Anorectal sleeve micromanometry for the diagnosis of Hirschsprung's disease in newborns

The prevalence and clinical presentation of Hirschsprung's disease in preterm infants: a systematic review and meta-analysis

PURPOSE

Hirschsprung's disease (HD) is a rare occurrence in premature infants, and the exact prevalence varying across studies. Thus, we conducted this study to determine the prevalence of and clinical presentation of HD in preterm infants.

METHODS

The PubMed, EmBase, and Cochrane library databases were searched for eligible studies throughout May 2021. The pooled incidence with 95% confidence interval (CI) was calculated using the random-effects model.

RESULTS

Thirty studies involved 4,557 children with HD were included. The pooled proportion of HD patients who were preterm infants was 7% (95% CI 5-8%; P < 0.001); the sensitivity analysis indicated that the pooled prevalence of preterm infants with HD ranged from 5.0% to 5.6%. Moreover, the pooled incidence of abdominal distention in HD patients was 83% (P < 0.001), that of vomiting was 61% (P < 0.001), that of bilious vomiting was 54% (P < 0.001), that of delayed meconium passage was 48% (P < 0.001), that of constipation was 44% (P < 0.001), and that of enterocolitis was 13% (P < 0.001).

CONCLUSIONS

This study reported the prevalence of HD patients who were preterm infants, and the most common presentations were abdominal distention, vomiting, bilious vomiting, delayed meconium passage, constipation, and enterocolitis.

A Critical Analysis of Rectal Biopsy to Exclude Hirschsprung's Disease

INTRODUCTION

 Most Hirschsprung's disease (HD) are diagnosed in young children with increased risk ("red flag"). Older children (>6 months) require open rectal biopsy (ORB) with its own impact on risk and resources. We investigated if "red flag", age, and sex used in combination could exclude HD.

MATERIALS AND METHODS

 "Red flags" are risk factors associated with HD, including neonatal bowel obstruction, genetic association, failure of passage of meconium in <48 hours, infantile constipation, distension with vomiting, or family history. All rectal biopsies (2015-2018) were reviewed for indications, methods, and histopathological findings. Logistic regression analysis was adopted to assess predictive value of "red flag," age, and sex (p < 0.05* was significant).

RESULTS

 A total of 187 children underwent 84 suction rectal biopsies and 113 ORBs (n = 197 in total). Final histopathological diagnoses were non-HD (n = 154) and HD (n = 43). Total 78% of rectal biopsies were non-HD, of which 63% by ORB. Non-HD was associated with absence of "red flag" (49 vs. 16%*), increased age at biopsy (22 months vs. 28 days*), >6 months old (62 vs. 30%*), and female gender (54 vs. 16%*), compared with HD. In the absence of "red flag," 7/82 (9%) had HD (negative predictive value = 91%). Logistic regression analysis found absent "red flag" predicted non-HD biopsy with odds ratio 4.77 (1.38, 16.47), corrected for age and sex.

CONCLUSION

 Negative rectal biopsy rate for HD is very high. The majority required ORB. Although "red flag" and gender, but not age, have strong predictive values, it is inadequate for excluding HD. This study supports the need for alternative strategies in excluding HD.

Importance of evaluating for cow's milk allergy in pediatric surgical patients with functional bowel symptoms

BACKGROUND

Cow's milk allergy (CMA) can cause functional bowel symptoms. This can lead to confusion and difficulty in managing pediatric surgical patients who also have CMA. We examined CMA's effect on the management of pediatric surgical patients in our institute.

METHODS

With institutional review board approval, 14 pediatric surgical patients with CMA were reviewed. Cow's milk allergy was diagnosed according to clinical findings and stimulation index (normal range <300%) of the lymphocyte stimulation test.

RESULTS

The main symptoms were abdominal distension (n = 10), vomiting (n = 6), constipation (n = 2), and apnea (n = 1). Stimulation index median value was 731% (range, 341%-2132%). Patients were divided into 3 groups. In group 1 (n = 8), persistent postoperative bowel symptoms were initially considered related to surgical diseases. Following CMA diagnosis, CM elimination therapy improved symptoms. In group 2 (n = 4), CMA was diagnosed concurrently with surgical disease, and elimination therapy was continued postoperatively. In group 3 (n = 2), the pathogenesis of bowel symptoms was initially attributed to CMA and later diagnosed as Hirschsprung's disease.

