pedro Luiz Toledo de Arruda Lourenção
- Department of Surgery, Division of Pediatric Surgery, Botucatu Medical School, UNESP - São Paulo State University, Botucatu CEP 18618-687, SP, Brazil.
| | - Erika Veruska Paiva Ortolan
- Department of Surgery, Division of Pediatric Surgery, Botucatu Medical School, UNESP - São Paulo State University, Botucatu CEP 18618-687, SP, Brazil
| | | | - Marcos Curcio Angelini
- Department of Surgery, Division of Pediatric Surgery, Botucatu Medical School, UNESP - São Paulo State University, Botucatu CEP 18618-687, SP, Brazil
| | | | - Simone Antunes Terra
- Department of Pathology, Botucatu Medical School, UNESP - São Paulo State University, Botucatu, SP, Brazil
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Kang YN, Fung C, Vanden Berghe P. Gut innervation and enteric nervous system development: a spatial, temporal and molecular tour de force. Development 2021; 148:148/3/dev182543. [PMID: 33558316 DOI: 10.1242/dev.182543] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
During embryonic development, the gut is innervated by intrinsic (enteric) and extrinsic nerves. Focusing on mammalian ENS development, in this Review we highlight how important the different compartments of this innervation are to assure proper gut function. We specifically address the three-dimensional architecture of the innervation, paying special attention to the differences in development along the longitudinal and circumferential axes of the gut. We review recent information about the formation of both intrinsic innervation, which is fairly well-known, as well as the establishment of the extrinsic innervation, which, despite its importance in gut-brain signaling, has received much less attention. We further discuss how external microbial and nutritional cues or neuroimmune interactions may influence development of gut innervation. Finally, we provide summary tables, describing the location and function of several well-known molecules, along with some newer factors that have more recently been implicated in the development of gut innervation.
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Affiliation(s)
- Yi-Ning Kang
- Laboratory for Enteric NeuroScience (LENS), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven 3000, Belgium
| | - Candice Fung
- Laboratory for Enteric NeuroScience (LENS), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven 3000, Belgium
| | - Pieter Vanden Berghe
- Laboratory for Enteric NeuroScience (LENS), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven 3000, Belgium
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Angelini MC, Silva AME, Felix TF, Lapa RML, Terra SA, Rodrigues MAM, Ortolan EVP, Reis PP, Lourenção PLTA. Identification of potential molecular pathogenesis mechanisms modulated by microRNAs in patients with Intestinal Neuronal Dysplasia type B. Sci Rep 2019; 9:17673. [PMID: 31776429 PMCID: PMC6881445 DOI: 10.1038/s41598-019-54245-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/06/2019] [Indexed: 01/15/2023] Open
Abstract
This study proposed to determine global microRNA (miRNA) expression and miRNA-regulated pathways in Intestinal Neuronal Dysplasia type B (IND-B). Fifty patients (0-15 years old) with IND-B were included in the study. Peripheral blood samples were collected from all 50 patients and from 10 healthy asymptomatic children (controls). Rectal biopsies were collected from 29/50 patients; biopsy tissues were needle microdissected to isolate the different intestinal layers, for molecular analysis. Global miRNA expression was determined using TaqMan arrays. Correlation analysis between miRNA expression in plasma and biopsy samples as well as among tissues derived from the distinct intestinal layers was performed. Computational approaches were used for miRNA target prediction/identification of miRNA-regulated genes and enriched pathways biologically relevant to IND-B pathogenesis. miRNAs were statistically significantly deregulated (FC ≥ 2 and p ≤ 0.05) in submucosal and muscular layers: over-expressed (miR-146a and miR-146b) and under-expressed (miR-99a, miR-100, miR-130a, miR-133b, miR-145, miR-365, miR-374-5p, miR-451). Notably, let-7a-5p was highly over-expressed in patient plasma compared to healthy controls (FC = 17.4). In addition, miR-451 was significantly under-expressed in both plasma and all biopsy tissues from the same patients. Enriched pathways (p < 0.01) were axon guidance, nerve growth factor signalling, NCAM signalling for neurite out-growth, neuronal system and apoptosis. miRNA expression is deregulated in the submucosa and muscular layers of the rectum and detected in plasma from patients with IND-B. Biologically enriched pathways regulated by the identified miRNAs may play a role in IND-B disease pathogenesis, due to the activity related to the neurons of the enteric nervous system.
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Affiliation(s)
- Marcos C Angelini
- UNESP - São Paulo State University, Faculty of Medicine, Department of Surgery and Orthopedics, Botucatu, SP, Brazil
| | - Alana Maia E Silva
- UNESP - São Paulo State University, Faculty of Medicine, Department of Surgery and Orthopedics, Botucatu, SP, Brazil
| | - Tainara F Felix
- UNESP - São Paulo State University, Faculty of Medicine, Department of Surgery and Orthopedics, Botucatu, SP, Brazil
- UNESP - São Paulo State University, Faculty of Medicine, Experimental Research Unity (UNIPEX), Botucatu, SP, Brazil
| | - Rainer M L Lapa
- Institute of Livestock and Biotechnology, Laboratory of Molecular Physiology, Toribio Rodriguez de Mendoza National University, Amazonas, Peru
| | - Simone A Terra
- UNESP - São Paulo State University, Faculty of Medicine, Department of Pathology, Botucatu, SP, Brazil
| | - Maria A M Rodrigues
- UNESP - São Paulo State University, Faculty of Medicine, Department of Pathology, Botucatu, SP, Brazil
| | - Erika V P Ortolan
- UNESP - São Paulo State University, Faculty of Medicine, Department of Surgery and Orthopedics, Botucatu, SP, Brazil
| | - Patricia P Reis
- UNESP - São Paulo State University, Faculty of Medicine, Department of Surgery and Orthopedics, Botucatu, SP, Brazil
- UNESP - São Paulo State University, Faculty of Medicine, Experimental Research Unity (UNIPEX), Botucatu, SP, Brazil
| | - Pedro L T A Lourenção
- UNESP - São Paulo State University, Faculty of Medicine, Department of Surgery and Orthopedics, Botucatu, SP, Brazil.
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Bathgate JR, Matarese L, Ziegler J, Touger-Decker R. Case Report: Transitioning to a Mixed-Oil Intravenous Lipid Emulsion in an Adult Patient Receiving Home Parenteral Nutrition. Nutr Clin Pract 2019; 35:871-884. [PMID: 31478264 DOI: 10.1002/ncp.10387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A potential risk of long-term parenteral nutrition (PN) is intestinal failure-associated liver disease (IFALD). One recommendation for mitigating risk is limiting the fat dose to reduce the harmful effects of the ω-6 fatty acids, which are the main ingredient in traditional fats. SMOFlipid (SMOF) (Kabi-Fresenius, Bad Homburg, Germany) is a combination of soybean oil, medium-chain triglycerides, olive oil, and fish oil emulsion. This fat source may alleviate the risk of IFALD and improve liver function tests. A patient with a long history of PN reliance and IFALD is presented in this case report. After 4 months on SMOF, total and direct bilirubin levels improved.
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Affiliation(s)
- Jennifer R Bathgate
- Rutgers School of Health Professions, Newark, New Jersey, USA.,Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Laura Matarese
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Jane Ziegler
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, New Jersey, USA
| | - Riva Touger-Decker
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, New Jersey, USA
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Kapur RP, Reyes-Mugica M. Intestinal Neuronal Dysplasia Type B: An Updated Review of a Problematic Diagnosis. Arch Pathol Lab Med 2018; 143:235-243. [DOI: 10.5858/arpa.2017-0524-ra] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Intestinal neuronal dysplasia type B (IND B) is a controversial histopathologic phenotype that has been associated with intestinal dysmotility, either as an isolated condition or in conjunction with established pathologic disorders (eg, Hirschsprung disease). Many factors contribute to the debate over the existence and/or clinical significance of IND B, including a large body of published data based on inconsistent diagnostic criteria and methods, which have fostered many unwarranted conclusions that lack sufficient scientific basis.
Objective.—
To critically analyze existing published data regarding IND B to provide supporting evidence-based diagnostic practice and to stimulate necessary and scientifically sound research.
Data Sources.—
This update focuses on published literature related to the pathology of IND B because without a reliable pathologic diagnosis, studies of epidemiology, pathogenesis, natural history, management, and outcome are all suspect. Problems with existing data are identified explicitly with suggestions as to how future investigations should be designed and evaluated to better understand this entity.
