At what age is a suction rectal biopsy less likely to provide adequate tissue for identification of ganglion cells?

Diagnostic and therapeutic approach to children with chronic refractory constipation: Consensus report by the SIGENP motility working group

Constipation is a common problem in children, accounting for about 3% of all primary care visits and up to 25% of referrals to paediatric gastroenterologists. Although polyethylene glycol often proves effective, most children require prolonged treatment and about 50% of them have at least one relapse within the first 5 years after initial recovery. When conventional treatment fails, children are considered to have refractory constipation. Children with refractory constipation deserve specialist management and guidance. Over the last decades, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed. The present review analyses the possible diagnostic investigations for children with refractory constipation, focusing on their actual indications and their utility in clinical practice. Moreover, we have also analytically reviewed medical and surgical therapeutic options, which should be considered in selected patients in order to achieve the best clinical outcome.

Late Diagnosis of Hirschsprung Disease: Clinical Presentation and Long-Term Functional Outcomes

PURPOSE

Hirschsprung Disease (HD) is typically diagnosed in the neonatal period. A small subset of patients have a prolonged course of abdominal distention and constipation prior to diagnosis. Late HD is defined as having been diagnosed at greater than or equal to one year of age. The literature is limited and offers conflicting data on the implications of a late diagnosis. We aim to investigate the presentation, operative approach, and functional outcomes of a large cohort of patients with a late HD diagnosis.

METHODS

All patients with a late diagnosis of HD (after 1 year of age) at our institution between 1997 and 2021 were included.

RESULTS

Twenty-eight patients were diagnosed with HD at a median age of 3.4 years. Chronic constipation, failure to thrive, and enterocolitis occurred in 100 %, 31 %, and 14 %, respectively. All patients underwent contrast enema and biopsies during their workup, identifying primarily rectosigmoid disease (n = 27) and total colonic aganglionosis (n = 1). Surgical intervention was performed in 27 patients, with 4 patients (15 %) needing a stoma (3 with plan for staged pull-through, 1 long-term stoma) and 23 patients (85 %) undergoing a single-stage pull-through. Postoperative complications included Hirschsprung-associated enterocolitis (n = 5), ostomy prolapse and revision (n = 2), abdominal distention requiring ileostomy creation (n = 2), redo pull-through (n = 2), retroperitoneal hematoma (n = 1), and cecostomy tube placement (n = 1). At a median follow-up of 5.4 years, 83 % of eligible patients achieved fecal continence with 43 % needing laxatives for persistent constipation.

CONCLUSION

Recognizing a late presentation of HD requires a high index of suspicion. Patients with a late diagnosis did not experience an increased rate of permanent stoma, complications, or redo surgery compared to rates reported for the larger HD population. Similar long-term functional outcomes were achieved compared to the larger HD population.

LEVEL OF EVIDENCE

IV.

Hirschsprung disease

Hirschsprung disease (HSCR) is a rare congenital intestinal disease that occurs in 1 in 5,000 live births. HSCR is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the intestine. Most patients present during the neonatal period with the first meconium passage delayed beyond 24 h, abdominal distension and vomiting. Syndromes associated with HSCR include trisomy 21, Mowat-Wilson syndrome, congenital central hypoventilation syndrome, Shah-Waardenburg syndrome and cartilage-hair hypoplasia. Multiple putative genes are involved in familial and isolated HSCR, of which the most common are the RET proto-oncogene and EDNRB. Diagnosis consists of visualization of a transition zone on contrast enema and confirmation via rectal biopsy. HSCR is typically managed by surgical removal of the aganglionic bowel and reconstruction of the intestinal tract by connecting the normally innervated bowel down to the anus while preserving normal sphincter function. Several procedures, namely Swenson, Soave and Duhamel procedures, can be undertaken and may include a laparoscopically assisted approach. Short-term and long-term comorbidities include persistent obstructive symptoms, enterocolitis and soiling. Continued research and innovation to better understand disease mechanisms holds promise for developing novel techniques for diagnosis and therapy, and improving outcomes in patients.

Rectal Biopsy for Hirschsprung's Disease: A Multicentre Study Involving Biopsy Technique, Pathology and Complications

BACKGROUND

The heterogeneity of rectal biopsy techniques has encouraged us to search for a surgical and pathological standardisation of this diagnostic technique to exclude Hirschsprung's disease. The different amounts of information on the anatomopathology report prompted us to compile a template for the anatomopathology report for diagnostic rectal biopsies for surgical colleagues and pathologists working on Hirschsprung's disease.

METHODS

We gathered the anonymous biopsy information and its pathology information from five hospitals for all patients in which rectal biopsies were taken to diagnose Hirschsprung's disease over two years (2020-2021).

