肠神经元性发育不良的病理形态学研究

目的 探讨常规组织切片中肠神经元性发育不良的病理形态学特征。方法 送检４８例ＨＤ及ＨＤ类缘病肠段采取定长度纵行全层取材,常规制片;观察肠神经元及神经节细胞形态和数量的变化并与正常组进行比较。结果 肠神经元性发育不良（Ｂ型）肠壁肌间神经节细胞数明显增我心甘产高,８１．２５％的病例可见巨神经丛,５０％的病例可见孤立枵异位神经节细胞。结论 巨神经丛、孤立和异位神经节细胞、肠壁神经节细胞数目增多是ＩＮＤ（     

先天性巨结肠经肛门Ⅰ期根治术的研究进展

先天性巨结肠是一种以肠道末端肠壁神经节细胞完全缺如为特征的常见消化道发育畸形。主要原因是患儿在胚胎期肠神经发育过程中,肠神经元发育出现停顿,肠壁肌间神经丛内的神经节细胞缺失,以致受累肠段异常收缩,近端结肠代偿性扩张与肥厚形成巨结肠。     

先天性巨结肠症及其同源病神经标志物的表达以及图形测量定量研究

目的免疫组织化学方法检测4种肠道神经标志物在正常结肠、先天性巨结肠症（HD）、神经元发育不良-B（IND-B）及神经节细胞减少症（HG）病变结肠的表达特点，并采用图像分析技术对肠道神经系统进行定量分析。方法组织蛋白酶D、蛋白基因产物9．5、S-100蛋白和外周蛋白4种抗体，对10例正常结肠、20例HD、8例IND-B型及20例FIG的患儿结肠石蜡标本切片采用过氧化酶标记的链霉卵白素免疫组织化学染色。ImageJ图像处理软件对所有数码图像（×400）中神经丛、节细胞计数以及节细胞形态进行定量测量。结果组织蛋白酶D仅在神经节细胞表达阳性，不表达于神经纤维；PGP9．5和外周蛋白在肠壁肌间、黏膜下神经丛及神经节细胞中均有阳性表达；S-100在神经节细胞中表达阴性。定量分析：HD病变肠段缺乏神经节细胞；IND-B病变肠段肌间神经节细胞与正常比较计数明显增多，节细胞直径以及细胞核直径分别为正常的1．22倍和1．34倍（P〈0．01）；HG病变肠段神经丛内节细胞数量明显减少（P〈0．05）。结论免疫组织化学染色图像分析技术使不同病变间的形态差异得到定量分析，有助于对HD和同源病的病理学研究以及临床诊断和鉴别诊断。     

先天性巨结肠伴先天性巨结肠类缘病1例

肠神经元性发育异常（NID）是先天性巨结肠类缘病的一种,临床诊断困难,主要根据病理特征诊断。现就我科1例先天性巨结肠(HD)伴NID的病理改变报告如下。临床资料患儿,男,7 a,生后未排便,我院诊断为HD,生后52 d行横结肠肝曲造瘘。术后排便功能正常,9个月时行巨结肠根治术。病理报告：直肠壁肌间神经丛未见神经节细胞,吻合口肠壁神经丛内可见神经节细胞,个别节细胞呈空泡变性,诊断为HD（常见型）。术后3个月开始便秘,伴腹胀,洗肠无明显好转,反复发生肠炎和肠梗阻、水电解质紊乱、营养不良住院,肠镜下发现残留的升结肠及回…     

神经元特异烯醇化酶和S100蛋白在巨结肠及其类缘病中的表达

目的探讨神经元特异烯醇化酶(NSE)和S100蛋白(S100)在巨结肠及其类缘病的表达和临床意义。方法对120例拟诊为先天性巨结肠的病变肠段行HE染色,结合光镜下肠壁神经节细胞的形态特征,并对29例应用免疫组织化学技术行NSE、S100蛋白染色,比较其染色结果和分布特点。结果巨结肠类缘病标本的神经丛及神经节细胞数与正常组比较差异有显著性(P<0.01)。结论NSE、S100可作为巨结肠与其类缘病鉴别诊断的标记物,能提高临床巨结肠类缘病的确诊率。     

