Fourteen-year experience of acetylcholinesterase staining for rectal mucosal biopsy in neonatal Hirschsprung's disease

BACKGROUND/PURPOSE: Acetylcholinesterase (AChE) staining of rectal mucosal biopsy specimens is the most important and popular examination for making a definite diagnosis of Hirschsprung's disease. This examination often is performed for patients with constipation in the daily clinic. The results of this examination are reflected immediately in the treatment. However, the authors sometimes encountered difficult cases to diagnose, especially in neonates. Therefore, a retrospective investigation was conducted on the benefits and problems of AChE staining of rectal mucosal biopsy specimens in neonates. METHODS: The authors encountered 459 cases (91 neonates) of suspected Hirschsprung's disease, clinically, from April 1986 to March 2000. Mucosal specimens were taken by punch biopsies. Samples were stained by the modified Karnovsky Roots method using rubeanic acid as an amplifier and immediately examined with a light microscope. These results were collected and assessed mainly on neonatal cases. The authors also analyzed the 104 cases of Hirschsprung's disease diagnosed in patients less than 1 year of age to evaluate the relationship between the grade of proliferation of AChE positive fiber and age. RESULTS: Forty-one neonatal cases of Hirschsprung's disease were diagnosed based on the findings of AChE staining. A definite diagnosis of Hirschsprung's disease was confirmed based on the pathologic findings of operative samples. Forty-eight cases that were diagnosed as normal included 4 cases that turned out to be false-negative (3 Hirschspurung's disease cases and 1 case of an allied disorder of Hirschsprung's disease). There were no major complications in mucosal punch biopsy. In the cases of Hirschsprung's disease diagnosed in a patient less than 1 year of age, the grade of AChE-positive fiber tended to increase with the aging of patients. CONCLUSIONS: The specificity of AChE staining was high (100%), but its sensitivity was slightly low (91%). Careful long-term follow-up is required for any cases diagnosed as normal. Mucosal biopsies should be repeated in cases of persistent clinical symptoms.     

Problems and advantages of acetylcholinesterase histochemistry of rectal suction biopsies in the diagnosis of Hirschsprung's disease

One hundred fifty-seven children, aged 2 days to 15 years, had rectal biopsies for suspected Hirschsprung's disease from 1980 to 1987. Sixty had adequate suction rectal biopsies stained for acetylcholinesterase (ACE); 41 of these were reported as normal and eight showed atypical innervation in children who progressed satisfactorily without surgery. Two showed hyperganglionosis and nine were from children with Hirschsprung's disease. Four of the latter nine biopsies (44%) gave false-negative results in infants aged 9, 10, 13 days, and 6 weeks. The last had total colonic aganglionosis. There were two false-positive results, one in a normal child with atypical innervation and the other in a child with hyperganglionosis. Thus, six of 60 (10%) of ACE-stained suction rectal biopsies gave misleading results.     

Laparoscopy-assisted suction colonic biopsy and intraoperative rapid acetylcholinesterase staining during transanal pull-through for Hirschsprung's disease

Background: It is crucial to identify the exact level of transition to normal ganglion cells in instances of Hirschprung's disease. This report describes a technique for laparoscopy-assisted suction colonic biopsy during transanal pull-through. Methods: Laparoscopy-assisted suction colonic biopsy (SCBx) was used in 12 patients with Hirschsprung's disease affecting the rectosigmoid. Average age was 4.4 [plusmn] 2.1 months with a mean operative weight 6.2 [plusmn] 1.0 kg. The pull-through was performed as the primary operative procedure in 11 patients. Using a 2-team approach (laparoscopic team and transanal team), the site was chosen for transanal suction biopsy and marked externally by the laparoscopic team with a silver clip. Biopsies were processed for ganglion cells and rapid AChE technique. Results: There were no biopsy-induced perforations. Abnormal biopsies were repeated more proximally until ganglion cells were observed. Transanal pull-through was performed and an open full-thickness biopsy performed to confirm the presence of ganglion cells. All procedures were performed successfully. Conclusions: Laparoscopy-assisted SCBx can be used successfully in patients with Hirschsprung's disease affecting the rectosigmoid (80% of cases). The technique, when used with rapid AChE staining, provides accurate identification of the level of normoganglionosis.     

Rectal suction biopsy for the diagnosis of Hirschsprung's disease.