Conclusions.—
Inconsistencies in diagnostic criteria and methods used to define IND B justifiably encumber the universal acceptance of IND B as a neuropathologic etiology for intestinal dysmotility. IND B will remain a controversial diagnosis until rigorous, well-controlled scientific studies are conducted to establish reproducible and reliable diagnostic criteria that reliably translate from one laboratory to another.
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Affiliation(s)
- Raj P. Kapur
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Kapur); the Department of Pathology, University of Washington School of Medicine, Seattle (Dr Kapur); and the Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Dr Reyes-Mugica)
| | - Miguel Reyes-Mugica
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Kapur); the Department of Pathology, University of Washington School of Medicine, Seattle (Dr Kapur); and the Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Dr Reyes-Mugica)
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Masuda T, Nonaka T, Adachi T, Hisanaga M, Nagayoshi S, Tokunaga T, Taniguchi K, Kurohama H, Ito M, Fujioka H. A case of single incision laparoscopic total colectomy for intestinal neuronal dysplasia type B. Int J Surg Case Rep 2017; 38:122-127. [PMID: 28756361 PMCID: PMC5537404 DOI: 10.1016/j.ijscr.2017.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 02/06/2023] Open
Abstract
In patients with refractory constipation, it is necessary to care in mind that some patients require surgery. Single incision laparoscopic surgery (SILS) is regarded as the major advance in minimally invasive surgery. Total colectomy by SILS is very useful for the patients with intestinal neuronal dysplasia-type B.
Introduction Intestinal neuronal dysplasia type B (IND-B) is an infrequent disease of the submucosal plexus of intestine manifesting chronic intestinal obstruction or severe chronic constipation. IND is rarely reported in adult patients. Presentation of a case The present study reports on the case of a 36 year-old woman suffering from longstanding chronic constipation and who was diagnosed with severe constipation in more than 20 years. Although she began to take a large amount of stimulant laxatives, such as “senna” and “bisacodyl”, constipation symptoms did not improve, she was admitted to our hospital. It was diagnosed with refractory constipation of the medication treatment-resistance, total colectomy with ileorectal anastomosis by single incision laparoscopic surgery (SILS) was performed. The final pathological diagnosis was IND-B. Discussion Refractory constipation after medical treatment is often seen in young generation. SILS has benefits of better cosmesis, reduced morbidity, reduced postoperative pain, and reduced length of hospital stay. Conclusion For the patients with refractory constipation associated with neuropathy such as IND, total colectomy by SILS was very effective.
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Affiliation(s)
- Taro Masuda
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Takashi Nonaka
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan.
| | - Toshiyuki Adachi
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Makoto Hisanaga
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Shigeki Nagayoshi
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Takayuki Tokunaga
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Ken Taniguchi
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Hirokazu Kurohama
- Department of Pathology, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Masahiro Ito
- Department of Pathology, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Hikaru Fujioka
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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Abstract
Surgical management of Hirschsprung disease requires resection of the aganglionic bowel and transition zone, a length of ganglionic bowel, immediately proximal to the aganglionic segment, with neuropathologic features that seem to correlate with dysmotility. Pathologists must be able to recognize histopathologic features of the transition zone in hematoxylin and eosin-stained sections in order to interpret intraoperative frozen sections and ensure adequate resection. The proximal ganglionic portions of colonic resection specimens from 59 patients with distal aganglionosis were analyzed with closely spaced transverse sections to map the distribution of the 3 most commonly referenced features of transition zone (partial circumferential aganglionosis, myenteric hypoganglionosis, and submucosal nerve hypertrophy). Each of these "primary" findings was restricted to a region ≤5 cm proximal to the aganglionic segment in the overwhelming majority of patients. Exceptions were more common with longer aganglionic segments. Three other neuroanatomic phenotypes (gangliosclerosis, ectopic myenteric ganglia, and eosinophilic ganglionitis) of uncertain clinical significance were distributed more irregularly and often over much longer distances. Routine resection of at least 5 cm of ganglionic bowel proximal to the aganglionic segment may reduce the incidence of transition zone pull-through. However, routine intraoperative frozen section examination of the proximal resection margin to exclude the 3 primary forms of hematoxylin and eosin neuropathology described in this study is strongly advised.
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Terra SA, de Arruda Lourenção PL, G Silva M, A Miot H, Rodrigues MAM. A critical appraisal of the morphological criteria for diagnosing intestinal neuronal dysplasia type B. Mod Pathol 2017; 30:978-985. [PMID: 28304401 DOI: 10.1038/modpathol.2017.4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 01/23/2023]
Abstract
Intestinal neuronal dysplasia type B is a controversial entity expressed by complex changes in the enteric nervous system. Diagnosis depends on rectal biopsy histopathology and diagnostic criteria, both qualitative and quantitative, have changed over time, hindering the diagnostic practice. We analyzed the morphological criteria for the histological diagnosis of intestinal neuronal dysplasia type B in a series of patients with intestinal neuronal dysplasia type B according to the 1990 Frankfurt Consensus criteria and verified the applicability of the numerical criteria proposed by Meier-Ruge et al in 2004 and 2006. Qualitative criteria adopted for the histological diagnosis of intestinal neuronal dysplasia type B included hyperplasia of the submucous plexus with hyperganglionosis and hypertrophy of the nerve trunks. Quantitative criteria considered more than 20% giant ganglia in the submucosa, with more than eight neurons each on 25 ganglia, and children aged over 1 year. Distal colon surgical specimens from 29 patients, aged 0-16 years, diagnosed with intestinal neuronal dysplasia type B were retrospectively analyzed using sections processed for conventional histology (H&E) and calretinin immunohistochemistry. Hyperplasia of the submucosal nerve plexi with hyperganglionosis and hypertrophy of the nerve trunks was observed in all cases. Ganglia with small, immature neurons were detected in the majority of cases. Quantitative analysis confirmed hyperganglionosis (mean number=10.7 neurons per ganglion) and hypertrophy of the nerve trunks (median=44.6 μm thickness). Neurons showed immunostaining for calretinin, but neuron counts in calretinin-stained sections were lower compared with H&E (P<0.01). No significant differences were verified between children aged under and over 1 year regarding hyperganglionosis (P=0.79), neuron counts (P=0.36), and immature ganglia (P=0.66). Only one patient met the numerical criteria proposed by Meier-Ruge et al in 2004 and 2006. In conclusion, the numerical criteria showed limited applicability when transposed to conventional histopathology. Children aged over 1 year presented very similar histological features of neuronal immaturity to younger children, questioning the need for an age criterion when diagnosing intestinal neuronal dysplasia type B.
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Affiliation(s)
- Simone A Terra
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Pedro L de Arruda Lourenção
- Department of Surgery, Division of Pediatric Surgery, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Márcia G Silva
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Hélio A Miot
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Maria A M Rodrigues
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
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Lourenção PLTDA, Ortolan EVP, Rosa LLM, Angelini MC, Terra SA, Rodrigues MAM. Long-term follow-up of patients with intestinal neuronal dysplasia type B: Protocol for an observational, ambispective, and comparative study. Medicine (Baltimore) 2017; 96:e7485. [PMID: 28700491 PMCID: PMC5515763 DOI: 10.1097/md.0000000000007485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Intestinal neuronal dysplasia type B (IND-B) is a pathological entity of the group of gastrointestinal neuromuscular diseases characterized by complex alterations in the enteric nervous system. Patients typically present with intestinal constipation, sometimes complicated by episodes of intestinal obstruction. The 2 therapeutic modalities include conservative clinical treatment and surgical treatment. Nevertheless, the results of the different therapeutic modalities are conflicting, and follow-up studies are scarce and include only a limited number of patients.This is a single-center, ambispective, observational, longitudinal, and comparative follow-up study to compare the results of conservative clinical and surgical treatments in patients with IND-B. Sixty-three patients (<15 years) who received this diagnosis will be included. These patients will be divided into 2 groups according to the type of treatment that they previously received: 29 patients in the surgical treatment group and 34 patients in the conservative treatment group. Previous data will be recovered from the medical records of the study patients, including signs and symptoms present at the time of diagnosis, particularly those related to bowel habits, and treatments undergone. Later, these patients will be invited to participate in a semistructured interview during which aspects related to the long-term functional results of the bowel habit and quality of life will be investigated after a minimum interval of 5 years posttreatment.This project aims to assess the long-term clinical evolution of patients diagnosed with IND-B and compare the results obtained following conservative clinical and surgical treatments.This protocol will provide sufficient data to analyze the long-term clinical outcome obtained through the 2 treatment modalities proposed for patients with IND-B.
