Three-generation transmission of Hirschsprung''s disease

A three-generation family with non-syndromic biopsy-proven Hirschsprung's disease involving both short and long segments of the large bowel is reported. Although this is the first three-generation family reported, it is expected that with the improved diagnosis and treatment that has occurred over the last 30 years further such families will be described, and that the heritability of this condition will be further clarified.     

Three-generation dominant transmission of the Silver-Russell syndrome

We report on 7 patients with the Silver-Russell syndrome (SRS) in two 3-generation families. Three patients in each of the families had an undergrowth of the left side of the body when compared with the normal right side. The clinical courses were mild as compared to the severity sometimes described in sporadic cases. These patients and a review of 190 SRS cases from the literature showed that there were 23 families in which 38 patients had completely expressed SRS. In 17 of the families, multiple maternal relatives had complete or partial expressions of the SRS. Most SRS patients have been reported to occur sporadically; however, of the 197 propositi analyzed, 19% had more than one affected individual in a family and several different modes of inheritance could have been responsible. Two families (8.7%) had spontaneous dominant mutations (twins) and possible autosomal recessive transmission was present in 4 families (17.4%). Because no male-to-male transmission has yet been documented in the 21 families in the literature and the two families reported here, X-linked dominant inheritance is a possibility in 17 families (74%). Thus, although sporadic occurrences and genetic heterogeneity appear to be involved in the SRS, dominant inheritance may be a major causal factor.     

Hirschsprung's disease and mongolism

Two mongoloid patients with Hirschsprung''s disease are presented. Mongoloid children who have severe constipation should be investigated for Hirschsprung''s disease.     

Hirschsprung's disease: revisited

The diagnosis and therapy of Hirschsprung's disease has changed in recent times and a firm diagnosis of the entity can be made pre-operatively by immunohisto-chemistry. There has been a recent trend of switching over from the conventional staged surgical procedures to primary pull-through procedures. In this article the newer concepts referring to its aetiology, pathogenesis, and the current technical advancements like stapler anastomosis, laparoscopic assisted pull-through and single one stage operation without colostomy are discussed along with a brief mention of current concepts in intestinal neuronal dysplasia, enterocolitis and total colonic aganglionosis.     

Familial occurrence of Hirschsprung's disease

We assessed the familial occurrence of Hirschsprung's disease from 224 probands born in Denmark after 1959. Probands who were still alive received a mailed questionnaire, and medical reports for the probands and their relatives with suspected Hirschsprung's disease were examined. The diagnosis of Hirschsprung's disease required a histologically verified biopsy or surgical colonic specimens, and exclusion of a secondary causes for Hirschsprung's disease. Familial occurrence was seen in 11 families. Ten first-degree, two third-degree and one fifth-degree relatives had Hirschsprung's disease. Both short segment agangliosis (the sigmoid colon or below) and long segment agangliosis (above the sigmoid colon) occurred in five of the 11 families, implying that the etiology of Hirschsprung's disease with short and long segment agangliosis is the same. Compared with the general population, the first-degree relatives of the 224 probands had a minimum of a 93-fold increased risk of Hirschsprung's disease. This strongly suggests that genetic factors play a role in Hirschsprung's disease     

Hirschsprung's disease: practical considerations

Hirschsprung's disease (1/5000 live births) is defined by the congenital absence of neuronal cells in the nervous plexuses in the distal part of the digestive tract. The disease affects the rectum and sigmoid colon in 80% of cases, or is more extensive. Hirschsprung's disease is suspected in cases of low gastrointestinal obstruction in the neonatal period, or in cases of chronic severe constipation in childhood. It is diagnosed by pathological examination of rectal biopsies that include the submucosa. After standard staining, multiple sections are scrutinized for neuronal cells. Acetylcholinesterase staining is performed on a frozen fragment to demonstrate the hyperplasia of cholinergic fibers that is very suggestive of Hirschsprung's disease. This hyperplasia decreases from the rectum to the splenic flexure of the colon. Hyperplasia of extrinsic nerve fibers and rarefaction of neuromuscular junctions in Hirschsprung's disease may be demonstrated immunohistochemically. Differential diagnosis includes chronic intestinal pseudo-obstructions. The treatment for Hirschsprung's disease is, most often, anastomosis of the normally innervated gut to the anal canal. Peri- or pre-operative biopsies assist surgery, but their interpretation is difficult in the transitional zone. The examination of the surgical specimen allows measurement of the aganglionic segment and transitional zone. Different genes (RET, most often) may be involved in sporadic or familial Hirschsprung's disease. Hirschsprung's disease is associated with other digestive or extra-digestive abnormalities in 5 to 30% of patients. Associated abnormalities may delay the diagnosis and treatment of Hirschsprung's disease.     