RESULTS

Of the 82 biopsies, 20 suction (24.4%), 31 punch (37.8%) and 31 open biopsies (37.8%) were taken. Of all biopsies, 69 were conclusive (84.2%), 13 were not (15.8%). In the suction biopsy group, 60% were conclusive and 40% were not; for punch biopsy, the values were 87% and 13%, respectively and for open biopsy, 97% and 3%. Inconclusive results were due to insufficient submucosa in 6/8 suction biopsies, 4/4 punch biopsies and 0/1 open biopsies. An insufficient amount of submucosa was the reason for an inconclusive result in 6/20 cases (30%) after suction biopsy, 4/31 (12.9%) cases after punch biopsy and 0 cases (0%) after open biopsy. We had one case with major postoperative bleeding post suction biopsy; there were no further adverse effects after biopsy.

CONCLUSIONS

Diagnostic rectal biopsies in children are safe. Non-surgical biopsies are more likely to give inconclusive results due to smaller amounts of submucosa present in the specimen. Open biopsies are especially useful when previous non-surgical biopsies are inconclusive. An experienced pathologist is a key factor for the result. The anatomopathology report should specify the different layers present in the specimen, the presence of ganglion cells and hypertrophic nerve fibres, their description and a conclusion.

Systematic orientation of fresh rectal suction biopsies improves histopathological diagnostics in hirschsprung's disease - a method description and preliminary report

BACKGROUND

Optimizing rectal suction biopsy (RSB) diagnostics in Hirschsprung's disease (HD) may shorten diagnostic time and prevent need for repeated biopsies.

AIM

To explore whether systematic orientation of fresh RSB specimens increased biopsy quality, diagnostic times, diagnostic efficacy, and histopathologic workload, and to explore these outcome measures for aganglionic specimens.

MATERIALS/METHODS

This was an observational case-control study conducted at a national referral center for HD on data collected from the local HD-diagnostic register. From 2019 each fresh RSB was oriented by the collector in a notch in a foam cushion, placed in a separate cassette, and sent in formalin for pathological analysis. Outcome measures of oriented RSB samples collected 2019-2021 were compared to those of non-oriented RSB samples collected 2015-2018. Staining/immunohistochemistry consisted of hematoxylin eosin, S-100 and calretinin.

RESULTS

78 children with 81 RSBs and 242 biopsy analyzes were included. The frequency of high-quality RSB specimens was higher in oriented: 40% (42/106) versus non-oriented 25% (34/136) (p = 0.018), the diagnostic turnaround time was shorter: 2 days (1-5) versus 3 days (2-8) (p = 0.015), and the number of additional sectioning/leveling/re-orientation per biopsy was lower: 7 (3-26) versus 16 (7-72) (p = 0.011). Specifically for aganglionic specimens, the frequency of high-quality biopsies was generally higher in oriented than in non-oriented RSB specimens: 47% (28/59) versus 14% (7/50) (p < 0.001); the diagnostic efficacy was higher 95% (19/20) versus 60% (9/15) (p = 0.027) and the diagnostic turnaround time shorter: 2 days (2-3) versus 3 days (2-8) (p = 0.036).

CONCLUSIONS

Systematic orientation of fresh RSB specimens improves HD diagnostics. Improvement was consistent in aganglionic specimens.

A Case Report of Hirschsprung's Disease in a Neonate: Early Detection and Review of Management

Hirschsprung's disease is a rare disease characterized by the complete absence of ganglionic cells in the colon, thereby causing loss of peristalsis movement of the bowel. Most cases are diagnosed before the age of one. Here, we present a case of a newborn baby boy who was not feeding well and then developed a distended abdomen and began bilious vomiting. Blood mucoid stools were also observed. The diagnosis of Hirschsprung's disease was confirmed through a full-thickness rectal biopsy, and the Duhamel surgical procedure was performed as a course of treatment all within the first few days of birth. No complications were reported, and the baby was safely discharged after seven days. This case demonstrates the importance of timely treatment after prompt diagnosis due to the early recognition of the severe symptoms. Even though this disease is rare, pediatricians should be trained to recognize and treat the child to prevent further detrimental outcomes.

Rectal suction biopsy versus incisional rectal biopsy in the diagnosis of Hirschsprung disease

BACKGROUND

Hirschsprung disease is one of the most common congenital anomalies that affect colorectal function. Rectal biopsy demonstrating the absence of ganglion cells in the affected bowel is the gold standard for diagnosis. Suction and incisional rectal biopsies are appropriate methods for obtaining diagnostic tissue. The goal of this study is to determine if any differences in adequacy exist between suction and incisional rectal biopsies at our institution.