The diagnosis of Hirschsprung's disease is at times difficult, particularly in the young patient. Since 1972 we have used rectal suction biopsy as a screening technique in neonates and infants with failure to pass meconium or evidence of obstruction. In addition, it is used to confirm the diagnosis of Hirschsprung's disease when suspected by barium enema study. This technique has been used in 444 patients, 302 of whom were less than one year of age. No anesthesia is necessary, and there have been no associated complications. Only one patient early in the study had an initial misdiagnosis. There have been no false-positive or false-negative specimens since this initial problem, and no patients have undergone inappropriate pull-through procedures for suspected Hirschsprung's disease. It is recommended that all neonates who do not pass meconium in the first 48 hours of life undergo rectal suction biopsy to establish the diagnosis of congenital megacolon.     

Erythrocyte acetylcholinesterase activity in Hirschsprung's disease in Israel

Hirschsprung's disease is a relatively prevalent disorder in newborn babies and young children. Acetylcholinesterase (AChE) activity is augmented locally, in the neural plexus of the affected gut segment. It has been suggested that this enzyme will also be increased in red blood cells (RBCs) of affected children. Thus, we studied AChE activity in newborn babies and children, as well as age-adjusted data. This Israeli study consisted of healthy and affected Bedouins as well as Ashkenazi and Sephardic Jews. This study supports the Japanese study in that the RBC AChE is not augmented in Hirschsprung's disease. However, final conclusions cannot yet be drawn, because of the small sample.     

Serum and erythrocyte acetylcholinesterase activity in Hirschsprung's disease

Acetylcholinesterase activity was measured in the serum and erythrocytes from 22 children. The 12 patients in whom the diagnosis of Hirschsprung's disease was confirmed, had a significantly higher concentration of enzyme in both serum and erythrocytes than the 10 children in whom the diagnosis was excluded. This systemic manifestation, may prove of value in the diagnosis of Hirschsprung's disease.     

Full-thickness rectal punch biopsy for the diagnosis of Hirschsprung's disease.

The authors propose a full-thickness rectal punch biopsy method for the diagnosis of Hirschsprung's disease when the results of other diagnostic investigations have been equivocal. This procedure has been utilized in 48 patients in the last 8 yr and the method was diagnostically reliable.     

Histochemical criteria for the diagnosis of Hirschsprung's disease in rectal suction biopsies by acetylcholinesterase activity

Histochemistry to demonstrate cholinergic fibers in rectal suction biopsies is a reliable method to diagnose or exclude Hirschsprung's disease. The histochemical criterion of a positive reaction consists of the presence of many coarse discrete cholinergic fibers in the muscularis mucosae and in the immediately subjacent submucosa, best assessed under medium power with the condenser lowered. A marked increase in cholinergic fibers in the lamina propria is seen only in some cases of Hirschsprung's disease. At least some cases of Hirschsprung's disease may be the result of destruction of ganglian cells by a viral infection in the intrauterine and early postnatal life.     

Solo-RBT: a new instrument for rectal suction biopsies in the diagnosis of Hirschsprung's disease

BACKGROUND/PURPOSE: Preoperative histochemistry on rectal mucosal-submucosal specimens is the most important step in the diagnosis of Hirschsprung's disease and other dysganglionoses. Today, rectal mucosal-submucosal biopsy specimens are obtained by suction with the widely used tool first designed by Noblett in the late 1960s. The authors developed a new instrument, for which a patent has already been filed, for one-hand execution of rectal suction biopsies, which will make this operation easier and faster. METHODS: The authors modified the old tool but maintained the cutting method described by Noblett. The authors' innovative automatic tool (Solo-RBT) is based on the possibility of sequencing suction and cutting of the rectal mucosa just by pressing a "trigger." The trigger activates a plunger to obtain the vacuum necessary for the suction and a cutter for mucosal sampling. To perform a correct biopsy in children with different weight and in adults, Solo-RBT can be adjusted suitably to obtain automatically the vacuum required in each case. Additionally, this tool is provided with 2 different sizes of both capsules and cutters, and it can be disassembled completely for easy cleaning, maintenance, and sterilization. RESULTS: The instrument was tested clinically on 62 children (189 biopsies), and it proved to be versatile, atraumatic, and extremely handy, because it can be used by just 1 physician who only needs to press the trigger to obtain the biopsy. CONCLUSIONS: Solo-RBT not only maintains the benefits (atraumatic, easy to use, rapid) and the main characteristic (cutting system) of Noblett's tool but it also improves its features and eliminates most of its disadvantages. Therefore, Solo-RBT represents a significant improvement in the diagnosis of Hirschsprung's disease and other dysganglionoses.     

