Clinicopathological features in 102 cases of Hirschsprung disease

BIOCHEMICAL PREDICTORS OF ENTEROCOLITIS IN CHILDREN WITH COLORECTAL ANOMALIES POST COLOSTOMY AT UNIVERSITY COLLEGE HOSPITAL, IBADAN

Background

A large proportion of patients with preoperative enterocolitis still have enterocolitis persisting even after surgery while others resolve thereafter. Some researchers have studied Calprotectin, C-reactive protein (CRP), Blood and Plasma viscosity as markers of inflammation, hence, the choice of their use. The aim of the study is to determine the sensitivity and reliability of Calprotectin, C-reactive protein (CRP), Blood and Plasma viscosity as biochemical predictors of enterocolitis in children with colorectal anomaly post-surgery at University College Hospital Ibadan.

Patients and Methods

This is an observational analytic study of 32 patients with either Hirschsprung's disease or Anorectal malformation carried out over a year period. The demographic data of the patients, clinical condition and the preoperative and postoperative readings of the biochemical analytes were recorded in a chart. Statistical analysis were carried out using SPSS version 23 and test for statistical association done.

Results

The incidence of Hirschsprung associated enterocolitis is 12.5% and for Ano rectal malformation 6.3 %. Gender difference was not statistically significant even with the observed clinical difference. Plasma viscosity and blood viscosity correlate positively with each order. C-reactive Protein and Calprotectin did not predict enterocolitis in this study and the Sensitivity of blood viscosity at T1 and T2 is as low as 66% with a Positive Predictive Value of 25 %.

Conclusion

The incidence of Enterocolitis associated with Hirschsprung's disease and Anorectal malformation is 19 %. Calprotectin and C-reactive protein did not predict enterocolitis in this patients. The outcome of care was satisfactory in over 90 % of the patients.

Diagnostic Role of Calretinin in Suspicious Cases of Hirschsprung's Disease

Background Hirschsprung's disease (HD) is a developmental disorder of the intrinsic component of the enteric nervous system. It is characterized by the absence of ganglion cells in the myenteric and submucosal plexus. Histopathological diagnosis becomes difficult many times due to submucosal ganglionic cells are not easily identifiable. Aims and objective The aim of this study was to examine the clinical and histopathological features of HD and to establish the utility of calretinin staining to diagnose the case of suspicious HD. Materials and methods After taking necessary informed consent, we studied 41 cases in which clinical suspicion of HD had been made, in a study duration of three years (July 2017-June 2020). Open biopsies were taken from spastic segment, transition zone and dilated segment. Histopathological diagnosis had been made in three categories: HD, no Hirschsprung's disease (NHD) and suspicion of HD. Post histopathological diagnosis calretinin immunohistochemistry (IHC) was applied to all cases and interpretations were noted. Results On the basis of histopathological findings, 25 cases were diagnosed as HD, nine cases were marked for suspicion for HD and seven cases as NHD. After evaluating calretinin IHC on the suspicious case, total of 30 cases were confirmed as HD while the remaining 11 cases were confirmed as NHD. Twenty-four patients of HD were males while the remaining six cases were females. The age of patients ranged from four days to 10 years. Median age six days while 22 patients were in the neonatal period. Conclusion Calretinin immunostaining is a useful modality in diagnosing suspicious cases of HD. Its results are easy to interpret by less experienced pathologist with accuracy.

Case report of a skip segment Hirschsprung's disease: A real phenomenon

INTRODUCTION AND IMPORTANCE

Hirschsprung's disease is a congenital anomaly that results from an incomplete craniocaudal migration and maturation of intestinal ganglion progenitor cells leading to distal intestinal aganglionosis. Skip segment Hirschsprung's disease is an extremely rare phenomenon. We report a case involving only the small bowel with confirmed colonic ganglionosis.

CASE PRESENTATION

A case report of a 14-month-old with a skipped segment involving the distal 50 cm of the small bowel associated with colonic ganglionosis is presented. A current review of the literature is discussed.

CLINICAL DISCUSSION

Our patient had persistent obstructive symptoms despite undergoing a technically good, ganglionic pull-through operation at an outside institution. A laparoscopic-assisted pull-through might have documented a small bowel wall diameter discrepancy.

CONCLUSION

Although rare, skip segment Hirschsprung's disease is a real phenomenon that paediatric surgeons should be aware of and could involve small and large bowels.