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Affiliation(s)
| | | | | | | | - Simone Antunes Terra
- Department of Pathology, Botucatu Medical School, São Paulo State University (UNESP), São Paulo, Brazil
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12
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Abstract
PURPOSE OF REVIEW Neurointestinal diseases are increasingly recognized as causes of significant gastrointestinal morbidity in children. This review highlights the most common pediatric enteric neuropathies and their diagnosis and management, emphasizing insights and discoveries from the most recent literature available. RECENT FINDINGS The embryologic and histopathologic causes of enteric neuropathies are varied. They range from congenital aganglionosis in Hirschsprung disease, to autoimmune-mediated loss of neuronal subtypes in esophageal achalasia and Chagas disease, to degenerative neuropathies in some cases of chronic intestinal pseudo-obstruction and gastroparesis. Increased awareness of the clinical presentation and diagnostic evaluation of these conditions is essential as it allows for earlier initiation of treatment and improved outcomes. Most current therapies, which include medical management, neurostimulation, and operative intervention, aim to minimize the symptoms caused by these conditions. The evidence base for many of these treatments in children is poor, and multiinstitutional prospective studies are needed. An innovative therapy on the horizon involves using neuronal stem cell transplantation to treat the underlying disorder by replacing the missing or damaged neurons in these diseases. SUMMARY Although recent advances in basic and clinical neurogastroenterology have significantly improved our awareness and understanding of enteric neuropathies, the efficacy of current treatment approaches is limited. The development of novel therapies, including pharmacologic modulators of neurointestinal function, neurostimulation to enhance gut motility, and neuronal cell-based therapies, is essential to improve the long-term outcomes in children with these disorders.
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Affiliation(s)
- Maggie L. Westfal
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Allan M. Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA
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Hao MM, Bergner AJ, Hirst CS, Stamp LA, Casagranda F, Bornstein JC, Boesmans W, Vanden Berghe P, Young HM. Spontaneous calcium waves in the developing enteric nervous system. Dev Biol 2017; 428:74-87. [PMID: 28528728 DOI: 10.1016/j.ydbio.2017.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 12/20/2022]
Abstract
The enteric nervous system (ENS) is an extensive network of neurons in the gut wall that arises from neural crest-derived cells. Like other populations of neural crest cells, it is known that enteric neural crest-derived cells (ENCCs) influence the behaviour of each other and therefore must communicate. However, little is known about how ENCCs communicate with each other. In this study, we used Ca2+ imaging to examine communication between ENCCs in the embryonic gut, using mice where ENCCs express a genetically-encoded calcium indicator. Spontaneous propagating calcium waves were observed between neighbouring ENCCs, through both neuronal and non-neuronal ENCCs. Pharmacological experiments showed wave propagation was not mediated by gap junctions, but by purinergic signalling via P2 receptors. The expression of several P2X and P2Y receptors was confirmed using RT-PCR. Furthermore, inhibition of P2 receptors altered the morphology of the ENCC network, without affecting neuronal differentiation or ENCC proliferation. It is well established that purines participate in synaptic transmission in the mature ENS. Our results describe, for the first time, purinergic signalling between ENCCs during pre-natal development, which plays roles in the propagation of Ca2+ waves between ENCCs and in ENCC network formation. One previous study has shown that calcium signalling plays a role in sympathetic ganglia formation; our results suggest that calcium waves are likely to be important for enteric ganglia development.
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Affiliation(s)
- Marlene M Hao
- Department of Anatomy and Neuroscience, University of Melbourne, Australia; Laboratory for Enteric Neuroscience, TARGID, University of Leuven, Belgium.
| | - Annette J Bergner
- Department of Anatomy and Neuroscience, University of Melbourne, Australia
| | - Caroline S Hirst
- Department of Anatomy and Neuroscience, University of Melbourne, Australia
| | - Lincon A Stamp
- Department of Anatomy and Neuroscience, University of Melbourne, Australia
| | - Franca Casagranda
- Department of Anatomy and Neuroscience, University of Melbourne, Australia
| | | | - Werend Boesmans
- Laboratory for Enteric Neuroscience, TARGID, University of Leuven, Belgium
| | | | - Heather M Young
- Department of Anatomy and Neuroscience, University of Melbourne, Australia
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Subramanian H, Badhe BA, Toi PC, Sambandan K. Morphometric profile of large intestinal neuronal plexuses in normal perinatal autopsies and Hirschsprung disease. Neurogastroenterol Motil 2017; 29. [PMID: 27620161 DOI: 10.1111/nmo.12939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/08/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To derive objective values for the diagnosis of Hirschsprung disease (HSCR) from a comparison of the morphometric profile of large intestinal neuronal plexuses in normal perinatal autopsies and surgical specimens of HSCR. METHODS A cross-sectional comparative study with 40 subjects each in (i) non-HSCR perinatal group encompassing neonates and stillborn babies beyond 30 weeks of gestation on whom autopsies were conducted and (ii) HSCR group comprising all patients clinicoradiologically diagnosed as HSCR. The morphometric assessment was done on hematoxylin-and-eosin-stained sections. KEY RESULTS The morphometric profile in terms of average number of ganglia/linear mm of colon, interganglion distance, number of ganglion cells/ganglion, average ganglion cell length, ganglion cell nuclear area, ganglion cell nuclear diameter, nerve trunk thickness, and density has been outlined. On comparison with the neuroanatomically normal zone of HSCR, the cut-offs to identify hypertrophic nerve trunks (nerve trunk thickness of >37.85 μm) and reduced number of ganglia (number of ganglia/linear mm of colon <2.05 and interganglion distance of >229 μm) were derived. CONCLUSIONS & INFERENCES The determined objective values, after testing on diagnostic rectal biopsies, may serve to formulate a diagnostic algorithm along with immunostaining for diagnosis of HSCR in colorectal specimens.
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Affiliation(s)
- H Subramanian
- Department of Pathology (Histopathology section), Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - B A Badhe
- Department of Pathology (Histopathology section), Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - P C Toi
- Department of Pathology (Histopathology section), Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - K Sambandan
- Department of Paediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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15
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Moore SW. Advances in understanding functional variations in the Hirschsprung disease spectrum (variant Hirschsprung disease). Pediatr Surg Int 2017; 33:285-298. [PMID: 27988850 DOI: 10.1007/s00383-016-4038-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/11/2022]
Abstract
Hirschsprung disease (HSCR) is a fairly well understood congenital, genetically based functional obstruction due to the congenital absence of ganglion cells in the distal bowel. However, although over 90% of Hirschsprung cases conform to the normally accepted histological diagnostic criteria, it has become increasingly clear that in addition to HSCR, there is a group of functional disturbances relating to a number of other congenital neurodysplastic conditions causing some degree of gastrointestinal tract malfunction. Although these represent a variety of possibly separate conditions of the enteric nervous system, this spectrum it would appear to be also influenced by similar developmental processes. The term "variant Hirschsprung" is commonly used to describe these conditions, but ganglion cells are mostly present if abnormal in number and distribution. These conditions are a problem group being amongst the most difficult to diagnose and treat with possible practical and legal consequences. The problem appears to be possibly one of definition which has proven difficult in the relative paucity of normal values, especially when correlated to age and gestation. It is the purpose of this paper to review the current position on these conditions and to explore possible shared common pathogenetic and genetic mechanisms. This article explores those conditions where a similar pathogenetic mechanisms to HSCR can be demonstrated (e.g. hypoganglionosis) as well as other neural features, which appear to represent separate conditions possibly linked to certain syndromes.
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Affiliation(s)
- S W Moore
- Division of Paediatric Surgery, Faculty of Medicine, University of Stellenbosch, P.O. Box 19063, Tygerberg, 7505, South Africa.
