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Kapur RP, Reyes-Mugica M. Intestinal Neuronal Dysplasia Type B: An Updated Review of a Problematic Diagnosis. Arch Pathol Lab Med 2018; 143:235-243. [DOI: 10.5858/arpa.2017-0524-ra] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Intestinal neuronal dysplasia type B (IND B) is a controversial histopathologic phenotype that has been associated with intestinal dysmotility, either as an isolated condition or in conjunction with established pathologic disorders (eg, Hirschsprung disease). Many factors contribute to the debate over the existence and/or clinical significance of IND B, including a large body of published data based on inconsistent diagnostic criteria and methods, which have fostered many unwarranted conclusions that lack sufficient scientific basis.
Objective.—
To critically analyze existing published data regarding IND B to provide supporting evidence-based diagnostic practice and to stimulate necessary and scientifically sound research.
Data Sources.—
This update focuses on published literature related to the pathology of IND B because without a reliable pathologic diagnosis, studies of epidemiology, pathogenesis, natural history, management, and outcome are all suspect. Problems with existing data are identified explicitly with suggestions as to how future investigations should be designed and evaluated to better understand this entity.
Conclusions.—
Inconsistencies in diagnostic criteria and methods used to define IND B justifiably encumber the universal acceptance of IND B as a neuropathologic etiology for intestinal dysmotility. IND B will remain a controversial diagnosis until rigorous, well-controlled scientific studies are conducted to establish reproducible and reliable diagnostic criteria that reliably translate from one laboratory to another.
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Affiliation(s)
- Raj P. Kapur
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Kapur); the Department of Pathology, University of Washington School of Medicine, Seattle (Dr Kapur); and the Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Dr Reyes-Mugica)
| | - Miguel Reyes-Mugica
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Kapur); the Department of Pathology, University of Washington School of Medicine, Seattle (Dr Kapur); and the Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Dr Reyes-Mugica)
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Swaminathan M, Oron AP, Chatterjee S, Piper H, Cope-Yokoyama S, Chakravarti A, Kapur RP. Intestinal Neuronal Dysplasia-Like Submucosal Ganglion Cell Hyperplasia at the Proximal Margins of Hirschsprung Disease Resections. Pediatr Dev Pathol 2015; 18:466-76. [PMID: 26699691 PMCID: PMC4809533 DOI: 10.2350/15-07-1675-oa.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intestinal neuronal dysplasia type B (IND) denotes an increased proportion of hyperplastic submucosal ganglia, as resolved histochemically in 15-μm-thick frozen sections. IND has been reported proximal to the aganglionic segment in patients with Hirschsprung disease (HSCR) and is putatively associated with a higher rate of postsurgical dysmotility. We developed and validated histological criteria to diagnose IND-like submucosal ganglion cell hyperplasia (IND-SH) in paraffin sections and used the approach to study the incidence and clinical and/or genetic associations of IND-SH at the proximal margins of HSCR pull-through resection specimens. Full-circumference paraffin sections from the proximal margins of 64 HSCR colonic pull-through specimens and 24 autopsy controls were immunostained for neuron-specific Hu antigen, and nucleated ganglion cells in each submucosal ganglion were counted. In controls, an age-related decline in the relative abundance of "giant" ganglia (≥7 nucleated Hu-positive [Hu+] ganglion cells) was observed. A conservative diagnostic threshold for IND-SH (control mean ± 3× standard deviation) was derived from 15 controls less than 25 weeks of age. No control exceeded this threshold, whereas in the same age range, IND-SH was observed at the proximal margins in 15% (7 of 46) of HSCR resections, up to 15 cm proximal to the aganglionic segment. No significant correlation was observed between IND-SH and length of or distance from the aganglionic segment, sex, trisomy 21, RET or SEMA3C/D polymorphisms, or clinical outcome, but analysis of more patients, with better long-term follow-up will be required to clarify the significance of this histological phenotype.