METHODS

We conducted a retrospective review of suction and incisional rectal biopsies for inadequacy per procedure at a tertiary pediatric hospital. Each procedure for rectal biopsy was also evaluated by a number of biopsies per procedure. We used a two-sample test of proportions to compare the inadequacy of suction vs. incisional biopsies.

RESULTS

133 rectal suction biopsy procedures (227 biopsies) and 125 incisional biopsy procedures (140 biopsies) were analyzed. In patients 6 months of age and older, the percentage of inadequate procedures was substantially higher in the suction biopsy group (24.1% vs 0.9%, p < 0.01).

CONCLUSIONS

A substantially higher proportion of inadequacy was found in the suction rectal biopsy group compared to the incisional cohort among the older patient cohort, suggesting incisional biopsies should be strongly considered as the primary rectal biopsy method in patients older than 6 months.

Diagnostic Efficacy of Rectal Suction Biopsy with Regard to Weight in Children Investigated for Hirschsprung’s Disease

Background/aim: Diagnostic efficacy, defined as the percentage of rectal suction biopsy (RSB) specimens sufficient enough to determine the absence of ganglia cells in Hirschsprung’s disease (HD) diagnosis, has been reported to be low, requiring repeated biopsies. The aim was to explore whether RSB diagnostic efficacy was influenced by the child’s weight and to ascertain whether RSB efficacy differed between aganglionic and ganglionic tissue. Materials and Methods: Efficacy analyses were conducted in a national HD-center’s register on children 0–15 kg, examined between 2011–2019. First-time RSB diagnostic efficacy was correlated to the children’s weight and final HD diagnosis. Results: Among the 84 children who had first-time RSB, the overall diagnostic efficacy was 85% (71/84). The efficacy was higher among children weighing less than the identified cut-off of 9.0 kg (89% in 0–9.0 kg versus 62% in 9.01–15.0 kg, p = 0.026). Among children diagnosed with HD, 96% (26/27) weighed 0–9.0 kg. In this weight group, the diagnostic efficacy was lower in aganglionosis compared to ganglionosis (77%; 20/26 versus 96%; 43/45), p = 0.045). Conclusions: The RSB diagnostic efficacy was significantly higher in children weighing less than 9.0 kg and was less in aganglionic compared to ganglionic tissue. Therefore, weight can be useful to predict RSB diagnostic efficacy.

Rectal Biopsy Technique for the Diagnosis of Hirschsprung Disease in Children: A Systematic Review and Meta-Analysis

ABSTRACT

The diagnosis of Hirschsprung disease (HD) depends on the histopathological analysis of rectal biopsies. This review aims to define the best rectal biopsy technique. A systematic literature review and proportional meta-analysis of the available case series studies of rectal biopsies were performed in this study. All case series with more than five rectal biopsies in children younger than 18 years of age suspected of HD that described at least one type of rectal biopsy were included. The studies that did not specify the rate of conclusive results and the rate of complications of the biopsy procedures were excluded. According to the literature review, there were four different techniques of rectal biopsy: open, suction, punch, and endoscopic. In the title and abstract screening process, we assessed 496 articles, 159 fulfilled the eligibility criteria, and 71 studies reported our outcomes of interest and were included in the meta-analysis. The pooled proportion of conclusive results was 94% in open biopsies (95% CI 0.89-0.98), 95% in punch (95% CI 0.90-0.98), and 88% in suction group (95% CI 0.85-0.92). The pooled proportion of complication rates was 2% in open biopsies (95% CI 0.00031-0.04), 0.039% in suction (95% CI 0.00023-0.0006), and 2% in punch biopsies (95% CI 0.00075-0.04). Suction, punch, and open techniques presented comparable rates of conclusive results. In the suction group, the association between different methods of histopathological analysis increased conclusive results rates; however, the punch biopsy was associated with significantly higher complication rates than the suction technique.

Comparison of inconclusive rates between suction rectal biopsy and open strip rectal biopsy in children of different age groups: a single-center retrospective study

Background

Rectal biopsy for the diagnosis for Hirschsprung's disease (HD) can be performed in several ways. Suction rectal biopsy (SRB) is the most widely used method for neonates and younger infants while open strip biopsy (OSB) is reserved for older children. Current notions suggest that SRB should not be used in older infants due to perceived thicker fibrous tissue in their rectal walls leading to higher rates of inconclusive results. This study aims to compare the inconclusive rates of both methods in children of different age groups.

Methods

A retrospective study were carried out with patients aged 13 years who underwent SRB or OSB during a 4-year period in a single center. Rectal biopsies were performed on patients with HD with previous endorectal pull-through surgeries excluded. Primary outcomes were rates of inconclusive results for SRB and OSB overall and when divided into different age groups.