The Prevalence and Clinical Profile of Hirschsprung's Disease at a Tertiary Hospital in Bahrain

Background Hirschsprung's disease (HD) is a rare but important congenital pediatric disease of the colon, and its incidence varies widely between ethnic groups. Its incidence was first studied in Bahrain in 1980 using hospital-based data. Over a 16-month period, 10 cases were reported, representing a relatively high incidence rate: 1 per 4000 births. Even though the number of live births in Bahrain has increased dramatically over the last four decades (doubling from 10,000 to 20,000 per year), published studies about the incidence of HD are uncommon. In this research, we aimed to determine both the prevalence and the clinical characteristics of HD at a tertiary hospital in Bahrain. Methods This retrospective observational cross-sectional study included children diagnosed with HD at a tertiary hospital in Bahrain over the last seven years (2014-2020). Children over 10 years were excluded. Clinical data collected included gestational age, birth weight, gender, associated anomalies, clinical features at presentation, disease management, and complications. Results The prevalence of HD in Bahrain was found to be 1.3 per 10,000 live births, according to 18 patients qualified for inclusion in this study. The median age at diagnosis was 18 days; approximately 72% were males, and nearly 94% were Bahraini nationals. Three patients (16.7%) had associated anomalies including cardiac and urogenital malformations. Abdominal distention was the most common clinical presentation (83.3%) followed by constipation (77.8%). Half of the patients (50%) passed meconium within 48 hours of birth. Transanal full-thickness rectal biopsy was the method of diagnosis in most patients (83.3%). Seven patients (38.9%) were diagnosed comparatively late (beyond the neonatal period), at a mean age of 1-2 years. Significant associations between age at diagnosis and clinical presentation, initial management, or surgical intervention were not found. A total of 17 patients (94.4%) underwent the definitive surgery (transanal pull-through procedure). In this surgical group, initial colonic decompression was performed via rectal washout in six patients (35.3%) and via temporary stoma in three patients (17.8%). Laparotomy combined with the definitive surgery was necessary for six patients (35.3%). Most of the patients treated surgically had a short segment disease (70.5%). Conclusions The awareness of HD is highly important, especially with more than one-third of cases diagnosed outside the neonatal period and half of them passing meconium within 48 hours of birth. In addition, early detection of HD in the neonatal period would result in a less complicated course by reducing the number of patients requiring a multi-stage surgery and further laparotomies.

Mesenteric Neural Crest Cells Are the Embryological Basis of Skip Segment Hirschsprung's Disease

BACKGROUND & AIMS

Defective rostrocaudal colonization of the gut by vagal neural crest cells (vNCCs) results in Hirschsprung's disease (HSCR), which is characterized by aganglionosis in variable lengths of the distal bowel. Skip segment Hirschsprung's disease (SSHD), referring to a ganglionated segment within an otherwise aganglionic intestine, contradicts HSCR pathogenesis and underscores a significant gap in our understanding of the development of the enteric nervous system. Here, we aimed to identify the embryonic origin of the ganglionic segments in SSHD.

METHODS

Intestinal biopsy specimens from HSCR patients were prepared via the Swiss-roll technique to search for SSHD cases. NCC migration from the neural tube to the gut was spatiotemporally traced using targeted cell lineages and gene manipulation in mice.

RESULTS

After invading the mesentery surrounding the foregut, vNCCs separated into 2 populations: mesenteric NCCs (mNCCs) proceeded to migrate along the mesentery, whereas enteric NCCs invaded the foregut to migrate along the gut. mNCCs not only produced neurons and glia within the gut mesentery, but also continuously complemented the enteric NCC pool. Two new cases of SSHD were identified from 183 HSCR patients, and Ednrb-mutant mice, but not Ret^-/- mice, showed a high incidence rate of SSHD-like phenotypes.

CONCLUSIONS

mNCCs, a subset of vNCCs that migrate into the gut via the gut mesentery to give rise to enteric neurons, could provide an embryologic explanation for SSHD. These findings lead to novel insights into the development of the enteric nervous system and the etiology of HSCR.

Diagnostic Role of Anal Sphincter Relaxation Integral in High-Resolution Anorectal Manometry for Hirschsprung Disease in Infants

OBJECTIVE

To investigate the possible diagnostic role of anal sphincter relaxation integral (ASRI) in high-resolution anorectal manometry (HRAM) for Hirschsprung disease.