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Affiliation(s)
| | | | - Sumantra Chatterjee
- Center for Complex Disease Genomics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine ,Balimore, MD
| | - Hannah Piper
- University of Texas Southwestern, Children's Health, Dallas, TX
| | | | - Aravinda Chakravarti
- Center for Complex Disease Genomics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine ,Balimore, MD
| | - Raj P. Kapur
- Seattle Children's Research Institute, Seattle, WA,University of Washington, Pathology, Seattle, WA
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Vougas V, Vardas K, Christou C, Papadimitriou G, Florou E, Magkou C, Karamanolis D, Manganas D, Drakopoulos S. Intestinal neuronal dysplasia type B in adults: a controversial entity. Case Rep Gastroenterol 2014; 8:7-12. [PMID: 24574943 PMCID: PMC3934697 DOI: 10.1159/000358045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Intestinal neuronal dysplasia (IND) is a well-defined entity which raises controversy among authors, described as a congenital malformation of gastrointestinal innervation and caused by dysplastic embryonal development of the enteric nervous system. It is potentially associated with mild and chronic gastrointestinal motility disturbances. IND is rarely reported in adults and especially elderly patients. The present study reports on the case of a 71-year-old man suffering from longstanding idiopathic constipation and who was misdiagnosed for more than 60 years, despite several hospital admissions and a sigmoidectomy in the meantime. On the last admission, the patient presented with megacolon, abdominal pain and X-ray finding of bowel obstruction. Due to massive large bowel dilatation, an exploratory laparotomy failed to reveal any obvious mechanical cause, and a subtotal colectomy and Hartmann's procedure was performed. Bowel continuity was performed 3 months later. Analysis of full-thickness biopsies revealed enlarged myenteric and submucosal neurons as well as an increased number of giant cells and increased acetylcholinesterase activity in the mucosa. The diagnosis of IND was established. The main diagnostic criteria, the underlining pathophysiology and the recommended therapeutic approach of this rare entity are extensively reviewed.
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Affiliation(s)
- Vasillis Vougas
- First Department of Surgery and Transplant Unit, Athens, Greece
| | | | | | | | | | - Christina Magkou
- Department of Pathology, Evangelismos General Hospital, Athens, Greece
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Abstract
OBJECTIVE Primary gastrointestinal neuropathies are a heterogeneous group of enteric nervous system (ENS) disorders that continue to cause difficulties in diagnosis and histological interpretation. Recently, an international working group published guidelines for histological techniques and reporting, along with a classification of gastrointestinal neuromuscular pathology. The aim of this article was to review and summarize the key issues for pediatric gastroenterologists on the diagnostic workup of congenital ENS disorders. In addition, we provide further commentary on the continuing controversies in the field. RESULTS Although the diagnostic criteria for Hirschsprung disease are well established, those for other forms of dysganglionosis remain ill-defined. Appropriate tissue sampling, handling, and expert interpretation are crucial to maximize diagnostic accuracy and reduce interobserver variability. The absence of validated age-related normal values for neuronal density, along with the lack of correlation between clinical and histological findings, result in significant diagnostic uncertainties while diagnosing quantitative aberrations such as hypoganglionosis or ultrashort Hirschsprung disease. Intestinal neuronal dysplasia remains a histological description of unclear significance. CONCLUSIONS The evaluation of cellular quantitative or qualitative abnormalities of the ENS for clinical diagnosis remains complex. Such analysis should be carried out in laboratories that have the necessary expertise and access to their own validated reference values.
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Abstract
"Variants of Hirschsprung's disease" are conditions that clinically resemble Hirschsprung's disease (HD), despite the presence of ganglion cells in rectal suction biopsies. The diagnosis and management of these patients can be challenging. Specific histological, immunohistochemical and electron microscopic investigations are required to characterize this heterogeneous group of functional bowel disorders. Variants of HD include intestinal neuronal dysplasia, intestinal ganglioneuromatosis, isolated hypoganglionosis, immature ganglia, absence of the argyrophil plexus, internal anal sphincter achalasia and congenital smooth muscle cell disorders such as megacystis microcolon intestinal hypoperistalsis syndrome. This review article systematically classifies variants of HD based on current diagnostic criteria with an additional focus on pathogenesis, epidemiology, clinical presentation, management and outcome.
