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.     

巨结肠类缘性疾病肛管测压、直肠黏膜活检和钡灌肠检查的意义

目的　根据病理学的诊断依据 ,评价先天性巨结肠类缘性疾病 (HAD)中直肠肛管测压、直肠黏膜活检AchE组化染色和钡灌肠检查的特点 ,了解其在诊断上的意义。方法　 1999～ 2 0 0 1年间 92例临床诊断为先天性巨结肠 (HD)或巨结肠类缘性疾病并施行手术的患儿 ,根据病理诊断排除HD和HAD共存病变病例 ,筛选出HD 4 0例 ,其中男 36例 ,女 4例 ,平均年龄 2 1个月 ;HAD 34例 ,其中男 2 1例 ,女 13例 ,平均年龄 6 3个月。研究二组的临床征候指标以及在经典的测压、组化以及钡灌肠三项检查上的差别。结果　二组病例相比 ,三项检查每项指标间都存在着极显著差异 (P <0 .0 1) :在HAD组患儿 ,85 %都存在有直肠肛管抑制反射 ,其反射波出现特征性的“W”、“U”波形 ;直肠黏膜AchE组化染色 79%为阴性 ;钡灌肠常不能发现明显的狭窄、移行段 ,但有明显的结肠扩张和2 4h钡滞留。结论　HD和HAD是都以便秘为主要表现的两种不同的疾病。经典的三联检查在HAD的诊断和鉴别上也具有重要意义     

Hypoganglionosis

Between 1973 and 1988, 280 patients suspected of having Hirschsprung's disease were examined by rectal mucosal biopsies prepared by acetylcholinesterase (AChE) and hematoxylin-eosin staining. Twelve of these patients were histologically diagnosed as having hypoganglionosis; rectal mucosal biopsies in all 12 showed the presence of a few small ganglia. Cases of hypoganglionosis were divided into three groups based on the findings of AChE-positive nerve fibers: type A: rectal suction biopsies taken in the neonatal period showed proliferation of AChE-positive nerve fibers similar to those seen in aganglionic bowel; type B: AChE-positive nerves were virtually absent from the lamina propria in the neonatal period, but during or after infancy there was moderate to severe proliferation of AChE-positive fibers in the lamina propria; type C: rectal mucosal biopsies performed even after infancy showed no proliferation of AChE-positive fibers in the lamina propria. An accurate diagnosis of type C can only be made by examination of the myenteric plexus in a full-thickness rectal biopsy specimen. On barium examination, definite caliber changes were seen in 7 cases, equivocal changes in 4 and none were seen in 1. Anorectal manometry showed an atypical rectosphincteric reflex in 5 cases and absent reflex in 7. Treatment depends on the degree of clinical symptoms and length of the involved segment of bowel and consists of a definitive pull-through operation or internal sphincter myectomy [2, 3]. Offprint requests to: K. Munakata     

先天性巨结肠同源病:临床诊断与手术指征的确立

目的 报道一组前瞻性的先天性巨结肠同源病(HAD)临床研究总结.方法 2007年6月至2009年12月单一手术组连续行65例巨结肠根治术病例,依据临床症状、直肠肛管测压、直肠黏膜胆碱酯酶组化(AchE)组织化学染色以及钡灌肠检查做出术前诊断.先天性巨结肠症(HD)一旦确诊即有手术指征.HAD手术指征:依临床检查初步诊断后实行严格、系统的保守治疗3～6个月,经治疗无效或有效后又复发者.结果 临床初诊病例HD组为38例,HAD组为27例;术后经病理学诊断最后确诊HD组36例,HD组内有4例证实为HAD,术前误诊率为10.5%(4/38),HAD组最后病理确诊29例,HAD组内2例最后病理诊断为HD,术前误诊率为7.4%(2/27);HAD组中节细胞减少症(HG)22例(75.9%),肠神经元发育不良症(IND)7例(24.1%).HAD组27例(93.1%)存在直肠肛管抑制反射,但反射波形出现变异和延迟;AchE组化染色阳性为12例(41.4%),2项结果与HD组相比差异有统计学意义(P＜0.01);HAD病例钡灌肠检查特点:直肠高度扩张,直肠直径达盆腔的90%以上;超过90%的HAD病例有乙状结肠冗长;24 h后复查钡滞留(100%).29例HAD患儿中9例行次全切除术(31.0%),HD组36例中次全切除为8例(22.2%).结论 测压、AChE组化染色和钡灌肠检查仍是诊断HAD的重要方法.初步诊断HAD后,采取3个月到半年的严格保守治疗措施对最后确定手术指征非常重要.由于HD和HAD症状和检查结果在一定程度上相互重叠,致使HAD和HD病例术前可误诊,但这种误诊对手术指征的确定并无影响.     