STUDY DESIGN

We performed conventional anorectal manometry (ARM) in 24 infants (8 with Hirschsprung disease and 16 without Hirschsprung disease) and HRAM in another 21 infants (9 with Hirschsprung disease and 12 without Hirschsprung disease) before and after October 2014. All infants underwent rectal suction biopsy for confirmation of Hirschsprung disease. We quantified rectoanal inhibitory reflex (RAIR) adequacy by calculating the ASRI in HRAM study at pressure cutoffs of less than 10, 15, and 20 mm Hg (ASRI10, ASRI15, and ASRI20, respectively) and investigated the diagnostic utility.

RESULTS

Patients with Hirschsprung disease who underwent HRAM had significantly lower ASRI10, ASRI15, and ASRI20 values than did infants without Hirschsprung disease (P = .0002, .0002, and .0003, respectively), indicating significant difference in internal anal sphincter relaxation during RAIR test between these 2 groups. ASRI10 exhibited a greater diagnostic accuracy, area under the curve, sensitivity, and specificity than did ASRI15 and ASRI20 for Hirschsprung disease. Moreover, the diagnostic accuracy of HRAM for Hirschsprung disease based on ASRI10 <7 mm Hg.s.cm was significantly greater than that of conventional ARM (P = .02).

CONCLUSIONS

ASRI10 may be indicative of the adequacy of RAIR by HRAM in infants, thus assisting the diagnosis of Hirschsprung disease. The diagnostic accuracy of HRAM (based on the ASRI10 value) is greater than that of conventional ARM for Hirschsprung disease. ASRI10 may be used in an automatic HRAM analysis system for the diagnosis of anorectal motility disorders.

Epidemiology of Hirschsprung's Disease in Taiwanese Children: A 13-year Nationwide Population-based Study

BACKGROUND

Hirschsprung's disease (HD) is an important colon disease in children. The aim of this study is to describe the epidemiological features of HD in Taiwanese children.

METHODS

We conducted a study from the Taiwan National Health Insurance Research Database and analyzed cases who received surgical intervention between 1998 and 2010 due to HD (International Classification of Diseases, 9(th) Revision, Clinical Modification 751.3) or megacolon (International Classification of Diseases, 9(th) Revision, Clinical Modification 564.7). The incidence, sex ratio, age at the surgical intervention, associated complication, and medical expenditures were analyzed.

RESULTS

There were a total of 629 HD cases, including 458 boys and 171 girls, with an overall incidence of 2.2 per 10,000 live births. The male-to-female incidence ratio was 2.38. There was no secular trend of incidence across the years. Seventy-two percent of cases received surgical treatment before the age of 1 year. The younger cases had higher operation-related medical expenditures. Those patients with preoperative enterocolitis (EC) had a higher possibility of postoperative EC than those patients without preoperative EC (34.6% vs. 24.3%, p = 0.013). There were 169 (26.9%) HD cases with additional anomalies, the most common being gastrointestinal and circulatory system anomalies. Of these, 12 (1.9%) cases were Down syndrome.

CONCLUSION

The incidence of HD in Taiwanese children, a majority Chinese population, was one per 4545 live births with a male predominance. Preoperative EC was a significant factor that was associated with postoperative EC. The percentage associated with Down syndrome was relatively low, probably due to a prenatal screening program.

Distal Rectal Skip-Segment Hirschsprung Disease and the Potential for False-Negative Diagnosis

In skip-segment Hirschsprung disease (SS-HSCR), an aganglionic segment of bowel, which extends proximally from the distal rectum, is interrupted by a ganglionated "skip segment." Skip segments are usually located far proximal to the rectum where they do not interfere with initial diagnosis, although the possibility of distal SS-HSCR should be considered during interpretation of intraoperative biopsies or patients with atypical postoperative courses. We report 2 cases of SS-HSCR with skip areas in the distal rectum, 1 of which led to a false-negative diagnosis by suction rectal biopsy. These 2 cases of SS-HSCR, along with others in the literature, highlight the point that ganglionic skip segments can confuse clinicians and lead to inadequate bowel resection, diagnostic delay, or a false-negative diagnosis. The pathogenesis of SS-HSCR is discussed in light of recent discoveries regarding transmesenteric migration of vagal neural crest cells and the role of sacral neural crest cells in hindgut neurodevelopment.

Histological Spectrum of Large Intestinal Lesions with Clinicopathological Correlation

INTRODUCTION

Large intestine is affected by various types of lesions, both non-neoplastic and neoplastic. Due to vague symptoms, the clinical diagnosis is usually delayed. A battery of laboratory tests including biopsy is essential to arrive at a specific diagnosis for appropriate management.