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Abstract
Intramucosal ganglion cells are incompletely understood. Reviewed were 100 normal specimens from colorectal biopsies of nonconstipated adults to firmly establish the existence of intramucosal ganglion cells in normal adult colorectal mucosa, determine whether intramucosal giant ganglia exist, and compare the prevalence of colorectal intramucosal ganglion cells between men and women. Fifty specimens from each gender were examined. Twenty specimens contained intramucosal ganglion cells, including 15 from women (75%) and only 5 from men (25%). Intramucosal ganglion cells occurred singly or in clusters. One woman had large disciform and globular clusters with 7 ganglion cells, resembling giant ganglia. Awareness of ganglion cells and large ganglia in normal mucosa is necessary to avoid potential confusion with ectopic ganglion cells and submucosal giant ganglia seen in adult intestinal neuronal dysplasia. Intramucosal ganglion cells in normal colorectal mucosa are particularly common in women. This disparity might contribute to colorectal neurophysiologic differences between genders.
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Affiliation(s)
- Vonny Tunru-Dinh
- Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Irvine, California, USA
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Meier-Ruge WA, Bruder E, Kapur RP. Intestinal neuronal dysplasia type B: one giant ganglion is not good enough. Pediatr Dev Pathol 2006; 9:444-52. [PMID: 17163795 DOI: 10.2350/06-06-0109.1] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Accepted: 08/11/2006] [Indexed: 12/20/2022]
Abstract
In this "Current Practice in Pediatric Pathology" article, 2 experts in the field and an associate editor of Pediatric and Developmental Pathology discuss the definition, diagnosis, clinical significance, and management of intestinal neuronal dysplasia type B. Intestinal neuronal dysplasia type B has constituted a diagnostic challenge ever since its first description more than 30 years ago. Intestinal neuronal dysplasia type B is regarded by many as a subtle malformation of the enteric nervous system that is limited to the submucosal plexus of the colon. The precise etiology remains unknown, and, to date, no specific diagnostic test exists other than morphology. Over time, with increasing experience, obligate pathological features have been adapted and refined, leading to contemporary diagnostic criteria that are enunciated in this review and placed into context with prior published data. Rigorous application of these criteria, under standardized laboratory conditions, is crucial for accurate diagnosis and future advances in this field.
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Abstract
Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation. This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.
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Affiliation(s)
- B R Southwell
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
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Coerdt W, Müntefering H, Rastorguev E, Gerein V. [Congenital disorders of the colonic innervation. A diagnostic guide]. DER PATHOLOGE 2004; 25:292-8. [PMID: 15179524 DOI: 10.1007/s00292-004-0704-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Hirschsprung's disease (HD, aganglionosis) is the most important form of congenital disturbance of intestinal innervation, requiring surgical intervention. Furthermore, hypoganglionosis of the transitional zone forms the most significant factor in morbidity. Pre-operative definition of the length of neuronally disturbed segment is still a diagnostic challenge for both clinical physician and pathologist. Enzyme histochemical studies form the method of choice, but certain limitations in their use must be observed. Other dysganglionoses, particularly the so-called "Intestinal Neuronal Dysplasia" (IND) cannot-because of an excessive overlapping with age-correlated normal values-unequivocally be defined as an entity on its own. The only exception to this, is the ganglionic neuromatosis, which arises as part of a genetic illness.
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Affiliation(s)
- W Coerdt
- Abteilung für Kinderpathologie, Klinikum der Johannes-Gutenberg-Universität Mainz.
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Hutson JM, Catto-Smith T, Gibb S, Chase J, Shin YM, Stanton M, King S, Sutcliffe J, Ong SY, Djaja S, Farmer P, Southwell B. Chronic constipation: no longer stuck! Characterization of colonic dysmotility as a new disorder in children. J Pediatr Surg 2004; 39:795-9. [PMID: 15185198 DOI: 10.1016/j.jpedsurg.2004.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- John M Hutson
- Department of Surgery, Royal Children's Hospital, Melbourne, Australia
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Kapur RP. Neuronal dysplasia: A controversial pathological correlate of intestinal pseudo-obstruction. ACTA ACUST UNITED AC 2003; 122A:287-93. [PMID: 14518065 DOI: 10.1002/ajmg.a.20470] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The infant or child with intestinal pseudo-obstruction poses many challenges for geneticists and other specialists. Although a well-defined anatomic diagnosis (e.g., Hirschsprung disease) can be established for a subset of patients, the pathological correlates for many patients are non-existent or controversial. Intestinal neuronal dysplasia (IND) is frequently considered in the differential diagnosis, despite the fact that existence and significance of the abnormal histopathological features that characterize IND are hotly debated. This review highlights some of the concerns regarding this diagnosis including problems with the diagnostic criteria, the manner in which these criteria are applied in contemporary pathology practices, and the likelihood that many of the pathological findings are secondary consequences of impaired motility with no other clear clinical significance. Possible genetic and developmental bases for IND are also discussed.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Children's Hospital and Regional Medical Center, University of Washington, Seattle, Washington 98105, USA.