Diagnosing Hirschsprung's disease: increasing the odds of a positive rectal biopsy result

Background/Purpose: Rectal biopsies are performed as a definitve means of diagnosing Hirschsprung's Disease (HD) in children presenting with constipation. The authors hypothesized that key features in the history, physical examination, and radiographic evaluation would allow us to avoid unnecessary rectal biopsies. Methods: A retrospective analysis was conducted on patients undergoing rectal biopsy between 1995 and 2001. Patients with HD were identified (n = 50), and a concurrent cohort of patients with idiopathic constipation (IC; n = 50) was selected. Pertinent features in patients with HD versus those with IC were cross tabulated using Pearson [Chi ]² testing (significance was P [lt ] .05). Results: Sixty percent of patients with HD and 15% of patients with IC experienced onset of symptoms in the first week of life. HD patients more frequently experienced delayed passage of meconium (P [lt ] .05), abdominal distension (P [lt ] .05), vomiting (P [lt ] .05), and transition zone on contrast enema (P [lt ] .05). All patients with HD had one or more of these significant features. In contrast, only 64% of patients with IC had one or more of these features. The classic triad of symptoms (ie, delayed passage of meconium, vomiting, and abdominal distension) was present in 18%, and one or more of these symptoms was present in 98% of HD patients. In contrast, only 60% of patients with IC had a history of delayed passage of meconium, vomiting, or abdominal distension. Conclusions: A history of delayed passage of meconium, abdominal distension, vomiting or the results of a contrast enema identified all patients with HD and excluded HD in approximately 36% of patients with idiopathic constipation. The authors have shown that key features in a patient's history, physical examination, and radiologic evaluation can differentiate between HD and IC. In a child presenting with constipation and none of the above features, it is not necessary to perform a rectal biopsy to exclude HD. J Pediatr Surg 38:412-416.     

Acetylcholinesterase activity in suction biopsies of the rectum in the diagnosis of Hirschsprung's disease

Rectal suction biopsies have been employed in 214 subjects suspected of having Hirschsprung's disease. By applying conventional histology and acetylcholinesterase (AChE) determinations, 66 (31%) cases were diagnosed as Hirschsprung's disease—all of which were surgically confirmed. The problem of unsatisfactory biopsy material was circumvented by exclusively assessing for AChE activity. Despite the normal paucity of ganglion cells within the lowest 3 cm of the rectum, excessive enzyme accumulation characteristic of Hirschsprung's disease paralleled the findings obtained from the classical narrowed aganglionic segment.     

A 7-year study of the diagnostic value of rectal mucosal acetylcholinesterase measurement in Hirschsprung's disease

Over a 7-year period, 213 children were investigated for failure to pass meconium or for chronic constipation. Of these, 45 were confirmed to have Hirschsprung's disease; in this group the acetylcholinesterase activity in rectal biopsy tissue was significantly increased (P less than .001; mean 34.2, 95% confidence limits, 8.6 to 95.2) units g-1 when compared with the non-Hirschsprung's group (mean 6.6, 95% confidence limits, 2.0 to 15.9 units g-1). By expressing the acetylcholinesterase activity as a percentage of the total cholinesterase activity it is possible to compensate for evaporative weight loss and the combination of these two measurements improves the overall diagnostic value of the test. There were no false-positive and only two false-negative results.     

Two-point rectal mucosal biopsy for selection of surgical treatment of Hirschsprung's disease

A two-point rectal mucosal biopsy (utilizing a histochemical study), namely biopsies at sites 5 to 10 mm and 30 to 50 mm oral to the dentate line, was developed to differentiate patients who can be treated adequately by rectal myectomy without colostomy and those who require other definitive surgery for Hirschsprung's disease. The examinations were performed in 28 patients suspected having a short aganglionic rectum. Ganglion cells were demonstrated by upper biopsy in four of 13 neonates, six of nine infants, and three of six children. These cases were successfully treated by rectal myectomy. The two-point rectal mucosal biopsy is useful not only for making definitive diagnosis but also for the selection of the surgical treatment for patients with Hirschsprung's disease.     

The prevalence of Hirschsprung disease in premature infants after suction rectal biopsy

Background

The prevalence of Hirschsprung disease (HD) in the premature infant population is not well documented. However, delayed passage of stool is common in premature infants, and suction rectal biopsy (SRB) is often used to evaluate for HD in this population. The use of SRB is unknown. Therefore, we evaluated the role of SRB in premature infants with abnormal stooling patterns.