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16
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Toledo de Arruda Lourenção PL, Terra SA, Ortolan EVP, Rodrigues MAM. Intestinal neuronal dysplasia type B: A still little known diagnosis for organic causes of intestinal chronic constipation. World J Gastrointest Pharmacol Ther 2016; 7:397-405. [PMID: 27602240 PMCID: PMC4986395 DOI: 10.4292/wjgpt.v7.i3.397] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 04/14/2016] [Accepted: 05/07/2016] [Indexed: 02/06/2023] Open
Abstract
Intestinal neuronal dysplasia type B (IND-B) is a controversial entity among the gastrointestinal neuromuscular disorders. It may occur alone or associated with other neuropathies, such as Hirschsprung's disease (HD). Chronic constipation is the most common clinical manifestation of patients. IND-B primarily affects young children and mimics HD, but has its own histopathologic features characterized mainly by hyperplasia of the submucosal nerve plexus. Thus, IND-B should be included in the differential diagnoses of organic causes of constipation. In recent years, an increasing number of cases of IND-B in adults have also been described, some presenting severe constipation since childhood and others with the onset of symptoms at adulthood. Despite the intense scientific research in the last decades, there are still knowledge gaps regarding definition, pathogenesis, diagnostic criteria and therapeutic possibilities for IND-B. However, in medical practice, we continue to encounter patients with severe constipation or intestinal obstruction who undergo to diagnostic investigation for HD and their rectal biopsies present hyperganglionosis in the submucosal nerve plexus and other features, consistent with the diagnosis of IND-B. This review critically discusses aspects related to the disease definitions, pathophysiology and genetics, epidemiology distribution, clinical presentation, diagnostic criteria and therapeutic possibilities of this still little-known organic cause of intestinal chronic constipation.
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17
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Brosens E, Burns AJ, Brooks AS, Matera I, Borrego S, Ceccherini I, Tam PK, García-Barceló MM, Thapar N, Benninga MA, Hofstra RMW, Alves MM. Genetics of enteric neuropathies. Dev Biol 2016; 417:198-208. [PMID: 27426273 DOI: 10.1016/j.ydbio.2016.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 12/23/2022]
Abstract
Abnormal development or disturbed functioning of the enteric nervous system (ENS), the intrinsic innervation of the gastrointestinal tract, is associated with the development of neuropathic gastrointestinal motility disorders. Here, we review the underlying molecular basis of these disorders and hypothesize that many of them have a common defective biological mechanism. Genetic burden and environmental components affecting this common mechanism are ultimately responsible for disease severity and symptom heterogeneity. We believe that they act together as the fulcrum in a seesaw balanced with harmful and protective factors, and are responsible for a continuum of symptoms ranging from neuronal hyperplasia to absence of neurons.
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Affiliation(s)
- Erwin Brosens
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Alan J Burns
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands; Stem Cells and Regenerative Medicine, Birth Defects Research Centre, UCL Institute of Child Health, London, UK
| | - Alice S Brooks
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ivana Matera
- UOC Medical Genetics, Istituto Giannina Gaslini, Genova, Italy
| | - Salud Borrego
- Department of Genetics, Reproduction and Fetal Medicine, Institute of Biomedicine of Seville (IBIS), Seville, Spain; Centre for Biomedical Network Research on Rare Diseases (CIBERER), Seville, Spain
| | | | - Paul K Tam
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine of the University of Hong Kong, Hong Kong, China
| | - Maria-Mercè García-Barceló
- State Key Laboratory of Brain and Cognitive Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Centre for Reproduction, Development, and Growth, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, Birth Defects Research Centre, UCL Institute of Child Health, London, UK
| | - Marc A Benninga
- Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Robert M W Hofstra
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands; Stem Cells and Regenerative Medicine, Birth Defects Research Centre, UCL Institute of Child Health, London, UK
| | - Maria M Alves
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
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Goldstein AM, Thapar N, Karunaratne TB, De Giorgio R. Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment. Dev Biol 2016; 417:217-28. [PMID: 27059882 DOI: 10.1016/j.ydbio.2016.03.032] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 02/07/2023]
Abstract
The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.
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Affiliation(s)
- Allan M Goldstein
- Department of Pediatric Surgery, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nikhil Thapar
- Division of Neurogastroenterology and Motility, Department of Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
| | - Tennekoon Buddhika Karunaratne
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
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Agrawal RK, Kakkar N, Vasishta RK, Kumari V, Samujh R, Rao KLN. Acetylcholinesterase histochemistry (AChE)--A helpful technique in the diagnosis and in aiding the operative procedures of Hirschsprung disease. Diagn Pathol 2015; 10:208. [PMID: 26631177 PMCID: PMC4668621 DOI: 10.1186/s13000-015-0443-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 11/19/2015] [Indexed: 01/05/2023] Open
Abstract
Background Hirschsprung’s disease (HD) is an anomaly characterized by the absence of myenteric and submucosal ganglion cells (GC) in the distal alimentary tract. Diagnosis of HD is made by the absence of GC and missing out on even a single ganglion cell can be very devastating. Acetylcholinesterase (AChE) histochemistry, done on frozen sections is said to be a very useful ancillary technique in the diagnosis and in aiding the operative procedures of HD. Methods To assess this, 73 samples from 42 suspected/known cases of HD were subjected to frozen section analysis with rapid haematoxylin and eosin, toluidin blue stain along with AChE histochemistry. The remnant sample was paraffin embedded for routine haematoxylin and eosin staining. Results On frozen section analysis, 33 samples showed absence of ganglion cells, AChE histochemistry showed a positive staining pattern in 17 samples and paraffin embedded routine, H&E stained sections showed absence of ganglion cells in 19 samples. Sensitivity and specificity of both tests ie frozen section rapid H&E/AChE histochemistry in the diagnosis of HD, were calculated taking paraffin embedded H&E stained sections as the gold standard. Sensitivity of frozen section rapid H&E in the diagnosis of HD is 57.57 % and specificity is 79.10 %. The p-value is <0.0001, which is significant. The sensitivity of AChE histochemistry in the diagnosis of HD is 90.47 % and specificity is 96.36 %. The p-value is <0.0001, which is significant. Conclusions Acetylcholineesterase (AChE) histochemistry is a very useful ancillary technique in the diagnosis and in aiding the operative procedures of HD. It acts as a double check in the diagnosis of HD.
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Affiliation(s)
- R K Agrawal
- Department of Pathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Nandita Kakkar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - R K Vasishta
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vandana Kumari
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - R Samujh
- Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - K L N Rao
- Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Waseem SH, Idrees MT, Croffie JM. Neuroenteric Staining as a Tool in the Evaluation of Pediatric Motility Disorders. Curr Gastroenterol Rep 2015; 17:30. [PMID: 26143629 DOI: 10.1007/s11894-015-0456-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The diagnosis of enteric neuromuscular disorders has come a long way since the first description of an enteric neuropathic disorder by the Danish physician Harald Hirschsprung in 1886. Advances in specialized enteric histopathological staining techniques have made it possible to identify subtle neuropathies and myopathies that cause intestinal motility disorders, from the common and now better understood and relatively easily diagnosed Hirschsprung's disease to the less common and more severe and not well-characterized chronic idiopathic intestinal pseudoobstruction, which continues to present a diagnostic challenge to the gastroenterologist and histopathologist alike. This article will discuss the common gastrointestinal motility disorders and some of the specialized histological stains, such as the relatively common enzyme stain, acetylcholinesterase, used to diagnose Hirschsprung's disease; advanced tinctorial stains, such as Masson trichrome, which may aid in diagnosis of enteric myopathies causing pseudoobstruction; and immunohistochemical stains such as C-Kit or PG 9.5, which may aid in the diagnosis of enteric neuropathies causing pseudoobstruction.
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Affiliation(s)
- Shamaila H Waseem
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, 705 Riley Hospital Drive #4210, Indianapolis, IN, 46202, USA,
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21
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Budianto IR, Obata S, Kinoshita Y, Yoshimaru K, Yanagi Y, Miyata J, Nagata K, Ieiri S, Taguchi T. Reevaluation of acetylcholinesterase staining for the diagnosis of Hirschsprung disease and allied disorders. J Pediatr Gastroenterol Nutr 2015; 60:606-12. [PMID: 25522309 DOI: 10.1097/mpg.0000000000000664] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Acetylcholinesterase (AChE) staining has become the gold standard for definitively diagnosing Hirschsprung disease (HD), although some pitfalls have been reported. We reevaluated a large series at our institute in order to validate the accuracy of AChE staining for detecting HD. METHODS A retrospective study of the rectal mucosal specimens of all of the children with suspected HD during a 13-year period was performed. The specimens were stained according to the modified Karnovsky-Roots method for AChE staining. The final diagnosis, prognosis, and management after the histopathological diagnosis were analyzed with a questionnaire sent to the patient's original hospital. RESULTS Three hundred and fifty-eight specimens were collected. One hundred twenty-two (34%) specimens were diagnosed as HD, 198 (55%) as nonHD, 25 (7%) as "undetermined," and 13 (4%) as "inappropriate." The non-HD group contained 190 (96%) specimens with a normal appearance and 8 (4%) specimens with suspected intestinal neuronal dysplasia (IND). Three hundred and six of 358 questionnaires were returned. The final diagnosis showed that no specimens first diagnosed as HD were identified as non-HD and vice versa, for a sensitivity and specificity of 100%. Four cases were finally diagnosed as chronic idiopathic intestinal pseudo-obstruction (CIIP) in the non-HD group. All of the patients with HD underwent radical surgery. Most non-HD patients were managed conservatively, although some continued to have constipation. CONCLUSIONS AChE staining is an accurate tool for differentiating between HD and non-HD with high sensitivity and specificity. CIIP can be included in cases of non-HD; therefore, careful follow-up is mandatory.
