Acetylcholinesterase-stained suction rectal biopsies in the diagnosis of Hirschsprung's disease.

Conflicting reports in the literature regarding the sensitivity and specificity of the acetylcholinesterase (AChE) stain in establishing or excluding the diagnosis of Hirschsprung's disease (HD) prompted this review of 497 rectal biopsies performed on 455 children. Using hematoxylin and eosin (H&E) to stain formalin-fixed, paraffin-embedded tissue sections is our preferred method of identifying ganglion cells. In this series, however, there were eight children with HD, and nine without HD in whom the AChE-stained portion of the sample provided invaluable diagnostic information not obtained from the concomitant, formalin-fixed, H&E-stained portion of the sample. The AChE stain also provided at least suggestive evidence of HD in some of the anal or anorectal biopsy specimens.     

Histochemical diagnosis of Hirschsprung disease

A histochemical staining technique for detection of acetylcholinesterase (AChE) in rectal suction biopsies was compared with the presence or absence of ganglion cells in full-thickness or suction biopsies for the diagnosis of Hirschsprung disease (HD) in infants and children. Biopsies from 55 of 58 children were adequate for both the AChE assay and routine pathologic examination for ganglion cells. Two patterns of AChE staining were noted. With pattern A, prominent nerve fibers staining for AChE were seen throughout the muscularis mucosa and the lamina propria. With pattern B, similar fibers were seen only in the muscularis mucosa and the areas of lamina propria that were immediately adjacent. No "false-negative" AChE staining reactions were found in patients with HD. No "false-positive" reactions showing pattern A were found. This pattern was diagnostic for HD. Three false-positive reactions were found showing pattern B in patients with conditions other than HD. Among 22 patients with HD, 19 were males and three were females. Pattern A occurred in all age groups and in both sexes. Pattern B in patients with HD was seen exclusively in male infants 1 month of age or less. Experience suggests that the AChE staining of rectal suction biopsies is an excellent screening test for HD in infants and children. If pattern B is encountered, however, the specimen should be examined by routine pathologic techniques for the presence of submucosal ganglion cells.     

What are the diagnostic criteria for intestinal neuronal dysplasia?

The incidence of isolated intestinal neuronal dysplasia (IND) has varied from 0.3% to 62% of all suction rectal biopsies in different centres. The uncertainty regarding the incidence has resulted from the considerable confusion regarding the essential diagnostic criteria. In an attempt to clarify the diagnostic criteria for IND, we examined biopsy material from the following three groups using acetylcholinesterase (AChE) histochemistry: (1) full-thickness normal colon from 23 controls; (2) suction rectal biopsies from 9 patients who had isolated IND; and (3) full-thickness biopsies from 10 patients with Hirschsprung's disease (HD) who demonstrated IND in the proximal margin of the resected segment. Our data show that hyperganglionosis is the most consistent finding in both IND associated with HD and isolated IND. Other histochemical criteria of IND were dependent upon whether the biopsy was full-thickness or a suction rectal biopsy. Where full-thickness biopsies were available, giant ganglia and ectopic ganglion cells were seen in all cases. Increases in AChE-positive nerve fibres in the mucosa was a frequent finding in patients with IND diagnosed by suction rectal biopsies. We recommend that patients suspected to have IND on suction rectal biopsy should have a full-thickness biopsy for detailed examination of the submucous and myenteric plexuses.     

The constipated child: how likely is Hirschsprung's disease?

The incidence of Hirschsprung's disease (HD) was determined in children who presented with constipation to a specialist paediatric surgical unit. During a 5-year period, 355 rectal biopsies were performed on 182 neonates, infants and children presenting with chronic constipation or intestinal obstruction: 25 (14%) were diagnosed HD. One hundred and four patients had suction and 78 had full-thickness rectal biopsies. Haematoxylin-eosin (HE) staining and acetylcholinesterase (AChE) histochemistry was used. In 13 cases (8%) of suction and 2 cases (2.5%) of full thickness rectal biopsies, specimens were inadequate to diagnose HD. The mean age of all patients was 2.9 years and that of patients diagnosed with HD was 3.64 months. Nineteen patients with HD were diagnosed in the first month, 5 in 1-12 months and 1 at 4 years of age (Fig. 1). The authors found that along with onset of constipation convincing indications for rectal biopsy to exclude HD were as follows: those infants and children who do not pass meconium within 48 hours, have low intestinal obstruction of unknown cause, severe constipation, chronic abdominal distension and failure to thrive. A diagnostic accuracy of 94% was achieved with AChE histochemistry for suction rectal biopsy. After this review, referring paediatricians were advised that screening of other common organic causes of constipation with the least invasive investigations, including laboratory, dietary and paediatric gastroenterology advice, should be undertaken to avoid unnecessary rectal biopsy to exclude HD and related disorders.     