CONCLUSIONS

A high index of suspicion regarding the possibility of concurrent CMA may be necessary to manage bowel symptoms in pediatric surgical patients.

Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait

BACKGROUND/PURPOSE

Anorectal manometry is a noninvasive test used to evaluate conditions like slow-transit constipation, anorectal outlet obstruction, and Hirschsprung disease and to assess postoperative results after Hirschsprung and anorectal malformations. This cross section study was designed to have normal manometric values of anorectal function in healthy children of different ages in Kuwait so that control values are available for comparisons with various pathological states.

METHOD

Anorectal manometry was conducted in 90 children aged 3 days to 12 years without any symptoms related to lower gastrointestinal tract. They were divided in 3 age groups (group 1-neonates up to 1 month, group 2-infants from 1 month to 1 year, and group 3-children more than 1 year). Water perfused system with anorectal catheter with 4 side holes was used to record length of anal canal or high-pressure zone, resting pressure of anal canal, and rectoanal inhibitory reflex (RAIR).

RESULT

Anorectal manometry was successfully done in all 90 children of different age groups without any complications. High-pressure zone or anal canal length was 1.67 +/- 0.34 cm in neonates, 1.86 +/- 0.6 cm in infants, and 3.03 +/- 0.52 cm in children. Mean resting pressure of anal canal was 31.07 +/- 10.9 mm Hg in neonates, 42.43 +/- 8.9 mm Hg in infants, and 43.43 +/- 8.79 mm Hg in children. Rectoanal inhibitory reflex was present in all of them. Mean RAIR threshold volumes of 9.67 +/- 3.6, 14.0 +/- 9.5, and 25.0 +/- 11.6 mL was required for noenates, infants, and children, respectively.

CONCLUSION

Resting pressure of the anal canal, manometic anal canal length, and RAIR volume varies with the age. Normal values anorectal manometry at different age groups should be obtained to compare with pathological states of anorectum.

Anorectal manometry with reference to operative rectal biopsy for the diagnosis/exclusion of Hirschprung's disease in children under 1 year of age

AIMS

To establish the accuracy of anorectal manometry (ARM) with reference to operative rectal biopsy in the investigation of children under 1 year of age with defaecation difficulties.

MATERIALS AND METHODS

The records of all infants who underwent ARM and operative rectal biopsy at our centre between 1994 and 2007 were reviewed. ARM was performed by a consultant paediatric surgeon in each and under ketamine anaesthesia, as operative rectal biopsy was taken.

RESULTS

There were 81 patients (49 males, 32 females). The median age at investigation was 2 months (range 0.1-11 months). Thirty-three patients (41%) had Hirschprung's disease. No patient with a normal recto-anal inhibitory reflex (RAIR) had Hirschprung's disease (100% negative predictive value). No patient with Hirschprung's disease exhibited a reflex (100% sensitivity). The specificity and positive predictive value of ARM for Hirschprung's disease were 83% and 80%, respectively. Bowel habit normalised in 88% of patients with a reflex within 1 year.

CONCLUSIONS

In children under 1 year of age, Hirschprung's disease is very unlikely in the presence of a RAIR. The specificity and positive predictive value of ARM for the diagnosis of Hirschprung's disease are inferior to those of rectal suction biopsy, and therefore, it cannot be recommended for use as a sole diagnostic tool for this disease. ARM may be a useful investigation in patients where the histologic specimen is inadequate and/or functional constipation is the most likely diagnosis. If RAIR is present, rectal biopsy may not be required.

Hirschsprung disease

Hirschsprung disease is a relatively common condition managed by pediatric surgeons. Significant advances have been made in understanding its etiologies in the last decade, especially with the explosion of molecular genetic techniques and early diagnosis. The surgical management has progressed from a two- or three-stage procedure to a primary operation. More recently, definitive surgery for Hirschsprung disease through minimally invasive techniques has gained popularity. In neonates, the advancement of treatment strategies for Hirschsprung disease continues with reduced patient morbidity and improved outcomes.