Results

79 biopsies (57 SRB and 22 OSB) were included in the study. 12 biopsies (9 SRB and 3 OSB) were deemed inconclusive. There was no significant difference in the rate of inconclusive results between patients underwent SRB and OSB overall (15.8% vs 13.6%, p=1.000). The same results were obtained when patients were divided into under one year and over one year groups or other different age groups (30.0% vs 33.3%, p=1.000).

Conclusions

Despite low biopsy numbers, our study suggests that SRB provides comparable rates of inconclusive results with OSB in children of all age groups.

Endoscopic full-thickness muscle biopsy for rectal tissue sampling in patients with severe gut motility disorders: an initial experience (with video)

BACKGROUND AND AIMS

Diagnosis of GI neuromuscular diseases is mostly on the basis of symptomatology and is often unreliable. Pathologic analysis of affected tissue (eg, the myenteric plexus and muscle) is a potentially valuable method for both diagnosis and advancement of our knowledge about the biologic basis for these syndromes. However, until now access to the deeper layers of the GI tract has been limited, generally requiring invasive surgical techniques.

METHODS

We report a "close-then-resect" endoscopic full-thickness biopsy sampling (EFTB) technique using an over-the-scope clip and telescope for rectal muscle biopsy sampling in patients with suspected severe neuromuscular gut disorders. The main outcome measures were technical success and adverse events.

RESULTS

Thirteen patients (11 women; mean age 27 ± 5.4 years) with diffusely delayed colonic transit underwent EFTB. The mean (± standard deviation) procedure time was 30 ± 5.2 minutes. The mean size of the resected specimen was 18 ± 3.5 mm. Histologic full-thickness tissue samples were achieved for all patients. Postprocedural adverse events were reported in 2 patients, and both were graded as mild (1 self-limited bleeding and 1 with rectal pain). Hematoxylin and eosin staining of tissue samples confirmed adequate cross-sectional imaging of muscularis propria in all patients with excellent demonstration of the myenteric plexus and both layers of muscle. Two patients demonstrated a decrease in interstitial cells of Cajal as demonstrated by CD117 staining. No cases demonstrated appreciable inflammation involving myenteric ganglia.

CONCLUSIONS

Diagnostic EFTB with modified over-the-scope clip for the close-then-resect method appears to be a safe and effective technique to obtain adequate full-thickness rectal specimens, allowing for both quantitative and qualitative analysis for the diagnosis of neuromuscular GI dysmotility.

Diagnosis of Hirschsprung's disease in children: Preliminary evaluation of a novel endoscopic technique for rectal biopsy

Background and Aim

The diagnosis of Hirschsprung's disease (HD) relies on anorectal manometry and rectal biopsy. The role of endoscopic biopsy is uncertain for the diagnosis of HD in children. In this study, we evaluated the adequacy of biopsies procured by endoscopic mucosal resection (EMR) for the diagnosis of HD.

Methods

Consecutive children with suspected HD from January 2013 to January 2018 were enrolled in the study. EMR was performed using the standard band ligation device at a distance of about 3 cm from dentate line in rectum. All samples were assessed macroscopically and microscopically. An adequate sample was defined as those measuring >3 mm and including adequate submucosa.

Results

A total of 132 children underwent evaluation for constipation in the study period. Of these, 10 children (median age, 4.25 years) underwent EMR using the band ligation device for the evaluation of HD. EMR was performed with and without submucosal lifting injection in four and six children, respectively. All the samples were adequate macroscopically (>3 mm). Absence of ganglion cells was noted in six children. Of these, three children underwent full‐thickness rectal biopsy followed by surgery. Three children did not undergo surgery. Ganglion cells were identified in four children, thereby excluding the diagnosis of HD.

Conclusion

Rectal biopsy using EMR with a band ligation device is feasible, safe, and provides adequate sample for the evaluation of HD in children.

EMR is superior to rectal suction biopsy for analysis of enteric ganglia in constipation and dysmotility

BACKGROUND AND AIMS

Patients with chronic constipation or motility disorders may be referred for rectal suction biopsy (RSB) to rule out Hirschsprung's disease (HD). RSB may not be successful beyond infancy because of the increased thickness of the rectal mucosa. EMR could improve the diagnostic yield for HD when compared with traditional RSB because larger and deeper samples are acquired for analysis.

METHODS

In this prospective, single-center study, patients referred for RSB were offered enrollment for concurrent EMR. Specimens were analyzed pathologically for size, submucosal ganglionic tissue, and acetylcholinesterase or calretinin staining. Biopsy results were compared with transit studies, anorectal manometry, and constipation severity through validated questionnaires.