The developmental genetics of Hirschsprung's disease

Hirschsprung's disease (HSCR), also known as aganglionic megacolon, derives from a congenital malformation of the enteric nervous system (ENS). It displays an incidence of 1 in 5000 live births with a 4:1 male to female sex ratio. Clinical signs include severe constipation and distended bowel due to a non‐motile colon. If left untreated, aganglionic megacolon is lethal. This severe congenital condition is caused by the absence of colonic neural ganglia and thus lack of intrinsic innervation of the colon due in turn to improper colonization of the developing intestines by ENS progenitor cells. These progenitor cells are derived from a transient stem cell population called neural crest cells (NCC). The genetics of HSCR is complex and can involve mutations in multiple genes. However, it is estimated that mutations in known genes account for less than half of the cases of HSCR observed clinically. The male sex bias is currently unexplained. The objective of this review is to provide an overview of the pathophysiology and genetics of HSCR, within the context of our current knowledge of NCC development, sex chromosome genetics and laboratory models.     

Synaptophysin expression abnormalities in Hirschsprung's disease

Hirschsprung's disease is defined by the congenital absence of ganglion cells in enteric plexuses. Immunostaining of synaptophysin after formalin fixation may be used to identify hyperplasia of nerve fibers and rarefaction of neuromuscular junctions in Hirschsprung's disease. The aim of the study was to evaluate semi-quantitatively the expression of synaptophysin in Hirschsprung's disease, in correlation with morphologic features. This retrospective study included 3 controls, 42 surgical rectal biopsies performed for suspicion of Hirschsprung's disease in children presenting with lower digestive occlusion or severe chronic constipation, including 18 Hirschsprung's disease, and 23 surgical specimens of Hirschsprung's disease. In the absence of Hirschsprung's disease, synaptophysin-positive fibers were numerous but thin in the muscularis mucosae, thin and scarce in the mucosa and submucosa. Neuromuscular junctions were thin and numerous in the muscularis propria. In Hirschsprung's disease, synaptophysin-positive fibers were coarse, and increased in number on each side of the muscularis mucosae. Plexuses were enlarged, weakly stained, and associated in the connective tissue of the muscularis propria with coarse and intensely stained fibers. In conclusion, staining for synaptophysin could be useful to demonstrate abnormalities of enteric innervation in rectal biopsies performed for suspected Hirschsprung's disease in the absence of acetylcholinesterase staining on frozen sections, in transmural biopsies performed for guiding surgery in Hirschsprung's disease, and in cases of extensive Hirschsprung's disease.     

Mucosal prolapse changes in Hirschsprung's disease

The aim of this study was to ascertain the incidence of mucosal prolapse changes in Hirschsprung's disease. Twenty-three random, consecutive resection specimens for this condition were analysed for the histological features of prolapse. Eight cases showed histological evidence suggesting mucosal prolapse at the junction between ganglionic and aganglionic bowel. Thickening and splaying of the muscularis mucosae with extension into the lamina propria, and the presence of metaplastic or hyperplastic tubules with goblet cell and cryptal hypertrophy were the dominant histological features found in the eight cases. In addition, an increase in elastic fibres in the lamina propria and diamond- shaped glands were seen to varying degrees in all eight cases.   Mucosal prolapse was more prominent in the older patients and is, therefore, related to duration of symptoms. Differential pressures in ganglionic and aganglionic segments of bowel, together with faecal stream and straining are likely to be of pathogenetic significance.     

Peptidergic innervation irregularities in Hirschsprung's disease

Summary The distribution of vasoactive intestinal polypeptide (VIP)-containing nerves and the contents of both VIP and substance P (S-P) in the intestines from 12 children with Hirschsprung's disease were examined using immunohistochemical methods and radioimmunoassay. VIP-containing nerve fibers were markedly decreased in number in the true muscle coats of aganglionic segments, while extrinsic hypertrophic nerve bundles in these segments showed positive VIP-immunoreactivities. This finding suggests the existance of extrinsic origins of VIP-containing nerves in the human gut. The contents of VIP were 44.5±8.2 in aganglionic segments and 130 ± 17.1 pg/mg wet tissue weight in normoganglionic segments. The contents of S-P were 0.42 ± 0.18 in aganglionic segments and 6.38 ± 2.3 pg/mg wet tissue weight in normoganglionic segments. Both VIP and S-P contents in aganglionic segments were significantly reduced as assessed by the use of radioimmunoassay (p<0.001 andp<0.05).These abnormal peptidergic patterns of innervation might relate to the non-peristaltic state in Hirschsprung's disease.     