COMPARISON OF NEUROPEPTIDE Y, PROTEIN GENE PRODUCT 9.5, AND ACETYLCHOLINESTERASE IN THE DIAGNOSIS OF HIRSCHSPRUNG'S DISEASE

We compared the results of acetylcholinesterase (AChE) staining of mucosal rectal biopsy specimens with those using neuropeptide Y (NPY) and protein gene product 9.5 (PGP9.5) in biopsies from 68 patients. Thirty-three did not have Hirschsprung's disease (HD), 28 had proven HD, and biopsies from 7 patients had shown a slight increase in AChE stain but the patients did not have HD. In our hands, AChE stain was superior to the other two; it was easier to read and gave the most accurate results with no false-positive cases and only two instances in which the findings were suggestive but not diagnostic. Neuropeptide Y and PGP9.5 have the advantage that they can be used in paraffin-embedded material. With NPY, the results are closer than with PGP9.5 to those obtained with the AChE. Protein gene product 9.5 had the highest incidence of false-positive and false-negative results, but it stains nerve fibers and all neurons intensely and may be useful in the assessment of increased or decreased amounts of neural elements in the bowel.     

Acetylcholinesterase activity in rectal biopsies: an assessment of its diagnostic value in Hirschsprung's disease

Acetylcholinesterase (AChE) activity was measured in rectal suction biopsies from 392 patients investigated for Hirschsprung's disease (HD). Results in HD (2.7-23.7 RU; n = 37) were not clearly differentiated from those in patients without HD (0.6-18.0 RU; n = 355). Sample instability was shown not to be a significant cause of error. From analysis of duplicate biopsies and a consideration of false-negative results, tissue inhomogeneity or incorrect siting of the biopsy appeared likely causes of error. Examination of a number of possible diagnostic decision levels indicated an optimal choice of AChE activity greater than 10 RU with an AChE activity not less than 60% of total cholinesterase activity. At a prevalence of 10%, this decision level resulted in sensitivity of 64.9%, specificity 98.7%, predictive value of positive 85.7%, and predictive value of negative 96.3%. The false positives (n = 4) and false negatives (n = 13) by these criteria were examined to detect possible common features.     

Study of acetylcholinesterase activity in rectal suction biopsy for diagnosis of intestinal dysganglionoses: 17-year experience of a single center

Although the utility of the acetylcholinesterase (AChE) histochemistry on rectal suction biopsy in diagnosing Hirschsprung's disease (HD) has been documented, few reports address a great number of biopsies and patients. Our aim is to present a 17-year experience on the method of rectal suction biopsy and AChE histochemical staining for diagnosis of intestinal dysganglionoses. Between August 1989 and July 2006, 297 children suspected of having HD were submitted to rectal suction biopsies that were evaluated by the same two surgeons. There were 18 complications (6.0%), namely one self-limited rectal bleeding and 17 (5.7%) inadequate procedures that were repeated. A total of 157 patients (52.8%) showed no increased AChE activity and the remaining patients (140-47.2.0%) presented patterns of increased AChE activity confirming the diagnosis of HD or neuronal intestinal dysplasia. Among the 140 cases suspected as having HD, in 131 children the diagnosis of HD was confirmed and they were operated on. The histological studies showed that 111 children presented the classic form of HD or a long spastic segment. Sixteen children presented total colonic aganglionosis and four children proved to have intestinal neuronal dysplasia, according to histological and radiological criteria. Nine (6.6%) newborns were identified as false-positives and no false-negative results were verified. The rectal suction biopsy combined with AChE staining is advantageous for the differentiation between normal bowel and intestinal dysganglionoses. The rectal suction method is simple and can easily be performed by experienced surgeons. The histological evaluation is very objective and can be performed by a non-pathologist.     