RESULTS

Seventeen patients (2 male, 15 female; mean age, 35.8 years; range, 22-61 years) were enrolled in the study from 2008 to 2014. All patients underwent anorectal manometry (88% with anorectal dysfunction, 68% with outlet obstruction) and transit studies (41% with delayed transit). There were no reports of adverse events from the RSB and EMR procedures. The RSB sample volumes were significantly lower than the EMR sample volumes (0.023 cm³ vs 0.26 cm³, P = .001). There was diagnostic tissue for submucosal visualization by RSB in 53% (9/17) of cases compared with 100% (17/17) with EMR (P = .003). No cases of HD were diagnosed by RSB; one patient had rare ganglions observed by EMR.

CONCLUSIONS

EMR provides greater tissue volume and can improve the characterization of ganglion cells in rectal tissue compared with RSB in patients with moderate to severe constipation with suspected HD.

Ganglion Cells Are Frequently Present in Pediatric Mucosal Colorectal Biopsies: H&E Sections and Calretinin Immunohistochemistry in the Evaluation of Children With Chronic Constipation

Hirschsprung disease (HD) rarely presents as chronic constipation after the newborn period. At our institution, calretinin immunohistochemistry (CAL) is frequently requested by clinicians on rectal mucosal biopsies (RMBs) taken during colonoscopy in older children in whom suspicion for HD is low. We hypothesized that review of these biopsies would frequently reveal ganglion cells (GCs). We reviewed features of mucosal biopsies (November 2013 to September 2015) from children ≥1 year of age on which clinicians had requested CAL on at least one specimen. A total of 93 biopsies with paired CAL from 83 patients were suitable for study (ages 1-18 years, M:F 1.2). Submitted clinical indication was constipation in 62 patients (75%). GCs were found within or subjacent to muscularis mucosa in 63 biopsies (68%), 12 (19%) of which were designated from a specific anatomic site, eg, 2 or 3 cm. In 25 of 63 (40%) cases, GCs were identified on one of the first 3 sections (median 5th, range 1st-54th). Forty-six cases (73%) contained no or <0.5 mm of submucosa (SM, range 0-2 mm). All but one case (62/63, 98%) with identified GCs showed positive CAL staining; a single case showed equivocal staining. Among the 30 biopsies with no observed GCs, none (0%) had >1 mm of SM, and 21 (70%) had no SM. CAL was positive in 28 (93%) and equivocal/weak in 2 (7%); no additional work-up for HD was pursued. The data suggest that H&E sections of RMBs can exclude HD at a specified site in many cases and provide the basis for a future study examining the utility of CAL in RMBs without SM as a means for excluding HD.

Current practice patterns of rectal suction biopsy in the diagnostic work-up of Hirschsprung's disease: results from an international survey

PURPOSE

The diagnosis of Hirschsprung's disease (HD) was revolutionized by the introduction of rectal suction biopsy (RSB), allowing specimens to be taken without general anesthesia on the ward or as an out-patient procedure. However, insufficient tissue samples are not uncommon, and subsequently histopathologists often remain reluctant to confirm the presence or absence of enteric ganglion cells merely on the basis of submucosal RSBs. The aim of this study was to evaluate the current usage of RSB in the diagnostic work-up of HD based on an international survey.

METHODS

A 15-item questionnaire was distributed among participants and faculty members at the 21st International Meeting of the Pediatric Colorectal Society.

RESULTS

Eighty-seven pediatric surgeons from 30 countries completed the anonymous survey (response rate 70.2 %), grouped into 68 (78.2 %) staff surgeons and 19 (21.8 %) trainees, with a median work experience of 18 years (range 2-45 years). Of these, 74 (85.1 %) use RSB in the diagnostic work-up of patients with suspected HD, whereas 13 (14.9 %) prefer open full-thickness biopsy under general anesthesia. In total, 47 (63.5 %) respondents perform ≥20 RSBs (range 3-100 RSBs) per year. Five different RSB instruments were reported, the most common ones being rbi2 (65.0 %), Solo-RBT (15.0 %) and multipurpose suction biopsy kit (8.3 %). Only 22 (29.7 %) of the respondents use a defined negative suction pressure, with a median of 10 mL air (range 6-25 mL air). The most proximal reported biopsy site was located at a median of 2 cm (range 1-15 cm) above the pectinate line and a median of 2 (range 1-5) specimens are routinely taken, mainly from the posterior rectal wall. Insufficient tissue samples with need for repeat RSB were encountered in a median of 10 % (range 0-40 %). Most frequently used staining methods for rectal biopsies are hematoxylin/eosin (75.9 %), acetylcholinesterase (73.6 %), and calretinin (33.3 %). Overall, 36 (48.6 %) respondents had experienced RSB-related complications, including self-limiting rectal blood loss (n = 28), persistent rectal bleeding requiring blood transfusion (n = 9) and rectal perforation requiring surgical intervention (n = 7).