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Affiliation(s)
- Iskandar R Budianto
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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22
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Swaminathan M, Oron AP, Chatterjee S, Piper H, Cope-Yokoyama S, Chakravarti A, Kapur RP. Intestinal Neuronal Dysplasia-Like Submucosal Ganglion Cell Hyperplasia at the Proximal Margins of Hirschsprung Disease Resections. Pediatr Dev Pathol 2015; 18:466-76. [PMID: 26699691 PMCID: PMC4809533 DOI: 10.2350/15-07-1675-oa.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intestinal neuronal dysplasia type B (IND) denotes an increased proportion of hyperplastic submucosal ganglia, as resolved histochemically in 15-μm-thick frozen sections. IND has been reported proximal to the aganglionic segment in patients with Hirschsprung disease (HSCR) and is putatively associated with a higher rate of postsurgical dysmotility. We developed and validated histological criteria to diagnose IND-like submucosal ganglion cell hyperplasia (IND-SH) in paraffin sections and used the approach to study the incidence and clinical and/or genetic associations of IND-SH at the proximal margins of HSCR pull-through resection specimens. Full-circumference paraffin sections from the proximal margins of 64 HSCR colonic pull-through specimens and 24 autopsy controls were immunostained for neuron-specific Hu antigen, and nucleated ganglion cells in each submucosal ganglion were counted. In controls, an age-related decline in the relative abundance of "giant" ganglia (≥7 nucleated Hu-positive [Hu+] ganglion cells) was observed. A conservative diagnostic threshold for IND-SH (control mean ± 3× standard deviation) was derived from 15 controls less than 25 weeks of age. No control exceeded this threshold, whereas in the same age range, IND-SH was observed at the proximal margins in 15% (7 of 46) of HSCR resections, up to 15 cm proximal to the aganglionic segment. No significant correlation was observed between IND-SH and length of or distance from the aganglionic segment, sex, trisomy 21, RET or SEMA3C/D polymorphisms, or clinical outcome, but analysis of more patients, with better long-term follow-up will be required to clarify the significance of this histological phenotype.
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Affiliation(s)
| | | | - Sumantra Chatterjee
- Center for Complex Disease Genomics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine ,Balimore, MD
| | - Hannah Piper
- University of Texas Southwestern, Children's Health, Dallas, TX
| | | | - Aravinda Chakravarti
- Center for Complex Disease Genomics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine ,Balimore, MD
| | - Raj P. Kapur
- Seattle Children's Research Institute, Seattle, WA,University of Washington, Pathology, Seattle, WA
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Abstract
The enteric nervous system is vulnerable to a range of congenital and acquired disorders that disrupt the function of its neurons or lead to their loss. The resulting enteric neuropathies are some of the most challenging clinical conditions to manage. Neural stem cells offer the prospect of a cure given their potential ability to replenish missing or dysfunctional neurons. This article discusses diseases that might be targets for stem cell therapies and the barriers that could limit treatment application. We explore various sources of stem cells and the proof of concept for their use. The critical steps that remain to be addressed before these therapies can be used in patients are also discussed. Key milestones include the harvesting of neural stem cells from the human gut and the latest in vivo transplantation studies in animals. The tremendous progress in the field has brought experimental studies exploring the potential of stem cell therapies for the management of enteric neuropathies to the cusp of clinical application.
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Affiliation(s)
- Alan J Burns
- Neural Development and Gastroenterology Units, Birth Defects Research Centre, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Nikhil Thapar
- 1] Neural Development and Gastroenterology Units, Birth Defects Research Centre, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK. [2] Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK
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24
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Chronic intestinal pseudo-obstruction: systematic histopathological approach can clinch vital clues. Virchows Arch 2014; 464:529-37. [DOI: 10.1007/s00428-014-1565-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 02/14/2014] [Accepted: 02/18/2014] [Indexed: 12/28/2022]
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25
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Abstract
"Variants of Hirschsprung's disease" are conditions that clinically resemble Hirschsprung's disease (HD), despite the presence of ganglion cells in rectal suction biopsies. The diagnosis and management of these patients can be challenging. Specific histological, immunohistochemical and electron microscopic investigations are required to characterize this heterogeneous group of functional bowel disorders. Variants of HD include intestinal neuronal dysplasia, intestinal ganglioneuromatosis, isolated hypoganglionosis, immature ganglia, absence of the argyrophil plexus, internal anal sphincter achalasia and congenital smooth muscle cell disorders such as megacystis microcolon intestinal hypoperistalsis syndrome. This review article systematically classifies variants of HD based on current diagnostic criteria with an additional focus on pathogenesis, epidemiology, clinical presentation, management and outcome.
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Kapur RP, Kennedy AJ. Histopathologic delineation of the transition zone in short-segment Hirschsprung disease. Pediatr Dev Pathol 2013; 16:252-66. [PMID: 23495711 DOI: 10.2350/12-12-1282-oa.1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Failure to completely resect the transition zone (TZ) between aganglionic and neuroanatomically normal bowel ("TZ pull-through") is considered one reason for postoperative obstructive symptoms in Hirschsprung disease (HD). Despite years of study, the proximal boundary of the TZ remains nebulous, complicated by discordant, often subjective, histopathologic definitions. In order to objectively delineate the TZ, transverse sections at 1 cm intervals from the rectums of 9 non-HD autopsy subjects and resections from 15 infants with short-segment HD were immunostained with Hu (ganglion cell bodies) and glucose transporter 1 (Glut1) (perineurium of extrinsic nerves), and 6 putative features of TZ were examined: (1) aganglionosis of ≥1/8th circumference; (2) myenteric or submucosal hypoganglionosis; (3) hypertrophic submucosal nerves; (4) Glut1+ submucosal innervation; (5) submucosal hyperganglionosis; and (6) "ectopic" ganglia in lamina propria, muscularis propria, or serosa. In non-HD controls, Glut1+ submucosal innervation, hypertrophic nerves, partial circumferential aganglionosis, and hypoganglionosis were absent or restricted to the distal 2 cm. In contrast, all 6 neuropathologic features of TZ were identified proximal to the aganglionic segment in the majority of HD resections, but the length of the TZ ranged from 0 to 12 cm, depending on which neuropathologic feature was considered. Excluding submucosal hyperganglionosis and ectopic ganglia, the TZ was generally ≤5 cm. Many features of TZ cannot be excluded intraoperatively with a biopsy or a full-circumference frozen section. However, partial circumferential aganglionosis, severe myenteric hypoganglionosis, and hypertrophic submucosal nerves can, and probably should, be assessed in full-circumference frozen sections of the proximal resection margin, to reduce the likelihood of TZ pull-through.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, USA.
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27
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Obermayr F, Hotta R, Enomoto H, Young HM. Development and developmental disorders of the enteric nervous system. Nat Rev Gastroenterol Hepatol 2013; 10:43-57. [PMID: 23229326 DOI: 10.1038/nrgastro.2012.234] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The enteric nervous system (ENS) arises from neural crest-derived cells that migrate into and along the gut, leading to the formation of a complex network of neurons and glial cells that regulates motility, secretion and blood flow. This Review summarizes the progress made in the past 5 years in our understanding of ENS development, including the migratory pathways of neural crest-derived cells as they colonize the gut. The importance of interactions between neural crest-derived cells, between signalling pathways and between developmental processes (such as proliferation and migration) in ensuring the correct development of the ENS is also presented. The signalling pathways involved in ENS development that were determined using animal models are also described, as is the evidence for the involvement of the genes encoding these molecules in Hirschsprung disease-the best characterized paediatric enteric neuropathy. Finally, the aetiology and treatment of Hirschsprung disease in the clinic and the potential involvement of defects in ENS development in other paediatric motility disorders are outlined.