How to improve histopathological results in the biopsy diagnosis of gut dysganglionosis

In a methodological survey, the technical prerequisites for optimal histopathological diagnosis of gut dysganglionosis are presented. To make a proper diagnosis, the pediatric surgeon or gastroenterologist and the pathologist must consider certain preconditions. The most important steps for the optimal biopsy diagnosis of an aganglionosis, an ultrashort Hirschsprung segment, a intestinal neuronal dysganglionosis (IND), a ganglioneuromatosis, a hypogenesis, or immaturity of the vegetative gut innervation are: (1) taking 3–4 biopsies the size of a peppercorn (3–5 mm³) with submucosa; (2) the best instruments for taking rectal mucosal biopsies are forceps and scissors or a conventional large biopsy forceps; and (3) biopsies may be taken 1 cm, 3–4 cm, 6–9 cm, and 9–12 cm (or from a preternatural anus) above the pectinate line. A biopsy containing mucosa, muscularis mucosae, and submucosa guarantees a satisfying histopathological diagnosis. The native biopsies can be transported on water-ice if the distance to the pathologist takes no longer than 4–6 h. For long distances, biopsies have to be frozen on dry ice (CO₂ –80 °C) and transported in a sufficient amount of dry ice (adapted to the time of transportation). For biopsy processing, the following points are important: a total of 122 to 160 15-m-thick native cryostat serial sections have to be cut per biopsy and distributed on four microscope slides. Forty sections are used for lactic dehydrogenase reactions, 32 for succinic dehydrogenase reactions, and the rest for an acetylcholinesterase (AChE) reaction. An AChE reaction alone is sufficient for the diagnosis of Hirschsprung's disease (HD), but never for IND or other developmental malformations of the submucous and myenteric plexuses. Enzymehistotopochemical reactions allow the assessment of functional parameters. These reactions, in contrast to immunohistochemical staining, offer information about the functional activity of special gut structures, e. g., increased AChE activity in nerve fibers of the rectal wall in HD or a lack of dehydrogenase activity in immature ganglia.     

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

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

Prevalence and outcome of allergic colitis in healthy infants with rectal bleeding: a prospective cohort study

OBJECTIVES: Allergic colitis is often diagnosed clinically in healthy infants with rectal bleeding and often treated with costly hypoallergenic formula. The true prevalence of allergic colitis is unknown. We tested the hypothesis that allergic colitis is overdiagnosed in healthy infants with rectal bleeding. The authors also determined whether rectal bleeding in infants without allergic colitis would resolve without diet change. METHODS: For the purposes of this study, allergic colitis was defined histologically as colonic mucosa with >or= 6 eosinophils per high power field and/or eosinophils in colonic crypts or muscularis mucosae. We surveyed all 56 Ohio NASPGHAN members to determine standard practice regarding the evaluation of rectal bleeding in infants. In addition, infants 相似文献   

Preliminary evaluation of anorectal manometry in diagnosing Hirschsprung’s disease in neonates

Purpose  The aim of this paper was to assess the clinical value of anorectal manometry (ARMM) in the diagnosing of Hirschsprung’s disease (HD) in neonates. Methods  From January 2003 to June 2005, 75 patients in whom HD was clinically suspected were analyzed. ARMM was performed using a desk, high rate gastrointestinal dynamic detection system and the results were compared with barium enema and rectal suction biopsy. Results  Based on rectal suction biopsies in 52 of 75 patients, the positive, false positive, negative, and false negative rates of ARMM in the diagnosis of HD in neonates were found to be 92.3, 1.9, 1.9, and 3.8%, respectively. Forty-three of 75 patients were diagnosed with HD by both ARMM and barium enema and the diagnoses were validated by pathologic results. The diagnosis of HD was excluded in 18 patients in whom HD was clinically suspected, but in whom the results of ARMM and barium enema were normal. Twelve patients who had ARMM results consistent with HD and a negative barium enema, had serial ARMM performed; a rectoanal inhibitory reflex (RAIR) was elicited in four patients, thereby excluding HD and the remaining eight patients were diagnosed with HD by review of barium enema and pathologic results. One of two patients with a positive barium enema for HD, but an ARMM showing the presence of RAIR was excluded by pathologic results and the other patient was lost to follow-up. The diagnostic accuracies of ARMM and barium enema for HD in neonates were 93.3 and 86.7%, respectively. There was no difference in rectal resting pressure and anal rhythmic wave frequency between neonates with HD and healthy neonates, but neonates with HD had higher anal sphincter pressures than healthy neonates (P = 0.0074). Conclusions  ARMM is a simple, safe, and non-invasive method with high specificity for the diagnosis of HD in neonates.     