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Kapur RP. Neuropathology of paediatric chronic intestinal pseudo-obstruction and related animal models. J Pathol 2001; 194:277-88. [PMID: 11439358 DOI: 10.1002/path.885] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic intestinal pseudo-obstruction (CIP) in paediatric patients is due to heterogeneous aetiologies that include primary disorders of the enteric nervous system. These conditions are poorly delineated by contemporary diagnostic approaches, in part because the complex nature of the enteric nervous system may shelter significant physiological defects behind subtle or quantitative anatomical changes. Until recently, relatively few experimental animal models existed for paediatric CIP. However, the availability of rodent models, particularly novel mutants created in the last few years by genetic manipulations, has brought unprecedented opportunities to investigate molecular, cellular, physiological, and histological details of enteric neuropathology. Information gleaned from studies of these animals is likely to change diagnostic and therapeutic approaches to paediatric CIP and related conditions.
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Affiliation(s)
- R P Kapur
- Department of Pathology, University of Washington, Seattle, Washington 98195, USA.
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Thakur A, Fonkalsrud EW, Buchmiller T, French S. Surgical Treatment of Severe Colonic Inertia with Restorative Proctocolectomy. Am Surg 2001. [DOI: 10.1177/000313480106700109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with severe constipation due to colonic inertia who remain symptomatic after extensive medical therapy or partial colonic resection have occasionally been treated with ileostomy as a last resort. The hospital records of five patients with persistent symptomatic idiopathic colonic inertia were reviewed. Each of the patients had undergone extensive medical management, and eventually four underwent one or more colonic resections to relieve the recurrent abdominal distention and pain. Three of the patients eventually received a distal ileostomy, which functioned well. Anorectal manometric studies were within normal range for each of the five patients. Restorative proctocolectomy (J pouch) was therefore performed for each. With a mean follow-up of 42 months after restorative proctocolectomy each of the five patients was relieved of constipation and small bowel distention. The average number of bowel movements per 24 hours at 6 months was 4.8. All patients were able to discriminate flatus from stool, could hold back for up to 1.5 hours after the initial urge to defecate, and had total daytime continence. Each returned to work or school within 3 months, and each reported greater satisfaction with bowel function than with the ileostomy. Restorative proctocolectomy with a J pouch provides a satisfactory option for the management of patients with persistent abdominal distention and pain due to idiopathic colonic inertia.
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Affiliation(s)
| | - Eric W. Fonkalsrud
- Department of Pathology, UCLA School of Medicine, Los Angeles, California
| | | | - Samuel French
- Department of Pathology, UCLA School of Medicine, Los Angeles, California
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Abstract
Hirschsprung disease has become a paradigm for multigene disorders because the same basic phenotype is associated with mutations in at least seven distinct genes. As such, the condition poses distinct challenges for clinicians, patients, diagnostic pathologists, and basic scientists, who must cope with the implications of this genetic complexity to comprehend the pathogenesis of the disorder and effectively manage patients. This review focuses on the anatomic pathology, genetics, and pathogenesis of Hirschsprung disease and related conditions. The nature and functions of "Hirschsprung disease genes" are examined in detail and emphasis is placed on the importance of animal models to this field. Where possible, potential uses and limitations of new data concerning molecular genetics and pathogenesis are discussed as they relate to contemporary medical practices.
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Affiliation(s)
- R P Kapur
- Department of Pathology, University of Washington, Seattle 98195, USA
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