CONCLUSIONS

Although RSB is considered to be today's gold standard for the diagnosis of HD, many aspects of its current usage are lacking consensus. Therefore, a prospective multi-center study or larger global audit appears warranted to identify if the present survey reflects common surgical practice and to establish universal standards for RSB.

Suction rectal biopsy yields adequate tissue in children

BACKGROUND/PURPOSE

Hirschsprung disease (HD) is diagnosed by rectal biopsy, with suction rectal biopsy (SRB), the preferred technique in neonates. Reported SRB adequacy has varied overall with concern for decreased diagnostic yield in older children. The study aim was to assess SRB adequacy by age in children with the current device used at our institution.

METHODS

Following IRB approval, a retrospective cohort of children (1 to 18years) evaluated by SRB for HD was identified through billing records. Data regarding demographics, procedure, results, and complications were collected and analyzed using SPSS.

RESULTS

56 children (median age 3.9years) underwent SRB with an 80.4% overall success rate. Patients older than 5years had 90.5% adequacy rate compared to 74.3% in those younger. Univariate analysis revealed weak association of inadequate specimens with younger age and males, and no association with insurance, race/ethnicity, weight-height or BMI percentile, sedation type, or procedure location. SRB under general anesthesia (GA) had 100% adequacy (n=6). Patients with inadequate initial biopsy achieved diagnosis by SRB with increased sedation (n=5) or full thickness biopsy under GA (n=5).

CONCLUSION

With adequacy of 80.4% overall and 90.5% for patients greater than 5years, SRB is effective in evaluating the older child for HD.

Rectal biopsy for Hirschsprung's disease: a review of techniques, pathology, and complications

BACKGROUND

Hirschsprung's disease (HD) is one of the most common congenital anomalies of colorectal function, affecting approximately 1 in 5000 live births, with a 4:1 male predominance. HD is characterized by aganglionosis that is most often limited to the rectosigmoid, but can extend proximally along the colon and, in rare instances, reach into the small intestine. A clinical history of delayed passage of meconium beyond 48 hours after birth, physical exam findings of abdominal distention and vomiting, and a contrast enema demonstrating a transition zone are highly suggestive of HD.

DATA SOURCES

We searched databases including PubMed, Google Scholar, and Scopus for the following key words: Hirschsprung's disease, rectal biopsy, pathology, ganglion cell, nerve trunk hypertrophy, pediatric constipation, and selected publications written in English that were relevant to the scope of this review.

RESULTS

Based on the data presented in the literature, we reviewed 1) biopsy techniques for the diagnosis of Hirschsprung's disease, addressed inadequate biopsies, and complications from rectal biopsy, and 2) pathologic and histologic interpretation of biopsy specimens for the diagnosis of Hirschsprung's disease.

CONCLUSION

A well-executed rectal biopsy with expert pathologic evaluation of the specimen remains the gold standard for the diagnosis of Hirschsprung's disease and is the subject of this review.

Rectal biopsies for Hirschsprung disease: Patient characteristics by diagnosis and attending specialty

PURPOSE

Hirschsprung disease (HD) is diagnosed with rectal biopsy. At our institution two services perform these biopsies: pediatric surgery and gastroenterology. Our objective was to review our institutional experience with rectal biopsies to diagnose HD and compare patients and outcomes between the two services.

METHODS

We reviewed all children undergoing a rectal biopsy for the evaluation of HD at our institution over a 10-year period. Comparisons were made using multiple logistic regression models.

RESULTS

We identified 518 children who underwent rectal biopsy for evaluation of HD; 451/518 (87%) were adequate and 56/518 (11%) were positive for HD. A positive biopsy was more likely with delayed passage of meconium (p<0.001), obstructive symptoms (p<0.001), trisomy 21 (p<0.001), full-term gestation (p=0.03), and male gender (p=0.02). Pediatric surgeons biopsied younger patients with more classic symptoms for HD compared to gastroenterologists. Pediatric surgeons were more likely to take adequate (OR 6.0, 95% CI 2.9-12.4, p<0.001) and positive biopsies (OR 6.7 95% CI 2.1-21.2, p=0.001) compared to gastroenterologists.

CONCLUSION

Infants with classic symptoms can reliably be diagnosed with HD by a pediatric surgeon. The work up for HD in older children with constipation should be a collaborative effort between pediatric surgery and gastroenterology.