NADPH-diaphorase histochemical staining of suction rectal biopsies in the diagnosis of Hirschsprung's disease and allied disorders

The purpose of this study was to investigate the specificity and sensitivity of NADPH-diaphorase (NADPH-D) staining in suction rectal biopsies (SRB) to determine whether it can be used as a diagnostic test for Hirschsprung's disease (HD) and related disorders. We studied SRB material in 80 patients suspected of having such disorders taken at 3, 5, and 7 cm above the pectinate line. Eight-micron sections were stained with hematoxylin and eosin, acetylcholinesterase histochemistry, and NADPH-D histochemistry. Normal biopsy specimens demonstrated strong NADPH-D reactivity in the submucosal ganglia and a large number of NADPH-D-positive fibers in the muscularis mucosae (MM). In contrast, there were no NADPH-D-positive fibers in the MM in patients with HD and hypertrophic nerve trunks stained weakly. Patients with hypoganglionosis (HYPG) demonstrated only a few NADPH-D-positive fibers in the MM and scant submucosal ganglia. Our results show that it is possible to diagnose HD and HYPG in mucosal rectal biopsies containing MM only and stained by NADPH-D histochemistry. As there is no background staining in NADPH-D histochemistry, it is easy to detect NADPH-D-positive fibers. NADPH-D histochemical staining may be an important additional technique for diagnosing HD and related disorders.     

Temporal stability of acetylcholinesterase staining in colonic and rectal neural tissue

Confirmation of the clinical diagnosis of Hirschsprung's disease on standard rectal suction biopsy requires demonstration of aganglionosis in 60 adequate serial sections of submucosa. Positive staining for acetylcholinesterase (AChE), demonstrating an increase in nerve fibres within the lamina propria, muscularis mucosae, and subjacent submucosa, is a useful adjunctive test. In this study, sections of distal colonic muscularis propria and rectal mucosa were stained for AChE over a period of days following storage at 4 °C and at room temperature (15–20 °C). Positive staining of neural tissue was demonstrated in specimens stored at 4 °C for up to 14 days, at which time the experiment was discontinued due to tissue autolysis. Positive staining of the myenteric plexus in colonic specimens stored at room temperature also continued until tissue dissolution became marked at 5 days. This study has demonstrated stability of AChE staining of intestinal neural tissue in specimens stored at 4 °C for 14 days, which suggests that reliable staining for AChE should still be achievable if rectal biopsies are taken in clinics/hospitals without access to staining facilities, provided that tissues are transferred (fresh and moist, at 4 °C) to a reference laboratory for staining within several days of the biopsy procedure. Accepted: 26 November 1996     

Mature B-cell lymphoma in children and adolescents: International group pathologist consensus correlates with histology technical quality

In pediatric mature B-cell non-Hodgkin lymphoma, international pathologist diagnostic agreement was previously evaluated using the Revised European-American Lymphoma Classification. Surgical biopsy histology technical quality (HTQ) is variable and may affect diagnostic accuracy. This study evaluated diagnostic agreement correlated with HTQ. Surgical biopsies obtained from international protocol FAB LMB96 Treatment of Mature B-Cell Lymphoma/Leukemia for Burkitt lymphoma (BL), diffuse large B-cell lymphoma (DLBCL), and high-grade B-cell lymphoma Burkitt-like (BLL), were independently reviewed by hematopathologists from 3 national groups (Children's Cancer Group, Société Fran?aise d'Oncologie Pédiatrique, and United Kingdom Children's Cancer Study Group) to determine each national diagnosis and a final diagnosis. HTQ grades for microscopic tissue sections included: good; medium; low; inconclusive. Final diagnoses in 187 cases included: BL 87 (47%); BLL 20 (11%); DLBCL 64 (34%); other 16 (9%). HTQ grades included: good 10 (5%); medium 100 (54%); low 75 (40%); inconclusive 2 (1%). The rate of uniform agreement between the national diagnoses was significantly higher with good or medium HTQ (62%) than with low HTQ (33%) (P = 0.001). In conclusion, in pediatric mature B-cell non-Hodgkin lymphoma, international pathologist diagnostic agreement is significantly higher in surgical biopsies with better HTQ. Poor HTQ may adversely impact diagnostic ability and affect prognosis and therapeutic management when different treatment regimens are employed for DLBCL versus BL/BLL.     