Ultrastructural localization of acetylcholinesterase activity in Hirschsprung's disease

Localization of acetylcholinesterase activity in congenital megacolon was studied by light and electron microscopy. Acetylcholinesterase activity was strongly positive at the light microscopic level in the Auerbach's plexus of the normal segment and in proliferated nerve fibers of the aganglionic segment. The reaction product observed by electron microscopy was deposited in and between the plasma membranes of the ganglion cells, nerve fibers, and their terminals. The product was also observed in the rough endoplasmic reticulum, nuclear envelope, and Golgi apparatus of the ganglion cells. Acetylcholinesterase activity in the aganglionic segment was observed in and between the plasma membranes of nerve fibers and nerve terminals, which terminated in proximity to smooth muscle cells. Reaction deposits were also observed in the interspace between nerve terminals and smooth muscle cells, suggesting direct innervation of smooth muscles by extrinsic nerve fibers.     

Nervous elements in the human colon of Hirschsprung's disease

Summary Neuronal profiles in the human and monkey colon and sphincter ani internus were analyzed microscopically and compared to those in the constricted aganglionic transitional and dilated, hypertrophic sections of colon from 3 cases of Hirschsprung's disease. Light microscopy revealed two different types of nerve bundles in the normal colon: 1. aniline-blue-positive nerve trunks (conventional peripheral type) containing endoneural collagen and layers of perineural sheath cells, in all probability of extrinsic origin and autonomic in nature, and 2. azocarmine-positive, large multiaxonal Schwann units in Auerbach's plexus, devoid of collagen and hardly ensheathed by perineurium (bundles of intrinsic type), resembling central nervous neurophil formations (with or without ganglion cells interspersed). Preterminal and terminal varicose axons in Auerbach's plexus—not distinguishable by light microscopy—were classified according to their vesicle populations and suspected transmitter type into adrenergic, cholinergic, p-type and sensory fibres.The internal anal sphincter receives predominantly large bundles of the conventional peripheral type containing a conspicuous amount of myelinated axons, as does the aganglionic portion of the Hirschsprung colon. Vesicle-filled profiles among the smooth muscle cells of the sphincter are considered adrenergic and cholinergic, but p-type fibres are present in the junctional area of the lower rectum and upper sphincter. In the aganglionic, constricted section of the colon from two cases of Hirschsprung's disease, adrenergic and cholinergic axons establish frequent synaptic contacts with smooth muscle cells by exposed varicosities.Throughout the aganglionic colon section, processes of intrinsic neurons are absent; but close to the cone-shaped transitional section abnormal nerve fascicles are present, bound by hypertrophic perineurium, and contain masses of collagen in distended endoneurial interspaces. Schwann cell units inside these bundles are mono- or oligoaxonal. The ultramorphology of supporting glial cells reveals features of immature, undifferentiated Schwann cells. These findings are interpreted as indicative of abortive regeneration and axonal sprouting from intact intrinsic pericarya in the transitional section of the Hirschsprung colon.Noradrenaline concentrations in both the normal internal anal sphincter and the aganglionic colon section from one case of Hirschsprung's disease are similar and about twice as high as in all colon sections from healthy individuals, indicating a functionally important, direct adrenergic innervation of smooth musculature in both situations.The lack of inhibitory extrinsic and intrinsic innervation in the constricted gut section in Hirschsprung's disease is considered to be the cause of its spastic contraction in vivo. Similarities and differences in innervation and pharmacological behavior of the internal anal sphincter in man and monkey and in the aganglionic colon section in Hirschsprung's disease are pointed out.