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     

Manometry and histochemistry in the diagnosis of Hirschsprung's disease.

Acetylcholine esterase histochemistry and rectal manometry have been used sequentially to evaluate constipated children and to make the diagnosis of Hirschsprung's disease. When applied together, these modalities give a reliable diagnosis of Hirschsprung's disease, restricting the use of deep rectal biopsy to those patients in whom symptoms are most suggestive of Hirschsprung's disease. Acetylcholine esterase histochemistry may be more reliable than rectal manometry in the newborn and premature periods. It is hoped that the combined use of these techniques may make deep rectal biopsy obsolete except in patients with hypoganglionosis.     

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.     

先天性巨结肠神经生长因子mRNA表达水平的RT-PCR研究

目的：探讨神经生长因子（ＮＧＦ）的生物作用与先天性巨结肠症发病机制间的关系。方法：采用加入一定量化因素的ＲＴ－ＰＣＲ技术检测了８例先天性巨结肠症、１例神经节细胞过少症以及１例肠神经元发育不良症不同节段肠组织ＮＧＦｍＲＮＡ的表达水平。结果：无神经节细胞的巨结肠狭窄段和节细胞过少的肠组织与扩张段近端正常肠组织相比，其ＮＧＦｍＲＮＡ表达水平降低，阳性率分别是２／９和８／９，肠神经元发育不良的病变肠组织ＮＧＦｍＲＮＡ表达水平亦有下调趋势。结论：ＮＧＦ与肠神经系统发育关系密切，ＮＧＦｍＲＮＡ表达的异常可能参与先天性巨结肠的发病机制；但无节细胞症是多因素综合作用的结果，ＮＧＦ也许仅影响节细胞功能的成熟     

Cytomegalovirus Infection of the Bowel in Infancy: Pathogenetic and Diagnostic Significance

Three infants had cytomegalovirus (CMV) infection of the bowel. Infected enteric ganglion cells were found in two, one of whom had hypoganglionosis and colonic dysmotility. The third infant had classic short segment Hirschsprung's disease and colitis with CMV inclusions in vascular endothelium, a situation wherein viral transformed cells may have led to misinterpretation of the diagnostic biopsy.     

Cytomegalovirus infection of the bowel in infancy: pathogenetic and diagnostic significance

Three infants had cytomegalovirus (CMV) infection of the bowel. Infected enteric ganglion cells were found in two, one of whom had hypoganglionosis and colonic dysmotility. The third infant had classic short segment Hirschsprung's disease and colitis with CMV inclusions in vascular endothelium, a situation wherein viral transformed cells may have led to misinterpretation of the diagnostic biopsy.     

Rectal biopsy: what is the optimal procedure?

Rectal suction biopsy (RSB) is a well-known diagnostic procedure for disorders of bowel motility such as Hirschsprung's disease (HD). However, there are few reports about the optimal method of obtaining rectal tissue. We introduce a new technique using Gruenwald's nasal cutting forceps (NCF). From 1986 to 1999, we performed 130 sets of rectal biopsies in patients suspected of having HD. In group I (1986 to 1994), 68 sets of three-site biopsies (2, 3, and 5 cm above the dentate line) were performed using a conventional blind RSB technique. In group II (1995 to 1999), 62 sets of one-site biopsies (2 cm above the dentate line) were performed using Gruenwald's NCF after anal dilatation during general anesthesia. Hematoxylin-eosin staining and acetylcholinesterase histochemistry were used to examine all specimens. Biopsy specimens in group II (4.39 +/- 1.07 mm(2)) were larger than in group I (1.59 +/- 0.39 mm(2)) ( P < 0.01). In 18 cases (26 %) in group I, normal and HD bowel could not be differentiated because the specimens were too small to detect ganglion cells (i.e., only lamina propria [9 cases] or a small area of submucosa [9 cases] was present). These cases required repeat biopsy. All cases of HD diagnosed in group I (n = 20) were based on the findings of biopsies taken at 2 cm; biopsies from 3 and 5 cm did not provide additional information. There were 2 cases of post-biopsy hemorrhage in group I. In group II, 18 subjects were diagnosed with HD and 39 were confirmed to have normal bowel. There were no complications and repeating the biopsy was unnecessary. Three cases of hypoganglionosis (1 in group I and 2 in group II) were missed because the myenteric plexus abnormalities could not be detected by RSB. Intestinal neuronal dysplasia (IND) was diagnosed in 5 cases (2 in group I by repeat full-thickness biopsy and 3 in group II by rectal biopsy). We conclude that our new technique is advantageous and safe to differentiate between normal bowel, HD, and even IND on the basis of a single biopsy taken 2 cm above the dentate line. The biopsy can be taken under direct vision and is histopathologically accurate.     