MATERIALS AND METHODS

This five years study was done during the period of 2005 to 2010 in a tertiary care centre which included 124 biopsies and resected specimens of large intestine and 64 from Anal canal. All tissues were fixed in formalin, stained with H&E and special stains like Periodic Acid Schiff (PAS), Reticulin, Zeihl Neelsen (ZN) along with Immunohistochemistry (IHC) were done as and when required.

RESULTS

Out of the 124 cases of large intestine 38 were non-neoplastic, 77 were neoplastic and 9 were inadequate biopsies. Sixty four cases from Anal canal included 55 non-neoplastic and 9 neoplastic lesions. The non-neoplastic conditions included congenital anomalies, infective and ischaemic lesions while neoplastic included benign and malignant lesions. Most of the cases presented with symptoms like abdominal pain, vomiting and constipation.

CONCLUSION

We observed that neoplastic lesions were more common in large intestine while non-neoplastic lesions were frequently seen in Anal canal. Present study emphasizes the need for early histopathological diagnosis for appropriate treatment.

Familial Hirschsprung's disease: a systematic review

INTRODUCTION

Hirschsprung's disease (HSCR) is a multi-genetic disorder with complex inheritance patterns. Population risk is 1 in 5000 but is reported to be increased in families of patients with HSCR. Appropriate counseling of affected families could be assisted by data from a large volume of patients. It was the aim of this study to systematically analyse the patterns of familial HSCR in the published literature.

METHODS

Pubmed (®) database was searched using the terms "Hirschsprung's disease" and "familial" for studies published between 1980 and 2015 on cohorts of index patients with HSCR reporting on familial recurrence. Studies giving rates of familial HSCR together with the total number of HSCR cases at that centre were included.

RESULTS

In 4331 index cases of HSCR, an overall rate of 7.6% familial recurrence was found. In total colonic aganglionosis, 20% of cases were familial. Recurrence of HSCR within families predominantly occurred in siblings (62%) and was reported between parent and offspring in 22% and in other relatives in 16%. Multiple generations were affected in 15% of families.

CONCLUSION

Familial recurrence of HSCR occurs frequently and should be discussed with families of diagnosed patients. Genetic counseling should be offered in these families and in particular for those patients with long segment and total colonic aganglionosis.

Hirschsprung's disease in children: a five year experience at a university teaching hospital in northwestern Tanzania

Background

Hirschsprung’s disease (HD) is the commonest cause of functional intestinal obstruction in children and poses challenges to pediatricians and pediatric surgeons practicing in resource-limited countries. This study describes the clinical characteristics and outcome of management of this disease in our setting and highlights challenges associated with the care of these patients and proffer solutions for improved outcome.

Methods

This was a descriptive prospective study of children aged ≤ 10 years who were histologically diagnosed and treated for HD at our centre between July 2008 and June 2013.

Results

A total of 110 patients (M: F ratio= 3.6:1) with a median age of 24 months were studied. Six (5.5%) patients were in the neonatal period. Sixty-four (58.2%) patients had complete intestinal obstruction whereas 42 (38.2%) and 4 (3.6%) patients had chronic intestinal obstruction and intestinal perforation respectively. No patient had enterocolitis. Constipation (94.5%) was the most common complaints. 109 (99.1%) patients had colostomy prior to the definitive pull-through. The median duration of colostomy before definitive pull-through was 4 months. The majority of patients (67.3%) had short segment of aganglionosis localized to the recto-sigmoid region. The definitive pull-through was performed in 94 (85.5%) patients (Swenson’s pull-through 76 (80.9%), Duhamel’s pull-through (12.8%) and Soave’s pull-through 4 (4.3%) patients). Postoperative complication rate was 47.3%. The median length of hospital stay was 26 days. Patients who developed complications stayed longer in the hospital and this was statistically significant (p <0.001). Mortality rate was 21.8%. The age < 4 weeks, delayed presentation and surgical site infection were the main predictors of mortality (p < 0.001). During the follow-up period, the results of Swenson’s and Duhamel’s pull through procedures were generally good in 87.8% and 42.9% of patients respectively. The result of Soave’s procedures was generally poor in this study.

Conclusion

HD remains the commonest cause of functional intestinal obstruction in children and contributes significantly to high morbidity and mortality in our setting. The majority of patients present late when the disease becomes complicated. Early diagnosis and timely definitive pull through procedure are essential in order to decrease the morbidity and mortality associated with this disease.

Long-term outcomes and quality of life after subtotal colectomy combined with modified Duhamel procedure for adult Hirschsprung's disease

BACKGROUND

Subtotal colectomy combined with modified Duhamel procedure (Jinling procedure) was used in patients with adult Hirschsprung's disease (AHD) at Jinling Hospital in the last decade. The aim of this study is to evaluate the safety, effectiveness and quality of life of Jinling procedure for AHD.