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Affiliation(s)
- Florian Obermayr
- Department of Pediatric Surgery, University Children's Hospital, University of Tübingen, Hoppe-Seyler Straße 3, Tübingen 72076, Germany
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28
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Kapur RP, Kennedy AJ. Transitional zone pull through: surgical pathology considerations. Semin Pediatr Surg 2012; 21:291-301. [PMID: 22985834 DOI: 10.1053/j.sempedsurg.2012.07.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Incomplete resection of the transitional zone (TZ) between histologically normal and aganglionic bowel in Hirschsprung disease is a putative cause of postoperative dysmotility. A review of literature indicates that diverse histopathological indexes have been used to define the TZ, and validated and reproducible diagnostic criteria have not been established. As a consequence, the proximal margin of the TZ is difficult to delimit, and the length of the TZ in a given patient depends on the diagnostic criteria used. Seromuscular biopsies are inadequate to exclude TZ, as diagnostic indexes may involve only a portion of the bowel circumference or the submucosa. Most published investigations of postoperative outcome after a TZ pull through (TZPT) conclude that the latter can cause persistent obstructive symptoms, which necessitate reoperation. However, the results of these studies are difficult to translate into clinical practice because most lack appropriate controls, and the overwhelming majority provide inadequate histopathological descriptions for reference at the time of intraoperative frozen section analysis. At present, a conservative approach based on frozen section examination of the entire proximal margin of the resection to exclude obvious subcircumferential aganglionosis (contiguous gap between ganglia of more than one-eighth of the circumference), hypoganglionosis (continuous string of myenteric ganglia comprised of 1 or 2 ganglion cells without surrounding neuropil), or hypertrophic submucosal nerves (>2 nerves with widths ≥40 μm per high-power field) seems prudent. Well-controlled studies to correlate proximal margin histology, especially subtle anatomic or immunohistochemical changes, with postoperative outcome are needed.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA 98115, USA.
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Li N, Xiang L, Wu X, Yang J, Wei J, Feng J. A rapid lactate dehydrogenase histochemical method for the intraoperative assessment of Hirschsprung's disease. Int J Colorectal Dis 2012; 27:1175-80. [PMID: 22407441 DOI: 10.1007/s00384-012-1443-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/29/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim was to assess the ability of a fast lactate dehydrogenase (LDH) staining technique to evaluate the boundary of the abnormal bowel segment in Hirschsprung's disease (HD) as a guide for surgical resection. METHODS Seventy children diagnosed with HD were equally divided into two groups. For the study group, fast LDH staining was used to confirm the diagnosis and determine the boundary of abnormal bowel. Frozen H&E staining was applied to the control group. Postoperatively, bowel samples were examined by paraffin H&E staining to confirm the intraoperative diagnosis. Patients received a follow-up analysis, and bowel function was scored and compared between the two groups. RESULTS In the study group, 19 children were diagnosed with isolated HD, and the remaining had HD in combination with HD-allied disorders (HAD). The diagnosis was identical to the post-operative H&E staining, and the ganglia cells at the proximal end of the resected bowel were normal. In the control group, 30 children were diagnosed with isolated HD. However, the paraffin H&E staining showed that only 16 cases had isolated HD, and the remaining had a combined diagnosis of HAD. Moreover, 12 of these allied disorders were found at the proximal end of the resected bowel. Patients received follow-up for 6-15 months. The bowel function score of the study group was significantly higher than the control group. CONCLUSIONS Fast LDH staining can clearly identify ganglion cells and rapidly diagnose HD and HAD intraoperatively. In addition, this method is helpful for improving patient prognosis.
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Affiliation(s)
- Ning Li
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Morphological alterations of the enteric nervous system in young male patients with rectal prolapse. Int J Colorectal Dis 2011; 26:1483-91. [PMID: 21800050 DOI: 10.1007/s00384-011-1282-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2011] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The pathogenesis of rectal prolapse (RP) defined by a circumferential, full-thickness invagination of the rectal wall into the anal canal is controversial. RP is normally encountered in elderly women and attributed to several etiological factors (e.g., advanced age, pudendal nerve injury, laxity of supporting ligaments). RP affecting young male patients is unlikely to be explained by these factors and may be due to a rectal motility disorder. Therefore, the enteric nervous system (ENS) as key regulator of intestinal motility was evaluated by a systematic morphometric analysis. PATIENTS AND METHODS Full-thickness rectosigmoid specimens obtained from young male patients with symptomatic RP (n = 5) and male controls (n = 15) were processed for conventional histology and immunohistochemistry using anti-HuC/D as pan-neuronal marker. Enteric ganglia, nerve and glial cells were quantified separately in the myenteric (MP) and submucosal plexus (SMP). RESULTS Compared to controls, patients with RP showed significantly (p < 0.05) increased mean ganglionic area both in MP and SMP, increased mean neuronal content of submucosal ganglia, and nearly threefold higher frequency of submucosal ganglia containing ≥7 neurons. CONCLUSION The morphometric analysis reveals distinct quantitative alterations of the ENS in young male patients with RP mainly characterized by submucosal hyperganglionosis similar to histopathological features described in intestinal neuronal dysplasia. The data give evidence that RP in this unusual subgroup is associated with morphological changes of enteric ganglia which may contribute to the development of RP and complement established etiological concepts.
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Hackett-Jones EJ, Landman KA, Newgreen DF, Zhang D. On the role of differential adhesion in gangliogenesis in the enteric nervous system. J Theor Biol 2011; 287:148-59. [PMID: 21816161 DOI: 10.1016/j.jtbi.2011.07.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 07/19/2011] [Accepted: 07/20/2011] [Indexed: 01/12/2023]
Abstract
A defining characteristic of the normal development of the enteric nervous system (ENS) is the existence of mesoscale patterned entities called ganglia. Ganglia are clusters of neurons with associated enteric neural crest (ENC) cells, which form in the simultaneously growing gut wall. At first the precursor ENC cells proliferate and gradually differentiate to produce the enteric neurons; these neurons form clusters with ENC scattered around and later lying on the periphery of neuronal clusters. By immunolabelling neural cell-cell adhesion molecules, we infer that the adhesive capacity of neurons is greater than that of ENC cells. Using a discrete mathematical model, we test the hypothesis that local rules governing differential adhesion of neuronal agents and ENC agents will produce clusters which emulate ganglia. The clusters are relatively stable, relatively uniform and small in size, of fairly uniform spacing, with a balance between the number of neuronal and ENC agents. These features are attained in both fixed and growing domains, reproducing respectively organotypic in vitro and in vivo observations. Various threshold criteria governing ENC agent proliferation and differentiation and neuronal agent inhibition of differentiation are important for sustaining these characteristics. This investigation suggests possible explanations for observations in normal and abnormal ENS development.
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Affiliation(s)
- Emily J Hackett-Jones
- Department of Mathematics and Statistics, University of Melbourne, Victoria 3010, Australia
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Knowles CH, Farrugia G. Gastrointestinal neuromuscular pathology in chronic constipation. Best Pract Res Clin Gastroenterol 2011; 25:43-57. [PMID: 21382578 PMCID: PMC4175481 DOI: 10.1016/j.bpg.2010.12.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 12/15/2010] [Indexed: 01/31/2023]
Abstract
Some patients with chronic constipation may undergo colectomy yielding tissue appropriate to diagnosis of underlying neuromuscular pathology. The analysis of such tissue has, over the past 40 years, fueled research that has explored the presence of neuropathy, myopathy and more recently changes in interstitial cells of Cajal (ICC). In this chapter, the data from these studies have been critically reviewed in the context of the significant methodological and interpretative issues that beset the field of gastrointestinal neuromuscular pathology. On this basis, reductions in ICC appear to a consistent finding but one whose role as a primary cause of slow-transit constipation requires further evaluation. Findings indicative of significant neuropathy or myopathy are variable and in many studies subject to considerable methodological bias. Methods with practical diagnostic utility in the individual patient have rarely been employed and require further validation in respect of normative data.