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     

结肠次全切除术治疗巨结肠同源病23例

目的探讨小儿巨结肠同源病(HAD)的诊断和治疗方法。方法回顾性分析23例巨结肠同源病的病例资料,男8例,女15例,年龄5个月～16岁,其中5个月～3岁4例,3～16岁19例。患儿均以便秘、腹胀为主诉,术前常规行钡灌肠、直肠肛管测压检查。其中11例行直肠粘膜活检术;5例因肠梗阻行结肠造瘘术;3例为先天性巨结肠术后复发便秘。结果全部病例均行腹会阴Soave法结肠次全切除术。23例中,钡剂灌肠均未见明显狭窄段、移行段,24h延迟拍片提示钡剂滞留;部分病例有结肠扩张和结肠冗长表现;直肠肛管测压均有抑制反射,11例直肠粘膜活检AchE阴性。23例术后病理诊断与术前诊断一致。术后均有不同程度腹泻,1例出现伤口裂开,2例直肠粘膜脱垂,2例粘连性肠梗阻;无吻合口瘘、肌鞘感染等并发症。结论腹会阴Soave法结肠次全切除术是治疗HAD较为彻底的术式。     

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（     

肠神经元性发育不良病理学特征临床意义的探讨

目的 探讨肠神经发育不良(IND)病理学特征的临床意义。方法回顾分析我院1990年-2002年间269例临床诊断为“HD”(小儿258例,成人11例)病人的临床和病理资料。选取HD病变段和近端各12例,节细胞减少症3例,IND8例,以及对照21例的全层结肠标本行SY免疫组化染色。光镜下观察肠神经丛的分布,肠壁肌层SY免疫活性纤维的分布。结果269例中单纯INDl5例(6％),HD IND6例(2％),两者各有1例因近端肠壁IND病变症状复发而再手术。对照中2例见纵肌异位神经丛,1例同时见粘膜下巨大神经丛;先天性肛门闭锁的横结肠和结肠肿瘤各2例,肠肌问见丰富的巨大神经丛。肠壁SY免疫活性在HD和节细胞减少症的病变段,有不同程度的明显减低;对照组和HD近端功能正常的肠壁多表现丰富;IND病变段表现正常和轻度减低的各一半。结论IND的病理特征缺乏特异性,是IND研究结果不一致的重要原因之一。IND与“具有IND特征改变的继发性现象”可能仅是组织学现象上的相似,应有不同的病理基础。IND的诊断应结合病人的年龄、合并的其它病理因素及临床症状的情况,量化IND的病变更有诊断意义。     

Usefulness of immunocytochemical demonstration of neuron-specific enolase in the diagnosis of Hirschsprung's disease

The work reported here was carried out to study the importance of immunocytochemical staining of neuron-specific enolase (NSE) in the diagnosis of Hirschsprung's disease and to compare its results with those obtained by hematoxylin-eosin (H&E) staining in consecutive sections. A retrospective study was made on 51 rectal mucosal biopsies and 19 colorectal surgical specimens from 52 patients clinically suspected of Hirschsprung's disease. Several consecutive sections from all cases were restained by H&E and for NSE demonstration. Sixteen (31%) patients had a histological diagnosis of Hirschsprung's disease, 9 (17%) had hypoganglionosis, 4 (8%) had neuronal intestinal dysplasia, and 2 (4%) had normal histology. In eight patients (15%) hypoganglionosis remained dubious, and in 10 (19%) the diagnosis was inconclusive. Although the NSE staining improved the identification of the nervous tissue of the colon, both H&E and NSE staining proved to be of equal value in the assessment of the presence of neurons in the rectal wall of people with clinically suspected cases of Hirschsprung's disease. Ten H&E-stained sections from different levels of the biopsy specimen would be enough to detect ganglion cells in most cases.     