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Zusammenfassung Im Colon und Sphincter ani internus des Menschen und des Affen wurden Nervenfasertypen licht- und elektronenmikroskopisch analysiert und mit den Nervenelementen in den verschiedenen Abschnitten des Colon von drei Hirschsprungfällen verglichen. Lichtmikroskopisch ließen sich zwei Arten von Nervenbündeln im normalen Colon beschreiben: 1. anilinblaupositive Nervenkabel (vom gewöhnlichen peripheren Typ), die endoneurales Kollagen und Lagen von perineuralen Hüllzellen besitzen und vermutlich extramuralen Ursprung haben und autonomer Natur sind; 2. azokarminpositive, große multiaxonale Schwannzelleinheiten im Auerbachschen Plexus, die praktisch kein Kollagen enthalten und von einer diskontinuierlichen Lage von Perineuralzellen umgeben sind (Bündel vom intramuralen Typ). Das ultrastrukturelle Bild dieser Nervenfasern ähnelt zentralnervösem Neuropil. Präterminale und terminale, varicöse Axone des Auerbachschen Plexus werden aufgrund ihrer Vesikelpopulationen und des vermuteten Transmittertyps in adrenerge, cholinerge, p-Fasern und sensorische Fasern eingeteilt.Der Sphincter ani internus empfängt vorwiegend große Nervenkabel vom gewöhnlichen peripheren Typ. Ebenso wie im aganglionären Abschnitt des Hirschsprungdarmes fallen sie durch ihren Reichtum an markhaltigen Fasern auf. Vesikelhaltige Axone zwischen glatten Muskelzellen des Sphincter internus sind entweder adrenerg oder cholinerg; in der Übergangsregion von distalem Rectum und proximalem Sphincter kommen außerdem p-Fasern vor. Nackte Axone adrenerger und cholinerger Neurone nehmen zu Muskelzellen des aganglionären Abschnitts im Hirschsprungdarm synaptische Beziehungen auf. Fortsätze intramuraler Neurone fehlen im aganglionären Colonabschnitt. In der Übergangszone zum hypertrophierten Abschnitt finden sich abnorme Nervenbündel mit hypertrophiertem Perineurium und Massen von Kollagenfibrillen. Die in diesen Bündeln vorkommenden Schwannzelleinheiten sind monooder oligoaxonal. Die Ultrastruktur des Gliagewebes erinnert an unreife, undifferenzierte Schwannzellen. Diese Befunde werden als Anzeichen für eine vergebliche Regeneration intramuraler Perikaryen im Übergangsabschnitt des Hirschsprungdarmes gewertet.Sowohl im normalen Sphincter ani internus als auch im aganglionären Abschnitt eines Hirschsprungfalles ist der Noradrenalingehalt etwa gleich hoch, im Vergleich zu allen Colonabschnitten eines gesunden Individuum jedoch mehr als zweimal so hoch.Das Fehlen einer extra- und intramuralen Hemminnervation im aganglionären Teil des Hirschsprungdarmes ist die Ursache seiner spastischen Dauerkontraktion. Gemeinsamkeiten und Unterschiede im Innervationsmuster und im pharmakologischen Verhalten des Sphincter ani internus und des aganglionären Colonabschnittes bei der Hirschsprungschen Krankheit werden hervorgehoben und diskutiert.

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Supported by grants from the Deutsche Forschungsgemeinschaft.     

der(4)t(Y;4): Three-generation transmission and sperm meiotic segregation analysis

We present a family where five members (three males and two females) are carriers of der(4)t(Y;4)(q11.23;p16.3). The adult carriers are phenotypicaly normal and fertile; the boy shows macrocephaly, psychomotor retardation, and atypical autism. The FISH on cultured lymphocytes confirmed that the redundant Yq heterochromatin was attached to the 4p-subtelomeric region maintained on the der(4). Sperm FISH analysis performed in a normospermic der(4) carrier showed a significant distortion of the expected 1:1 ratio of the X- and Y-bearing spermatozoa in favor of the X chromosome and significant lack of Y,der(4)spermatozoa. The overall lack of Y spermatozoa was not balanced even by a relative excess of Y,4 sperm. The analysis of X, Y, 7, 8, 18, and 21 sperm disomy and diploidy did not indicate any interchromosomal effect. The chromosome 4 disomy was significantly increased but still very low to be of considerable reproductive significance. The neurodevelomental phenotype of the boy was probably caused by a gene mutation. The coincidental occurrence of such chromosomal aberration and boy's phenotype might lead to misinterpretation of the causal relationship between these findings. It is necessary to consider the results of chromosomal analysis and clinical records of relatives for provide genetic counseling in such families.     

Increased neuropeptide Y-immunoreactive innervation of aganglionic bowel in Hirschsprung's disease

Summary The pathophysiology of Hirschsprung's disease has not been fully elucidated but is known to have a neurogenic basis. In recent years, new neural proteins and peptides have been discovered and our aim in this study was to use immunocytochemistry to investigate their involvement in the neuronal abnormalities associated with this condition. Large bowel samples from 9 children undergoing surgery for Hirschsprung's disease were compared with those taken from 8 children with other gastrointestinal diseases but no aganglionosis. Immunocytochemistry was carried out using antibodies to a wide range of neuron specific proteins and peptides. Examination of sections immunostained for the general neuronal markers, protein gene product 9.5, neuron specific enolase and neurofilament triplet proteins, allowed rapid identification of aganglionic segments. Nerves containing vasoactive intestinal polypeptide/peptide histidine methionine (VIP/PHM), galanin, substance P, somatostatin, met-enkephalin or calcitonin gene-related peptide (CGRP) showed a marked reduction in all layers of the aganglionic bowel. However, scattered VIP/PHM immunoreactive fibres were also found in the hypertrophied nerve bundles. In contrast with these reduced peptide-containing nerves, fibres displaying NPY immunoreactivity showed a marked increase in all aganglionic segments, particularly in the circular muscle where few are found normally. Our findings shed further light on the neurobiology of aganglionic bowel and suggest that immunostaining of neural proteins and the peptide NPY can aid rapid histopathological diagnosis of congenital aganglionosis.