MATERIALS AND METHODS

All the data are from the database of the Jinling Hospital Constipation Registry System. Primary outcomes, including safety (morbidity and adverse events), effectiveness (satisfaction rate, Wexner constipation scale (WCS) and bowel function score (BFS)) and gastrointestinal quality of life index (GIQLI), were all evaluated.

RESULTS

Fifty-nine patients were available for this study and the mean postoperative period was 44 months. Seventeen major complications were found in 11 patients and most of the complications could be managed conservatively. A significant improvement in WCS, BFS and GIQLI at 6 months postoperatively was obtained.

CONCLUSION

Jinling procedure is safe and effective for AHD.

Hirschsprung-associated enterocolitis: prevention and therapy

Hirschsprung-associated enterocolitis remains the greatest cause of morbidity and mortality in children with Hirschsprung disease. This chapter details the various approaches used to treat and prevent this disease process. This includes prevention of complications, such as stricture formation, prophylaxis with rectal washouts, and identification of high-risk individuals. The chapter also details approaches to diagnose Hirschsprung-associated enterocolitis as well as to exclude other etiologies.

Skip segment Hirschsprung's disease: a systematic review

PURPOSE

Hirschsprung's disease is characterised by the congenital absence of ganglion cells beginning in the distal rectum and extending proximally for varying distances. 'Zonal aganglionosis' is a phenomenon involving a zone of aganglionosis occurring within normally innervated intestine. 'Skip segment' Hirschsprung's disease (SSHD) involves a 'skip area' of normally ganglionated intestine, surrounded proximally and distally by aganglionosis. While Hirschsprung's disease is believed to be the result of incomplete craniocaudal migration of neural crest-derived cells, the occurrence of SSHD has no clear embryological explanation. The aim of this study was to perform a systematic review of SSHD, reported in the literature between 1954 and 2009, in order to determine the clinical characteristics of this rare entity and its significance.

METHODS

The first reported case of SSHD was published in 1954. A systematic review of SSHD cases in the literature, from 1954 to 2009, was carried out using the electronic database 'Pubmed'. Detailed information was recorded regarding the age, gender, presenting symptoms and location of the skip segment in each patient.

RESULTS

24 cases of SSHD have been reported in the literature to date. 18/24 (75%) of these cases were males and 6/24 (25%) were females. Of these, 22/24 (92%) were cases of total colonic aganglionosis (TCA), and 2/24 (8%) were rectosigmoid Hirschsprung's disease. Of the 22 TCA cases, 9 (41%) had a skip segment in the transverse colon, 6 (27%) in the ascending colon, 2 (9%) in the caecum and 5 (23%) had multiple skip segments. In both rectosigmoid Hirschsprung's disease cases, the skip segment was in the sigmoid colon. Overall, the length of the skip segment was variable, with the entire transverse colon ganglionated in some cases.

CONCLUSION

SSHD occurs predominantly in patients with TCA. The existence of a skip area of normally innervated colon in TCA may influence surgical management, enabling surgeons to preserve and use the ganglionated skip area during pull-through operations.

Hirschsprung's disease: a regional experience

BACKGROUND

Hirschsprung's disease (HD) is widely quoted to have an incidence of approximately 1 in 5000 live births. However, it is also known that regional variation in incidence can occur. The aim of this paper was to study the incidence of Hirschsprung's disease in Tasmania and to document a regional experience of HD.

METHODS

A retrospective review of all patients with newly diagnosed HD between January 1998 and December 2005 was carried out. Data were extracted from medical records and reported. Tasmanian birth statistics from 1998 to 2005 were obtained from the Australian Bureau of Statistics website and the incidence was calculated.

RESULTS

Over the 8-year study period, 14 new cases of HD were identified in Tasmania. The estimated incidence of HD in Tasmania based on this study is 1 in 3429. This incidence is higher than the widely quoted incidence of 1 in 5000, but the difference did not reach statistical significance. Between 2003 and 2005, there was a surge in the number of cases with 11 of 14 cases being derived from these 3 years. No obvious reasons were found to explain this surge in the number of cases. Abdominal distension and vomiting were most common modes of presentation (100 and 71%, respectively). There was delayed passage of meconium in 43%.

CONCLUSION

The incidence of Hirschsprung's disease seems higher in Tasmania. The surge in the number of cases is also of interest, although the reasons behind this remain unknown. Delayed passage of meconium was also less common than previously cited.