突触素在肠动力性疾病中的免疫表达及意义

目的观察突触素在先天性巨结肠、慢性便秘、先天性肛门闭锁等肠动力性疾病中的免疫表达,探讨突触素的表达对于肠动力性疾病的意义。方法自36例肠动力性疾病患儿中留取活检标本,应用免疫组化方法对突触素显色。结果先天性巨结肠患儿有神经节细胞肠壁平滑肌肌层突触素大量表达,其中环形肌和纵形肌肌层中神经节细胞、神经纤维呈现不同的免疫反应性;非先天性巨结肠患儿有神经节细胞肠壁粘膜肌层突触素大量表达。肠动力性疾病患儿无神经节细胞肠壁均无突触素表达;移行区肠壁仅可见零星神经节细胞,突触素少量表达。慢性便秘患儿镜下可见突触数量明显降低,但在正常范围。先天性肛门闭锁患儿闭锁部位近端肠壁可见神经节细胞及突触的正常分布,肠壁粘膜下层及肌层见少量发育异常的神经节细胞。结论通过对突触的特异性结合,突触素的免疫表达可以间接检验神经节细胞的数量,而肠动力性疾病的本质是神经节细胞的分布异常,因此突触素的表达对于肠动力性疾病的发病机制的探讨及症状描述有重要意义。     

粘附分子及其配体在先天性巨结肠发生中的作用

先天性巨结肠(HSCR)是一种常见的胃肠道发育畸形,有遗传倾向,其病理基本变化是病变肠段肌间神经丛和粘膜下神经丛内神经节细胞完全缺如。关于神经节细胞缺如的原因目前主要有以下三种学说:①胚胎发育期,形成神经元的神经嵴细胞分化及向肠道移行过程中发生障碍,停顿越早无神经节细胞段越长;②神经嵴细胞迁移到肠壁中去后某些局部因素的变化,如肠道缺血的作用,阻止了峭细胞聚集或导致已聚集起来的细胞     

小儿神经节细胞减少症肠壁肌间神经丛形态定量研究

目的研究神经节细胞减少症的形态定量特征。方法对15例小儿节细胞减少症、14例无神经节细胞症及14例正常神经分布的肠壁组织进行常规石蜡切片,并作HE染色、NSE及S-100免疫组织化学染色,在光学显微镜图像分析系统下对三组标本的肠壁肌间神经丛组织进行形态定量测定并对各组测量参数进行统计学的分析比较。结果节细胞减少症肠肌神经丛中每毫米肠壁的平均神经节细胞数是1.52个(仅为正常组的24.3%),其每毫米肠壁的平均神经丛面积是(5.61×103)μm2(为正常组的17.3%),无神经节细胞症神经丛面积亦有明显减少,数量更少,NSE、S-100免疫组织化学染色可帮助正确辨别神经节细胞。结论肠壁肌间神经丛中神经节细胞数量减少的同时伴有神经丛面积的减小是节细胞减少症的特征性改变,肠肌神经丛的形态定量测定可作为神经节细胞减少症的客观诊断依据,彻底切除节细胞减少的肠段对于根治此症具有重要意义。     

The expression and significance of calretinin in the colon of patients with Hirschsprung's disease

目的 本研究应用免疫组织化学染色方法,观察对照组肠壁、先天性巨结肠症(Hirschsprung's disease,HD)患儿有神经节细胞段和无神经节细胞段肠壁神经组织中钙视网膜蛋白(Calretinin,CR)的表达结果,目的在于了解HD的病理生理改变以及寻找诊断先天性巨结肠的简便有效的方法.方法 收集苏州大学附属儿童医院小儿外科2005至2008年手术切除HD标本54例,包括HD扩张段与痉挛段.以15例年龄与之相符的无HD患儿的手术切除结肠标本作为对照组.分别对HD痉挛段、扩张段、对照组肠壁组织切片进行CR的免疫组织化学染色和HE染色,计算机成像系统照相存盘,用图像分析软件(Image-Pro-Plus)分别判定CR在HD扩张段与痉挛段神经丛中阳性染色面积百分比.所得数据用SPSS 12.0统计软件包进行处理分析.结果 ①无论是HE或免疫组化染色HD的扩张段神经节细胞皆存在,肌层神经纤维有不同程度的排列改变,神经节细胞大小不等;痉挛段均未见神经节细胞;②在正常结肠及HD扩张段肠壁免疫组化染色可见钙视网膜蛋白在肌间及黏膜下神经丛中对神经节细胞呈强阳性表达,神经纤维也呈阳性反应;而HD痉挛段肠壁的免疫组化染色则可见钙视网膜蛋白在肌间神经丛及黏膜下神经丛大多表达阴性(90.7％),仅少量呈弱阳性表达(9.3％);③定量分析:CR分别在HD痉挛段之间神经丛中阳性染色面积百分率(0.00665±().00387)与其在HD扩张段神经丛中阳性染色面积百分率(0.26483±0.14626)存在差异,有显著统计学意义(P＜0.01).结论 钙视网膜蛋白免疫组化染色可很好的显示正常结肠及HD扩张段肠壁的神经节细胞及神经纤维,而在HD痉挛段该指标免疫组化染色结果呈阴性或弱阳性表达.钙视网膜蛋白可能作为诊断HD的神经标志物之一.     