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Affiliation(s)
| | - Gianrico Farrugia
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Knowles CH, Veress B, Kapur RP, Wedel T, Farrugia G, Vanderwinden JM, Geboes K, Smith VV, Martin JE, Lindberg G, Milla PJ, De Giorgio R. Quantitation of cellular components of the enteric nervous system in the normal human gastrointestinal tract--report on behalf of the Gastro 2009 International Working Group. Neurogastroenterol Motil 2011; 23:115-24. [PMID: 21175997 DOI: 10.1111/j.1365-2982.2010.01657.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with gastrointestinal neuromuscular diseases may undergo operative procedures that yield tissue appropriate to diagnosis of underlying neuromuscular pathology. Critical to accurate diagnosis is the determination of limits of normality based on the study of control human tissues. Although robust diagnostic criteria exist for many qualitative alterations in the neuromuscular apparatus, these do not include quantitative values due to lack of adequate control data. PURPOSE The aim of this report was to summarize all relevant available published quantitative data for elements of the human enteric nervous system (neuronal cell bodies, glial cells, and nerve fibers) from the perspective of the practicing pathologist. Forty studies meeting inclusion criteria were systematically reviewed with data tabulated in detail and discussed in the context of methodological variations and limitations. The results reveal a lack of concordance between observations of different investigators resulting in data insufficient to produce robust normal ranges. This diversity highlights the need to standardize the way pathologists collect, process, and quantitate neuronal and glial elements in enteric neuropathologic samples, as suggested by recent international guidelines on gastrointestinal neuromuscular pathology.
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Affiliation(s)
- C H Knowles
- Neurogastroenterology Group, Blizard Institute of Cell and Molecular Science, Barts, Queen Mary University of London, London, UK.
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SÁNCHEZ-MEJÍAS AVENCIA, FERNÁNDEZ RAQUELM, ANTIÑOLO GUILLERMO, BORREGO SALUD. A new experimental approach is required in the molecular analysis of intestinal neuronal dysplasia type B patients. Exp Ther Med 2010; 1:999-1003. [PMID: 22993632 PMCID: PMC3446721 DOI: 10.3892/etm.2010.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 07/29/2010] [Indexed: 01/08/2023] Open
Abstract
Intestinal neuronal dysplasia type B (INDB) is characterized by the malformation of the parasympathetic submucous plexus of the gut. It is generally accepted that INDB has a genetic basis, and several genes produce an INDB-like phenotype in mice when disrupted, such as EDNRB. However, no mutations associated with this disease have been identified in several series analysed. In the present studu, we sought to determine whether the EDNRB/EDN3 signalling pathway plays a role in the pathogenesis of INDB in humans. Denaturing high performance liquid chromatography (dHPLC) techniques were employed to screen the EDNRB and EDN3 coding regions in 23 INDB patients. In addition, association studies were performed on these genes with single nucleotide polymorphisms strategically selected and genotyped by TaqMan technology. Although several novel variants were detected in both genes, none of these variants appeared to play a functional role in protein function or expression. Our results indicate that additional screening of other candidate genes in larger patient series is required to elucidate the molecular basis of INDB. Additionally, the systematic lack of positive results in the screening of candidate genes for INDB reported in the literature, together with our results, leads us to propose that INDB may alternatively arise as a consequence of gain of function mutations in genes related to enteric nervous system development. Therefore, the use of different molecular approaches, such as screening for genetic duplication or enhancer mutations, is recommended for future studies on the genetic basis of INDB.
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Affiliation(s)
- AVENCIA SÁNCHEZ-MEJÍAS
- Unidad de Gestión Clínica de Genética, Reproducción y Medicina Fetal, Instituto de Biomedicina de Sevilla (IBIS), Hospitales Universitarios Virgen del Rocío/CSIC/Universidad de Sevilla
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Sevilla,
Spain
| | - RAQUEL M. FERNÁNDEZ
- Unidad de Gestión Clínica de Genética, Reproducción y Medicina Fetal, Instituto de Biomedicina de Sevilla (IBIS), Hospitales Universitarios Virgen del Rocío/CSIC/Universidad de Sevilla
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Sevilla,
Spain
| | - GUILLERMO ANTIÑOLO
- Unidad de Gestión Clínica de Genética, Reproducción y Medicina Fetal, Instituto de Biomedicina de Sevilla (IBIS), Hospitales Universitarios Virgen del Rocío/CSIC/Universidad de Sevilla
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Sevilla,
Spain
| | - SALUD BORREGO
- Unidad de Gestión Clínica de Genética, Reproducción y Medicina Fetal, Instituto de Biomedicina de Sevilla (IBIS), Hospitales Universitarios Virgen del Rocío/CSIC/Universidad de Sevilla
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Sevilla,
Spain
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Abstract
Varied intestinal neuromuscular pathologies are responsible for Hirschsprung disease and other forms of chronic pseudo-obstruction that are encountered in pediatrics. Pathologically distinct subtypes discussed in this review include aganglionosis, hypoganglionosis, neuronal intranuclear inclusion disease, ganglionitis, degenerative neuropathy, diffuse ganglioneuromatosis, neuronal dysplasia, malformations of the muscularis propria, degenerative leiomyopathy, leiomyositis, and mitochondriopathies. Emphasis is given to the histopathologic features that distinguish these conditions and their differential diagnoses.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital University of Washington, A6901, 4800 Sand Point Way North East, Seattle, WA 98105, USA.
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Giri DK, Quist EM, Ambrus A, Gold J, Porter BF, Bratton GR, Storts RW. Enteric dysganglionosis resembling intestinal neuronal dysplasia in a foal with bacterial colitis. Vet Pathol 2010; 47:654-7. [PMID: 20466864 DOI: 10.1177/0300985810370006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 5-day-old quarter horse colt with a history of hypothermia, agonal breathing, and diarrhea was euthanized. At necropsy, numerous slightly raised, discrete, closely approximated submucosal nodules were observed in the colon and small intestine. Histologically, these nodules were composed of expanded submucosal mesenchyme that contained numerous neurons either individually or in ganglia. Thirty-two percent of these ganglia included 8 or more neurons, in contrast to 6% in an age-matched foal. Some nodules had necrosuppurative inflammation with vasculitis, thrombosis, and bacterial colonization. A few heterotopic neurons were randomly distributed in the mucosa and the muscularis mucosa. Histologic changes were most consistent with intestinal neuronal dysplasia, a disease of the submucosal plexus described in humans.
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Affiliation(s)
- D K Giri
- Integrated Laboratory Systems, 601 Keystone Park Drive, Suite 100, Durham, NC 27713, USA.
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[Twenty years diagnostic competence center for Hirschsprung's disease in Basel]. Chirurg 2010; 81:572-6. [PMID: 20458567 DOI: 10.1007/s00104-010-1924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The experience gained by the Basel Hirschsprung Competence Center over 20 years is presented. MATERIALS AND METHODS A total of 19,365 rectal mucosal biopsies were investigated in the 20 years between 1987 and 2006. All biopsies of rectal mucosa originated from 6,615 children aged between 1 week and 4 years. Biopsies were collected in teaching hospitals all over Germany and transported on dry ice by Intercity Courier Service. Serial sections of frozen tissue were made using a cryostat. Enzyme histochemical staining was performed. RESULTS A total of 935 cases of Hirschsprung's disease (14%) were observed (769 cases of classical Hirschsprung's disease, 68 total colon aganglionosis, 98 ultrashort rectum aganglionosis). Total colon aganglionosis was found in 1.0% and the frequency of ultrashort Hirschsprung' disease was 1.4%. The quality of the histological results was confirmed by a second independent investigator. There were neither false positive nor false negative diagnoses. Enzyme histochemical staining results were readable within 2 h. Acetylcholinesterase, which is significantly increased in Hirschsprung's disease, was used for nerve fiber staining. Succinic and lactic dehydrogenases and nitric oxide synthase served as confirmatory proof of aganglionosis (elective nerve cell staining of the submucous plexus). CONCLUSION Among 100 children with chronic constipation an average of 12 children were diagnosed with Hirschsprung's disease. Of these 2% showed total colon aganglionosis or ultrashort Hirschsprung's disease. Enzyme histochemical diagnosis of Hirschsprung's disease proved 100% reliable and time saving.
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Puig I, Champeval D, De Santa Barbara P, Jaubert F, Lyonnet S, Larue L. Deletion of Pten in the mouse enteric nervous system induces ganglioneuromatosis and mimics intestinal pseudoobstruction. J Clin Invest 2009; 119:3586-96. [PMID: 19884655 DOI: 10.1172/jci39929] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 09/09/2009] [Indexed: 01/21/2023] Open
Abstract
Intestinal ganglioneuromatosis is a benign proliferation of nerve ganglion cells, nerve fibers, and supporting cells of the enteric nervous system (ENS) that can result in abnormally large enteric neuronal cells (ENCs) in the myenteric plexus and chronic intestinal pseudoobstruction (CIPO). As phosphatase and tensin homolog deleted on chromosome 10 (PTEN) is a phosphatase that is critical for controlling cell growth, proliferation, and death, we investigated the role of PTEN in the ENS by generating mice with an embryonic, ENC-selective deletion within the Pten locus. Mutant mice died 2 to 3 weeks after birth, with clinical signs of CIPO and hyperplasia and hypertrophy of ENCs resulting from increased activity of the PI3K/PTEN-AKT-S6K signaling pathway. Further analysis revealed that PTEN was only expressed in developing mouse embryonic ENCs from E15.5 and that the rate of ENC proliferation decreased once PTEN was expressed. Specific deletion of the Pten gene in ENCs therefore induced hyperplasia and hypertrophy in the later stages of embryogenesis. This phenotype was reversed by administration of a pharmacological inhibitor of AKT. In some human ganglioneuromatosis forms of CIPO, PTEN expression was found to be abnormally low and S6 phosphorylation increased. Our study thus reveals that loss of PTEN disrupts development of the ENS and identifies the PI3K/PTEN-AKT-S6K signaling pathway as a potential therapeutic target for ganglioneuromatosis forms of CIPO.