Infant's Age Influences the Accuracy of Rectal Suction Biopsies for Diagnosing of Hirschsprung's Disease

BACKGROUND & AIMS

Hirschsprung's disease (HD) is a rare birth defect of the distal colon. Analysis of rectal suction biopsy (RSB) is considered to be the most reliable method for its diagnosis in infants. However, the diagnostic accuracy of RSB analysis could be affected by the patient's age, possibly because of rapid development of the enteric nervous system in the first weeks after birth. Because there is a trend toward testing for HD at early ages, we aimed to determine whether the diagnostic accuracy of RSB analysis is associated with the patient's age.

METHODS

We performed a retrospective analysis of all patients from whom 1 or more RSBs were analyzed from 1975 through 2011 (529 RSBs from 441 patients). Outcomes of RSB analyses were categorized as positive, inconclusive, or negative for HD. Primary diagnoses, based only on RSB, were compared with final diagnoses made after at least 1 year of clinical follow-up. Age at time of RSB analysis was corrected for the gestational age. By using these criteria, we determined the diagnostic accuracy of RSB analysis for different age groups.

RESULTS

RSB analysis identified HD in patients with sensitivity values of 46% (patients -45 to 7 days old), 47% (8-22 days old), and 62% (23-39 days old) (corrected for gestational age). The average sensitivity with which RSB analysis identified HD in patients older than 39 days was 88%. RSB identified HD in patients younger than 39 days old with significantly lower sensitivity than in older patients (50% vs 88%, P < .001). The specificity with which RSB identified infants without HD was not affected by age (average 95%). Of all RSBs, 11% were inconclusive for the diagnosis of HD.

CONCLUSIONS

RSB analysis identifies HD in patients younger than 39 days old with only 50% sensitivity. Moreover, RSBs obtained from younger patients often lead to inconclusive outcomes and require additional biopsies. We propose that for infants suspected of HD at these ages, a noninvasive technique, such as anorectal manometry, should be used for a primary diagnosis. RSB should thereafter be used to confirm the diagnosis when the infant is older than 39 days.

Rectal suction biopsy for the diagnosis of Hirschsprung's disease: a systematic review of diagnostic accuracy and complications

PURPOSE

Rectal suction biopsy (RSB) combined with acetylcholinesterase (AChE) staining is currently the gold standard for the diagnosis of Hirschsprung's disease (HD). However, some pathologists are still reluctant to diagnose HD in RSBs as it requires thick submucosal tissue to confirm the absence of ganglion cells. Furthermore, insufficient specimens and adverse events have been reported. The objective of this study was to determine the diagnostic accuracy and incidence of complications of RSBs in patients suspected of HD based on a systematic review of the published literature.

METHODS

A literature-based search for relevant publications was conducted using multiple online databases. Staining for AChE/hematoxylin and eosin should have been used to evaluate RSBs. The number of true-positive, false-positive, true-negative and false-negative results was recorded and data on RSB-related complications was extracted. Pooled incidence rates and odds ratios (ORs) with 95% confidence intervals (CI) were calculated using standardized statistical methodology.

RESULTS

Fifty-eight studies met defined inclusion criteria, reporting a total of 14,053 RSBs. The median cohort size consisted of 72 patients (range 1-766) with a median age of 14.4 months (range 1 day-66 years) at time of biopsy. In 89.93% (CI 89.11-90.70%), RSB provided adequate tissue for the diagnosis of HD. Insufficient specimens were obtained in 10.07% (CI 9.30-10.89%) and in 8.46 % (CI 7.55-9.46%) RSB was repeated. The incidence of HD was 19.13% (CI 18.25-20.03%). Mean sensitivity of RSB was 96.84% (CI 95.57-97.47%) and mean specificity was 99.42% (CI 99.17-99.57%). The overall complication rate was 0.65% (CI 0.46-0.91%) with persistent rectal bleeding requiring blood transfusion in 0.53% (CI 0.36-0.77%), bowel perforation in 0.06% (CI 0.02-0.18%) and pelvic sepsis in 0.06% (CI 0.02-0.18%). Complications were significantly more frequent in newborns and infants compared to older children (OR 9.00 [CI 4.75-17.07], p < 0.0001).

CONCLUSIONS

RSB combined with AChE staining is a simple, safe and accurate method for the diagnosis of HD. The risk for RSB-related complications is higher in newborns and infants.

Hirschsprung's disease: Role of rectal suction biopsy - data on 216 specimens

BACKGROUND

The diagnosis of Hirschsprung's disease (HD) is dependent on the histological study of rectal ganglion cells, and an open rectal biopsy was the mainstay that required general anaesthesia (GA) and carried risk of postoperative rectal bleeding. Suction rectal biopsy later gained wide acceptance and became the choice as there is no requirement of GA and virtual absence of any complications.