NSE和S-100蛋自在巨结肠同源病的表达

目的 探讨巨结肠同源病的病理形态学特征,提高其诊断符合率.方法 对131例行巨结肠根治术患儿的病变肠段进行常规HE染色,观察肠神经元及神经节细胞形态和数量的变化,与正常组进行比较,并对21例标本采用NSE和S-100蛋白进行免疫组织化学染色.结果 巨结肠同源病(HAD)标本的神经元和神经节细胞数与正常组及巨结肠症(HD)比较,差异有显著统计学意义(P＜0.01).结论 巨结肠同源病的诊断主要根据病理特征而定,在HE染色基础上结合NSE及S-100蛋白免疫组织化学染色能提高确诊率.     

Clinical impact of intestinal neuronal malformations: a prospective study in 141 patients

A prospective study of 141 consecutive patients with intestinal neuronal malformations is presented. The single malformation of the autonomic nervous system that always required surgical intervention was aganglionosis. Giant ganglia, reduced parasympathetic tone, immature ganglia, and hypogenetic or heterotopic nerve cells were seen in all forms of malformations. However, the incidence in specific malformations was variable. Multiple giant ganglia were identified in all patients with intestinal neuronal dysplasia (IND) type B, but also in various other malformations. Heterotopic nerve cells in the myenteric plexus were seen in the proximal segment of 15 of 74 patients (20.3%) with aganglionosis and 5 of 9 patients (55.6%) with hypoganglionosis. A significant impact on symptoms was found for IND type B: 34 (45.9%) of 74 children with aganglionosis had associated IND type B, and these children more frequently developed ileus (P < 0.001) and more often needed a second resection (P < 0.05) compared to those with isolated aganglionosis. This indicates an additive effect of both malformations, and therefore, in these patients an extended resection should be carried out.Twelve of 67 patients (17.9%) without aganglionosis needed resection for untreatable constipation. This included 7 of 9 children with hypoganglionosis, both patients with heterotopia of the myenteric plexus, 1 of 20 with isolated IND type B, and 2 of 12 with reduced parasympathetic tone. None of the patients with immaturity, heterotopia of the submucous plexus, or mild dysganglionosis required surgery. Six children (8.9%) without aganglionosis underwent sphincteromyotomy and 2 with IND type B had a temporary colostomy. At follow-up (mean 2.4 ± 1.4 years), the outcome in patients with resected aganglionosis was better than in patients who had resections for other malformations; 49 (69%) of 71 patients with aganglionosis were asymptomatic compared to 4 (33.3%) of 12 with other malformations (P < 0.05). It is concluded that some intestinal malformations have a relevant clinical impact. However, the severity of symptoms in the individual patient may not be explained by specific histochemical findings from a limited number of mucosal biopsies. The pathognomonic histochemical criteria of isolated IND typeB — immaturity, reduced parasympathetic tone, heterotopia of the submucous plexus, and mild dysganglionosis —rarely require surgical therapy and should be treated conservatively.     