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Affiliation(s)
- Isabel Puig
- Institut Curie, Centre de Recherche, Developmental Genetics of Melanocytes, Orsay, France
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Abstract
Diagnosis and management of Hirschsprung's disease (HSCR) requires understanding of the malformation's anatomic features and multigenic nature. Rectal biopsies, intraoperative frozen sections, and resection specimens provide invaluable information. Extraction of these data requires thoughtful biopsy technique, adequate histologic sections, histochemistry, and collaboration of surgeon and pathologist. Critical consideration of transition zone anatomy and published studies of "transition zone pull through" indicate that more research is needed to determine how much ganglionic bowel should be resected from HSCR patients. Many HSCR-susceptibility genes have been identified, but mutational analysis has limited practical value unless family history or clinical findings suggest syndromic HSCR.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital, University of Washington, Seattle, Washington 98115, USA.
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Gastrointestinal neuromuscular pathology: guidelines for histological techniques and reporting on behalf of the Gastro 2009 International Working Group. Acta Neuropathol 2009; 118:271-301. [PMID: 19360428 DOI: 10.1007/s00401-009-0527-y] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 03/19/2009] [Accepted: 03/22/2009] [Indexed: 01/30/2023]
Abstract
The term gastrointestinal neuromuscular disease describes a clinically heterogeneous group of disorders of children and adults in which symptoms are presumed or proven to arise as a result of neuromuscular, including interstitial cell of Cajal, dysfunction. Such disorders commonly have impaired motor activity, i.e. slowed or obstructed transit with radiological evidence of transient or persistent visceral dilatation. Whilst sensorimotor abnormalities have been demonstrated by a variety of methods in these conditions, standards for histopathological reporting remain relatively neglected. Significant differences in methodologies and expertise continue to confound the reliable delineation of normality and specificity of particular pathological changes for disease. Such issues require urgent clarification to standardize acquisition and handling of tissue specimens, interpretation of findings and make informed decisions on risk-benefit of full-thickness tissue biopsy of bowel or other diagnostic procedures. Such information will also allow increased certainty of diagnosis, facilitating factual discussion between patients and caregivers, as well as giving prognostic and therapeutic information. The following report, produced by an international working group, using established consensus methodology, presents proposed guidelines on histological techniques and reporting for adult and paediatric gastrointestinal neuromuscular pathology. The report addresses the main areas of histopathological practice as confronted by the pathologist, including suction rectal biopsy and full-thickness tissue obtained with diagnostic or therapeutic intent. For each, indications, safe acquisition of tissue, histological techniques, reporting and referral recommendations are presented.
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Abstract
The mature enteric nervous system (ENS) is composed of many different neuron subtypes and enteric glia, which all arise from the neural crest. How this diversity is generated from neural crest-derived cells is a central question in neurogastroenterology, as defects in these processes are likely to underlie some paediatric motility disorders. Here we review the developmental appearance (the earliest age at which expression of specific markers can be localized) and birthdates (the age at which precursors exit the cell cycle) of different enteric neuron subtypes, and their projections to some targets. We then focus on what is known about the mechanisms underlying the generation of enteric neuron diversity and axon pathfinding. Finally, we review the development of the ENS in humans and the etiologies of a number of paediatric motility disorders.
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Affiliation(s)
- Marlene M Hao
- Department of Anatomy & Cell Biology, University of MelbourneParkville, Victoria, Australia
| | - Heather M Young
- Department of Anatomy & Cell Biology, University of MelbourneParkville, Victoria, Australia
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Wallace AS, Barlow AJ, Navaratne L, Delalande JM, Tauszig-Delamasure S, Corset V, Thapar N, Burns AJ. Inhibition of cell death results in hyperganglionosis: implications for enteric nervous system development. Neurogastroenterol Motil 2009; 21:768-e49. [PMID: 19400926 DOI: 10.1111/j.1365-2982.2009.01309.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The enteric nervous system (ENS) is derived from vagal and sacral neural crest cells (NCC) that delaminate from the neural tube and undergo extensive migration and proliferation in order to colonize the entire length of the gut and differentiate into many millions of neurons and glial cells. Although apoptotic programmed cell death is an essential physiological process during development of the majority of the vertebrate nervous system, apoptosis within early ENS development has not been comprehensively investigated. The aim of this study was to determine the presence and extent of apoptosis within the vagal NCC population that gives rise to most of the ENS in the chick embryo. We demonstrated that apoptotic cells, as shown by terminal deoxynucleotidyl transferase biotin-dUTP nick end labelling and active caspase-3 immunoreactivity, are present within an electroporated green fluorescent protein (GFP) and human natural killer-1 (HNK-1) immunopositive NCC population migrating from the vagal region of the neural tube to the developing foregut. Inhibition of caspase activity in vagal NCC, by electroporation with a dominant-negative form of caspase-9, increased the number of vagal NCC available for ENS formation, as shown by 3-dimensional reconstruction of serial GFP or HNK-1 labelled sections, and resulted in hyperganglionosis within the proximal foregut, as shown by NADPH-diaphorase whole gut staining. These findings suggest that apoptotic cell death may be a normal process within the precursor pool of pre-enteric NCC that migrates to the gut, and as such it may play a role in the control of ENS formation.
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Affiliation(s)
- A S Wallace
- Neural Development Unit, UCL Institute of Child Health, London, UK
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Abstract
Intestinal neuronal dysplasia type B (IND B) is currently considered to be a subtle malformation of the submucosal plexus, leading to an increased proportion of over-sized ganglia and potentially accompanied by a mild, chronic gastrointestinal motility disturbance. The diagnosis of IND B is morphologically based and involves the demonstration of an increased proportion of giant ganglia in the submucous plexus related to the patient's age. Giant ganglia are physiologically frequent in the neonatal period. Therefore, IND B should not be diagnosed prior to 1 year of age. Morphological features of IND B may occur as an isolated finding or may be observed proximal to an aganglionic segment. IND B and constipation may resolve spontaneously up to the age of 4 years. Treatment of IND B is usually conservative, surgical resection is currently deemed necessary only in a minority of patients. The pathogenesis of IND B is still incompletely understood and the etiology unknown. Future research on the basis of standardized diagnostic conditions is expected to result in a better understanding of this disease, and to reveal the cause of aberrant ganglion development.
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Bruder E, Meier-Ruge WA. [Intestinal neuronal dysplasia type B: how do we understand it today?]. DER PATHOLOGE 2008; 28:137-42. [PMID: 17279410 DOI: 10.1007/s00292-007-0894-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Intestinal neuronal dysplasia type B (IND B) is currently considered to be a subtle malformation of the submucosal plexus, leading to an increased proportion of over-sized ganglia and potentially accompanied by a mild, chronic gastrointestinal motility disturbance. The diagnosis of IND B is morphologically based and involves the demonstration of an increased proportion of giant ganglia in the submucous plexus related to the patient's age. Giant ganglia are physiologically frequent in the neonatal period. Therefore, IND B should not be diagnosed prior to 1 year of age. Morphological features of IND B may occur as an isolated finding or may be observed proximal to an aganglionic segment. IND B and constipation may resolve spontaneously up to the age of 4 years. Treatment of IND B is usually conservative, surgical resection is currently deemed necessary only in a minority of patients. The pathogenesis of IND B is still incompletely understood and the etiology unknown. Future research on the basis of standardized diagnostic conditions is expected to result in a better understanding of this disease, and to reveal the cause of aberrant ganglion development.
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Affiliation(s)
- E Bruder
- Institut für Pathologie, Universitätsspital Basel, Schönbeinstrasse 40, 4031 Basel, Switzerland.
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