Methods

After Institutional Review Board approval, a retrospective study was conducted on all infants having an SRB performed to exclude HD from January 2000 to December 2010. Infants were divided into two groups according to gestational age (premature < 37 wk; term ≥ 37 wk). Demographics, diagnosis, treatments, and outcomes were collected. A subset analysis was performed on patients diagnosed with HD.

Results

Two hundred sixty-nine infants were identified (113 premature and 156 term). Six premature infants (5.3%) and 79 term infants (50.6%) were found to have HD (P < 0.01). As expected, gestational age was significantly different between groups (31.7 versus 38.9 wk, P < 0.01) (Table 1). Premature infants were less likely to have prenatal care (35% versus 55%, P < 0.01) and had longer lengths of hospital stay (45.6 versus 17.6 d, P < 0.01). The most common location of aganglionosis was rectosigmoid in both groups (group 1, 50%; group 2, 33%, P = 0.7).

Conclusions

HD occurs significantly less often in premature infants than in term infants. Alternative diagnoses should be investigated in this population when delayed stooling patterns are encountered. SRB should be used more selectively in this group.     

Acetylcholinesterase activity in rectal mucosa and blood in the diagnosis of Hirschsprung's disease

Histochemical and biochemical examinations of rectal biopsy specimens were performed in 13 patients with Hirschsprung's disease and in seven with idiopathic constipation and no megacolon. Serum and erythrocyte acetylcholinesterase (AchE) activity in these two groups was compared with that in 30 normal controls. AchE staining of rectal biopsy specimens proved to be a reliable and convenient diagnostic approach in patients with Hirschsprung's disease. Biochemical assay of AchE activity in rectal biopsy specimens was also of value in the diagnosis, however, there was an overlap between Hirschsprung's disease and idiopathic constipation. Erythrocyte AchE activity correlated well with AchE activity in rectal biopsy specimens. Therefore, assays of erythrocyte AchE activity provided useful additional information, especially in screening tests for Hirschsprung's disease.     

Intensity and proximal extension of acetylcholinesterase activity in the mucosa of the rectosigmoid in Hirschsprung's disease

By staining for AChE activity, 51 consecutive rectal biopsies were investigated for the presence of mucosal nerve fibers in order to evaluate the possibilities of suction biopsies for the diagnosis of Hirschsprung's disease. Of nine patients suffering from Hirschsprung's disease, AChE activity was increased in eight. This study suggest that the intensity and proximal extension of AChE activity increase with age, and that mucosal activity does not extend as far proximally as in the submucous and intramuscular plexuses. From the study of resected bowel segments of eight patients it is concluded that false-negative findings in the rectal mucosa of patients with Hirschsprung's disease are avoidable by taking the biopsy immediately beyond the pectinate line. There were no false-positive findings.     

An improved staining technique for acetylcholinesterase activity using rubeanic acid in the diagnosis of Hirschsprung's disease

An improved staining technique for acetylcholinesterase (AChE) activity using rubeanic acid was used to make a clinical diagnosis in 54 children with constipation. Nineteen were thus confirmed to have Hirschsprung's disease. False positive or negative reactions were nil. The sites of AChE activities were in the form of black deposits and the contrast was sharp. This approach should find a wide application for the diagnosis of Hirschsprung's disease.     

'Hop the skip' with extended segment intestinal biopsy in Hirschsprung's disease

INTRODUCTIONSkip segment Hirschsprung's is an extremely rare condition, with only 25 reported cases in the English language literature. Diagnosis of skip segment Hirschsprung's may be missed as it is rarely suspected at initial surgery.PRESENTATION OF CASEA case report of an infant with total colonic aganglionosis and a skip segment Hirschsprung's in the cecum is presented. A review of literature on current surgical practice is presented along with our suggested modification to the diagnostic and therapeutic algorithm of this rare condition.DISCUSSIONIn our patient the initial leveling colostomy was incorrectly sited at the level of the first detected ganglionated segment. Subsequent recurrent episodes of enterocolitis led to a diagnosis of a long skip segment involving the ascending colon, cecum and terminal ileum. Correct leveling colostomy and a subsequent Duhamel procedure led to a good outcome.CONCLUSIONDetermination of the transition zone in Hirschsprung's may be incorrect if intestinal biopsies are terminated at the first evidence of ganglion cells. Extended segment intestinal biopsies should be included in the algorithm for management of long segment Hirschsprung's disease and will enable the surgeon to correctly detect rare manifestations such as skip segment disease at the initial procedure.