神经节和神经胶质细胞在小肠闭锁中的分布研究

目的了解神经节细胞在先天性小肠闭锁中的分布情况,并探讨其临床意义。方法应用免疫组化技术检测13例先天性小肠闭锁患儿肠壁内NT-3、Trk-C、GFAP和Nf的表达情况,并以正常小肠标本作为对照穴n=3雪。结果NT-3、Trk-C和Nf在对照组中的表达明显高于闭锁组(P<0.05);GFAP在闭锁组的胶质细胞中表达明显增高。结论小肠闭锁的近端肠壁内神经节细胞的减少和神经干的变细可以影响闭锁区域肠道的功能,是影响病人术后肠道功能不良的原因所在。     

Morphological abnormalities in the innervation of the atretic segment of bowel in neonates with intestinal atresia

The aim of this study was to examine precisely the morphological abnormalities in the myenteric plexus at the atretic end of the bowel in jejunoileal atresia (JIA). Although changes in the myenteric plexus has been examined in the proximal and distal segments of bowel in JIA, a histochemical analysis of the atretic segment is lacking. Specimens from the atretic end of bowel were obtained from six neonates with JIA. Whole-mount preparations were made of the myenteric plexus, and the cholinergic and nitrergic components were studied by staining with acetylcholine esterase (Ach E) and NADPH diaphorase, respectively. Controls were obtained from two neonates undergoing small bowel resection for Meckel’s diverticulum. At the blind end of bowel in type 3a atresia (5 neonates), the intensity of NADPH staining was comparable with controls. However, there was distortion of polygonal architecture of the primary and secondary plexuses at the blind end arranged in concentric fashion parallel to the circular muscle fibres. The ganglia were large and irregularly shaped and contained round neuronal cells. In the sausage shaped segment of bowel in multiple atresia, there was total loss of polygonal architecture with abnormal ganglia, and whorls of nerve fibers. Neuronal cells could not be made out in the ganglia. In specimens stained with Ach E, the findings were similar except that the staining intensity was markedly reduced compared with controls. The morphological abnormalities in the atretic bowel in type 3a were restricted to the architecture of the plexuses and ganglia. The neuronal cells were normal. However, the total loss of polygonal architecture and absence of neuronal cells in the ganglia in multiple atresia probably indicate a different etiology for this type of atresia     

Intestinal neuronal dysplasia and its morphometric evidences

The aim of this study was to morphometrically objectify the characteristics of intestinal neuronal dysplasia (IND) B by optic electronic image analysis. Biopsies of 60 children divided into two age groups (8 ± 4 months and 4 years ± 20 months) were examined. Three groups (n = 20) were studied: (1) isolated IND B; (2) Hirschsprung-associated IND B (NAIND), and (3) normal controls. A histotopochemical lactic dehydrogenase (LDH) reaction was used for the morphometric measurement of ganglion size, nerve cell size, and number of nerve cells per ganglion. The submucous neural density was measured with an acetylcholinesterase reaction. The results showed no significant morphometric differences between isolated IND and HAIND. Aging caused an increase in ganglion and nerve cell size. The density of the submucous plexus decreased with age. All parameters measured were significantly different from normal controls. Giant ganglia with a high number of LDH-positive nerve cells (IND: > 7, controls: 4 ± 1 nerve cells/ganglion) were the most relevant diagnostic parameter of IND. The pathogenesis of a dysganglionosis is dominated by abnormal early, genetically caused laminin expression during embryonic life, blocking neuroblast migration (aganglionosis) and prematurely differentiating neuroblasts into myenteric (hypoganglionosis) and submucous plexus (IND). IND B, hypoganglionosis, and aganglionosis are different manifestations of an identical developmental abnormality in which IND is the weakest form.     

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.     

Intestinal neuronal dysplasia of the myenteric plexus - a new entity in humans?

Intestinal neuronal dysplasia is a rare cause of bowel obstruction in neonates and infants, the diagnosis of which poses a formidable challenge to both clinicians and pathologists alike. The importance of this entity lies not only in the fact that it mimics Hirschsprung's disease, but also in that untreated cases may prove fatal. The authors describe one such case of enigmatic entity of intestinal neuronal dysplasia of the myenteric plexus.     

Isolated intestinal neuronal dysplasia Type B (IND-B) in Japan: results from a nationwide survey

Purpose

Intestinal neuronal dysplasia Type B (IND-B) has been proposed to be an allied disorder of Hirschsprung’s disease (ADHD). The original histological criteria included hyperganglionosis, giant ganglia, ectopic ganglion cells and an increased AChE activity in the lamina propria. The criteria for IND-B have been gradually revised. The present diagnostic criteria are [1] more than 20 % of the submucosal ganglia contain nine or more ganglion cells and [2] the patient is older than 1 year. To clarify the current status of IND-B in Japan, a nationwide retrospective cohort study was performed.