MATERIALS AND METHODS

A retrospective review of the histological findings of 216 rectal suction biopsies studied from 2005 to 2009.

RESULTS

There were 143 male and 73 female children. 196 (90.7%) children were within 1 year of age. Among 216 rectal suction biopsies 181 (83.80%) were aganglionic, 27 (12.5%) were ganglionic and 8 (3.7%) were inadequate. Majority of patients were of less than 1 year of age (94.47%).

CONCLUSIONS

The rectal suction biopsy is a bed side procedure, safe, cheap and time saving. There is high degree of accuracy, simplicity and absence of complications.

Adult Hirschsprung's disease in Jamaica: operative treatment and outcome

AIM

This study reviewed the operative management and outcome of patients with adult Hirschsprung's disease treated at the University Hospital of the West Indies, Mona, Jamaica.

METHOD

The case notes for 11 patients with adult Hirschsprung's disease, treated operatively between January 1986 and December 2007, were reviewed and data on preoperative diagnosis, operative procedures and postoperative complications were retrieved.

RESULTS

Diagnosis was by open rectal biopsy in nine patients and by rectal suction biopsy in two patients. The time taken for preoperative bowel preparation ranged from 10 to 35 days, and colostomy was required in three patients to facilitate bowel cleansing. The Soave and Swenson procedures were used in six and five patients, respectively, leading to anastomotic stricture in one patient treated using the Soave procedure and to leakage in two patients treated using the Swenson procedure. All procedures took longer than 300 min, and 300-800 ml of blood or plasma was transfused.

CONCLUSION

Therapeutic procedures for adult Hirschsprung's disease may result in life-threatening anastamotic complications. A protective colostomy is recommended when Swenson's procedure is used.

Rectal biopsies obtained with jumbo biopsy forceps in the evaluation of Hirschsprung disease

BACKGROUND AND AIM

Refractory constipation is an extremely common problem in infants and children. The diagnostic suspicion of Hirschsprung disease often arises in this clinical setting. Diagnosing Hirschsprung disease can be difficult; however, excluding the diagnosis is much easier, only requiring the demonstration of ganglion cells in the distal rectum. The most common method for obtaining tissue from the rectum involves a blind suction biopsy. This technique has been complicated by serious adverse events, equipment malfunction, and inadequate specimens. Our goal was to evaluate the adequacy of specimens obtained with a flexible endoscope and jumbo biopsy forceps to rule out Hirschsprung disease in the child outside the newborn period.

PATIENTS AND METHODS

We retrospectively reviewed 668 rectal biopsies taken during 167 endoscopies on 156 patients being evaluated for Hirschsprung disease from 2001 to 2008 at the Baystate Medical Center Children's Hospital. Four biopsies were taken from each patient approximately 2.5 cm from the anal verge. Biopsies were obtained using a flexible endoscope and jumbo biopsy forceps. During the first 6 years the Olympus FB-50U-1 large cup fenestrated biopsy forceps was used. During the last 2 years the Boston Scientific Radial Jaw 4 Jumbo biopsy forceps was used instead.

RESULTS

The Boston Scientific Radial Jaw 4 Jumbo biopsy forceps yielded adequate specimens 93% of the time, which surpassed most published results of other techniques. There were no complications reported.

CONCLUSIONS

Obtaining rectal biopsies with a flexible endoscope and jumbo biopsy forceps is a safe and effective means to rule out the diagnosis of Hirschsprung disease in children.

Congenital large intestinal hypoganglionosis in a domestic shorthair kitten

CLINICAL PRESENTATION AND INVESTIGATIONS: An 11-week-old female domestic shorthair kitten presented with a history of constipation since weaning. Abdominal distension was noted on physical examination and abdominal radiographs revealed a large volume of faeces in the descending and transverse colon. Colonoscopy was unremarkable and euthanasia was performed at the owners' request.

DIAGNOSIS

The histological diagnosis of large intestinal hypoganglionosis was made post mortem.

SIGNIFICANCE

This appears to be the first reported case of congenital hypoganglionosis in a kitten with histopathological confirmation of the diagnosis. It may potentially be a more common cause of constipation in kittens and young cats than has previously been suspected.

Evaluation and management of persistent problems after surgery for Hirschsprung disease in a child

Hirschsprung disease occurs approximately once in every 5000 live-born infants. It is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the intestine. Once the diagnosis of Hirschsprung disease has been made, most patients are now treated with a transanal approach to resection. We review the early and late postoperative complications. Late complications include persistent mechanical obstruction, recurrent or acquired aganglionosis, disordered motility in the proximal colon or small bowel, internal sphincter achalasia, or functional megacolon caused by stool-holding behavior. These children require complex interdisciplinary care to ensure an adequate quality of life.