Approaches to treatment for extraocular retinoblastoma: Children's Hospital Los Angeles experience

Extraocular retinoblastoma is associated with a very poor outcome. At Children's Hospital Los Angeles, 10 of 207 patients with retinoblastoma had extraocular disease. Four patients with no histopathologic risk factors developed extraocular disease. All patients with direct extension into the central nervous system or with distant metastatic disease died. One of three patients with trilateral retinoblastoma and one patient with regional recurrence are alive after autologous bone marrow transplant. Patients with extraocular retinoblastoma who achieve remission may benefit from consolidation of their therapy with autologous bone marrow transplant.     

Congenital and neonatal malignant tumors. A 28-year experience at Children's Hospital of Los Angeles

Fifty-one cases of congenital and neonatal malignant tumors were collected from the Children's Hospital of Los Angeles Department of Pathology files and reviewed. The study covered a 28-year period, 1958-1985. Thirty (59%) of the patients died. The types, incidence, clinical features, and behavior of neoplasms occurring in the neonate were different from those seen in older children and adolescents. Moreover, the response to therapy was also dissimilar. Leukemia and neuroblastoma were the most frequent malignancies and were responsible also for the largest number of deaths.     

The influence of chemotherapy on the prognosis of rhabdomyosarcoma.

A study of 77 consecutive cases of childhood rhabdomyosarcoma treated initially at the Children's Hospital of Los Angeles from 1950 to 1972 demonstrated an impressive improvement in survival of patients when intensive chemotherapy was occurred in Stage II and Stage III disease. Eight out of 9 patients with a primary lesion of the lower extremities developed intra-abdominal disease. A general approach for treatment of Stage II, III, and IV rhabdomyosarcoma is proposed which involves intensive chemotherapy, following biopsy, as the principle treatment, with radiation and surgery used as a adjuvants.     

Laparoscopic colonic mapping of dysganglionosis

 Retention of a proximal aganglionic segment or the unrecognized coexistence of other dysganglionoses may jeopardize the definitive surgical treatment of Hirschsprung's disease (HD). To assess the extent of the disease and/or the presence of other dysganglionoses without an additional laparotomy, we developed a laparoscopic-assisted technique to perform colonic full-thickness biopsies. After creation of a pneumoperitoneum, a 5-mm laparoscope is inserted in the supraumbilical area and a working 10/12-mm port is placed in the left iliac fossa. The sigmoid/descending colon is grasped and pulled through the abdominal wall and a full-thickness biopsy done. The same procedure is applied to the transverse and ascending colon. Rectal and colonic biopsy specimens were studied using enzyme histochemical methods. Over the last year, five children aged 7 months to 12 years with dysganglionosis underwent laparoscopic-assisted mapping of the colon. Previous rectal suction biopsies were diagnostic of HD in three patients and suspicious of hypoganglionosis in two. Proximal full-thickness biopsies revealed: normal colon in two cases of HD; coexistent type B intestinal neuronal dysplasia up to the descending colon in the other case of HD; and hypoganglionosis up to the ascending colon in the two patients with suspected hypoganglionosis. The procedures were performed easily, the patients being discharged after 36 to 48 h with no complications. Four children have already undergone pull-through procedures with resection of the affected colon in adhesion-free abdominal cavities and did not develop constipation or enterocolitis. Laparoscopic-assisted mapping of the entire colon is a simple, safe, and effective procedure that may contribute to improving the outcome of intestinal dysganglionosis by better characterization of the disease. Accepted: 27 October 2000     

Follow‐up experience in pediatric liver transplantation in an academic, non‐transplant‐based gastroenterology group

As pediatric liver transplantation has become relatively common since the early 1980s, most long-term follow-up care has shifted from transplant centers to the pediatric gastroenterologists at referring institutions. We reviewed our experience with 16 patients who have undergone liver transplantation at eight institutions from 1987 to 1996. Our initial follow-up visit took place at an average 4.1 months after the transplant. The mean duration of follow-up was 41 months. During this period 11 hospitalizations at the transplant center occured, including five that were to rule out lymphoma or post-transplant lymphoproliferative disease. At the Schneider Children's Hospital, NY, USA, 158 outpatient visits were recorded. Forty-two hospitalizations occurred. Twenty of the hospital admissions were accounted for by two patients. Forty-nine outpatient/inpatient surgical or diagnostic procedures were performed, including 15 percutaneous liver biopsies. In only one biopsy was there a disagreement in the histologic diagnosis between our pathologist and the pathologist at the transplant center. In conclusion, comprehensive follow-up care can be provided by an academic hospital-based gastroenterology group in conjunction with a transplant center.