Methods

Questionnaires were sent to 161 major institutes of pediatric surgery and gastroenterology in Japan.

Results

A total of 355 cases of ADHD were collected, including 18 cases of IND-B (5 %). Based on original criteria, 13 out of 18 cases were diagnosed as IND-B. However, only four cases met the current criteria. Three of the four patients (75 %) required pull-through operation. All of the patients exhibited giant ganglia and ganglioneuromatosis-like hyperplasia of the myenteric plexus.

Conclusions

IND-B cases matching the current criteria are thought to be quite rare and they are associated with marked hyperplasia of the myenteric plexus. “True” IND-B is a rare and intractable disease.     

Histochemical and immunohistochemical study of the intrinsic innervation in colonic dysganglionosis

Defective innervation of the neuromuscular junctions (NMJ) was recently described in intestinal neuronal dysplasia type B (IND B). The aim of the present study was to correlate the alterations in NMJs to other classically described parameters in dysganglionoses and to determine the relationship between NMJ abnormalities in IND B and clinical symptoms. The rectal biopsies and full-thickness colonic biopsy specimens of 17 patients were studied applying histochemical (acetylcholinesterase [AChE], lactic dehydrogenase [LDH], and succinic dehydrogenase [SDH] reactions) and immunohistochemical (neuronal-cell adhesion molecule [NCAM] and SY antibodies) methods. Thirteen patients had Hirschsprung's disease (HD). IND B was diagnosed in 11 (associated with HD in 8 cases, isolated in 2, and associated with hypoganglionosis in 1). In the aganglionic segment of HD there was very intense AChE activity; in contrast, NCAM- and SY-immunoreactive nerve fibers were markedly decreased. A spectrum of abnormalities was observed in IND B, usually more severe in the most distal segments: giant and immature ganglia in the submucous plexus were observed in all cases; heterotopic myenteric ganglia were frequent (72.7%); hyperganglionosis was observed in 6 (54.5%) and was not related to the patients' age; thick and tortuous NCAM- and SY- immunoreactive nerve fibers, irregularly distributed in the colonic wall, were observed in 81.8% of the cases. No relationship was observed between abnormalities of NCAM- and SY-immunoreactive nerve fibers and AChE activity, ganglion-cell maturity, heterotopy, or the clinical symptoms presented by the patients with IND B. In hypoganglionism, low AChE activity and a slight decrease in NCAM- and SY-immunoreactive nerves were observed. Thick and tortuous, irregularly-distributed intrinsic NCAM- and SY-immunoreactive nerves were observed in every colon layer in IND B. Our results do not support IND B as a NMJ disorder. Accepted: 12 May 2000     

Intestinal transit time in children with intestinal neuronal malformations mimicking Hirschsprung's disease.

A total of 106 consecutive children with intestinal neuronal malformations were included in a prospective study. The intestinal transit time was assessed using a modification of Hinton's method. The results of transit time studies, the associated specific histochemical findings, therapeutic procedures, and the clinical course on follow-up assessments over a mean period of 2.4 years were analysed. The intestinal transit time was prolonged in all 53 patients with aganglionosis and in 37 (69.8%) out of 53 children with other intestinal malformations. Eight out of 16 children with IND type B had an abnormal transit time, 1 underwent anterior resection, and 2 had a temporary colostomy. In 7 out of 8 children with hypoganglionosis and 9 out of 10 children with a reduced parasympathetic tone the transit time was prolonged. A resection was performed in 7 and 2 of these children respectively. Both patients with heterotopia of the myenteric plexus had a prolonged bowel transit and parts of the large bowel had to be resected. Only 11 out of 17 children with heterotopia of the submucous plexus, dysganglionosis, or immature ganglia had a prolonged transit time, 2 underwent sphincteromyotomy. At follow-up, all patients with malformations other than aganglionosis stated that symptoms had improved and they were willing to tolerate their complaints. However, 25 reported on persistent constipation, 6 on overflow encopresis. All children who required surgery had a prolonged intestinal transit time, but also 21 (56.8%) of 37 children who were successfully treated without surgery. None of the 16 children with normal transit had to be operated. It is concluded that specific histochemical findings do not always correlate with delayed intestinal transport. The determination of the intestinal transit time represents an important tool to identify the clinical relevance of histochemical findings in the individual patient.