临床诊断为先天性巨结肠症的肠神经元发育不良症

目的：对临床诊断为先天性巨结肠症（HD）而术后病理诊断确定为肠神经元发育不良症（IND）病例进行回顾性分析。方法：1995年1月－1999年12月140例临床诊断HD并经过根治手术患儿，其中12例（8．6％）术后病理诊断为IND，女1例，男11例，平均年龄29．28个月。结果：所有IDN患儿切除肠管病检均可发现粘膜下神经丛神经节细胞增多和巨大神经节，术前测压检查有4例，肛管直肠抑制反射（RAIR）阳性，占33．33％（4／12），直肠粘膜AchE组织化学检查有5例阴性，占41．675（5／12），而128例HD患儿则分别为15例占11．72％（15／128）和17例占13．28％（17／128），两组病例的测压和组化检查结果有明显差异，所有患儿均行手术治疗。结论：IND病例的术前检查表现为测压RAIR反射阳性率和组化检测阴性率明显高于典型HD病例；目前所沿用的测压－组化－钡灌肠诊断模式尚不能解决IND的术前诊断问题，临床及术中表现极类似地HD的病例，经典的根治术也可获得良好的治疗效果。     

Diagnosis and surgical treatment of isolated hypoganglionosis

Background

Some patients suspected with Hirschsprung’s disease (HD), however, were diagnosed as having isolated hypoganglionosis according to the updated pathohistologic methods. This study was undertaken to investigate the diagnostic methods and the therapeutic results of isolated hypoganglionosis in children.

Methods

A retrospective analysis was made on 17 patients with isolated hypoganglionosis (hypoganglionosis group) identified pathologically after operation. The data included clinical presentations, barium enema, anorectal manometry, histochemical staining for acetylcholinesterase (AChE) before operation, histological results after operation and follow-up outcomes. The data of hypoganglionosis with HD (HD group) were compared retrospectively.

Results

Common complaint of the patients with hypoganglionosis and HD was intractable constipation. Barium enema showed typical narrowing and distended segment of the colon in 9 patients in the hypoganglionosis group (9/16) and in 15 patients in the HD group (15/18). In the hypoganglionosis group, in 15 patients who underwent anorectal manometry only 5 showed absent rectal anal inhibitory reflex, significantly lower than the rate in the HD group (17/18) (P<0.05). From 16 patients in hypoganglionosis group, positive staining for AChE was noted in 3 patients (3/16, 18.8%), significantly lower than that in the HD group (16/18, 88.9%) (P<0.05). Thirteen patients in the hypoganglionosis group received subtotal colectomy, while only 5 patients needed subtotal colectomy in the HD group. In the hypoganglionosis group, except 2 patients who suffered from mild enterocolitis after operation and recovered after conservative therapy, all patients recovered uneventfully without wound dehiscence, intestinal fistula, fecal incontinence or constipation recurrence. In the HD group, one patient suffered from anastomotic leak and got secondary operation, one patient had anastomotic stricture at 1 year after operation and recovered by dilatation, and other three patients suffered from mild enterocolitis after operation and recovered after conservative therapy.

Conclusions

Hypoganglionosis is a common disease, and could be finally confirmed by full-thickness biopsies in different bowel segments. The resection range can be estimated according to barium enema and 24-hour delayed X-ray findings, by which the satisfactory result in short-term follow-up can be obtained.     

Rectal biopsy for Hirschsprung's disease: what is the optimum method?

During a 3-year period, 258 infants and children underwent rectal biopsy to exclude Hirschsprung's disease (HD) and related disorders; 32 (12%) were found to have HD. Major morbidity occurred in 3 (2%) of 148 patients undergoing rectal suction biopsy (RSB) and 22 (13%) of 168 suction biopsies were inadequate for diagnosis. In 102 children over 6 months of age, Storz rectal cup biopsy forceps were used with no significant morbidity and adequate biopsies were obtained in 96% of cases. Open rectal biopsy was performed in 8 patients. The RSB tube is safe and reliable, but attention to technique is important. For children over 6 months of age undergoing rectal biopsy for HD, the Storz rectal cup biopsy forceps yields superior results. Accepted: 26 February 1997