Risk factors for Hirschsprung disease-associated enterocolitis: a systematic review and meta-analysis

When is the optimal diagnostic biopsy timing of acetylcholinesterase staining in Hirschsprung disease?

PURPOSES

The preoperative diagnosis of Hirschsprung disease (HD) requires a rectal mucosal biopsy and acetylcholinesterase (AchE) staining. However, the optimal timing for performing these procedures remains unclear. In this study, we assessed the most effective timing for a rectal biopsy and AchE staining to diagnose HD.

METHODS

We retrospectively collected data from 57 patients who underwent radical surgery for HD at Mie University Hospital between January 2008 and April 2024. We reviewed all rectal biopsies, including those with multiple samples, and analyzed the biopsy date and the results of AchE staining (positive or negative).

RESULTS

Among the 57 children with a confirmed HD diagnosis, 36 were included in the study. Fifty-two rectal biopsy sessions were performed in these 36 patients with HD, including 15 with multiple biopsies. A receiver operating characteristic analysis showed that the optimal age for diagnosing HD was older than 21 days. Biopsies performed at ≤ 3 weeks of age had a low diagnostic accuracy rate of 30.8%, whereas rectal biopsies performed at > 3 weeks of age showed a high positive diagnostic rate of 87.5%.

CONCLUSIONS

Rectal mucosal biopsies performed after 3 weeks of age show a higher diagnostic accuracy for HD.

CLINICAL TRIAL NUMBER

Not applicable.

Development of Prediction Model for Hirschsprung-Associated Enterocolitis (HAEC) in Postoperative Hirschsprung Patients

BACKGROUND

Despite identifying numerous risk factors for postoperative Hirschsprung-associated enterocolitis (HAEC), predicting individual risk remains challenging. This study aimed to develop a clinical prediction model for predicting the probability of postoperative HAEC within 5 years after surgery in Hirschsprung individuals.

METHODS

The study included all children with Hirschsprung disease who underwent definitive surgery at Chiang Mai University Hospital from 2006 to 2021. Concomitant anorectal abnormalities and incomplete data were excluded. A multivariable logistic regression analysis, adjusted for correlated data, was utilized to develop the prediction model.

RESULTS

Of the included 274 patients, 75 patients (27.4%) experienced postoperative HAEC within 5 years, totaling 121 episodes. Based on statistical and theoretical significance, eight parameters were utilized as predictors, which included male (OR1.23,95%CI:0.53-2.86), trisomy21(OR1.34,95%CI:0.21-8.45), weight at the time of surgery (OR0.86,95%CI:0.73-1.02), absence of exclusive breastfeeding (OR1.51,95%CI:0.65-3.51), length of the aganglionic segment (rectosigmoid (OR1.32,95%CI:0.48-3.62), long segment (OR41.39,95%CI:3.00-570.37), and total colonic aganglionosis (OR710.20,95%CI:23.55-21420.72)), preoperative stoma (OR1.72,95%CI:0.34-8.58), surgical approach (Duhamel (OR0.06,95%CI:0.01-0.81) and abdominal assisted trans anal endorectal pull-through (OR0.04,95%CI:0.002-0.65)), and early HAEC before two weeks following surgery (OR1.98,95%CI:0.67-5.82). The derived predictive model exhibited acceptable discriminative performance (AuROC:0.749,95%CI:0.679-0.816). Risk groups were categorized into low and high-risk, with positive likelihood ratios of 0.65 and 10.70, respectively. Recommendations for management and follow-up were generated based on these risk groups. An online application has been developed for calculating individual risk of postoperative HAEC and offering management suggestions with follow-up schedule: [https://w1.med.cmu.ac.th/surgery/personnel/pedsurgerycmu/#HAEC-Calculator].

CONCLUSIONS

This risk predictive model accurately estimates the probability of postoperative HAEC within 5 years after surgery in Hirschsprung patients. It facilitates risk stratification and provides personalized recommendations to parents for the prevention and early detection of postoperative HAEC.

LEVELS OF EVIDENCE

Level II Retrospective cohort study (Prognosis study).

Prevalence and Factors associated with Bowel Dysfunctions after Pull-Through Surgery in Children Diagnosed with Hirschsprung Disease

Purpose

This study investigated the prevalence of bowel dysfunction and associated factors after pull-through surgery.

Methods

The medical records of children under 18 years old diagnosed with Hirschsprung disease (HD) based on histopathology between 2004 and 2022 were reviewed. Bowel dysfunction after pull-through surgery was categorized into Hirschsprung-associated enterocolitis (HAEC), constipation, and fecal incontinence.

Results

Among 97 children diagnosed with HD, the median age at presentation was 3 (2-15) days (84.54% male). The clinical manifestations included abdominal distension (58.76%), constipation (17.52%), bilious vomiting (17.52%), nonbilious vomiting (14.43%), and enterocolitis (12.37%). HDs were classified by the location of aganglionosis: short segments (74.23%), long segments (8.25%), total colonic (12.37%), and small intestinal (5.15%). Excluding surgical complications, the prevalence of bowel dysfunction was 64.95% during an average follow-up of 8.33 years. HAEC was the most common issue (46.39%), followed by nonretentive incontinence (22.68%), constipation (20.62%), and retentive incontinence (15.46%). Preoperative HAEC was significantly associated with post-surgery HAEC (adjusted odds ratio [aOR] 18.31; 95% confidence interval [CI], 1.30-257.73; p=0.031). The Duhamel operation was associated with constipation and retentive incontinence (aOR 62.15; 95% CI, 1.64-2,349.13; p=0.026). Age under 6 months at pull-through surgery was associated with nonretentive fecal incontinence after 4 years (aOR 8.83; 95% CI, 1.11-70.39; p=0.040).

Conclusion

The prevalence of bowel dysfunction in children with HD remains high despite successful surgical correction. Preoperative HAEC, Duhamel operation, and pull-through surgery before the age of 6 months were found to be independent factors associated with bowel dysfunction after pull-through surgery.

Hirschsprung-associated enterocolitis: a comprehensive review

Hirschsprung-associated enterocolitis (HAEC) is an important cause of morbidity and the leading cause of mortality in patients with Hirschsprung disease. The pathophysiology of disease includes dysmotility of the enteric nervous system, dysbiosis of the microbiota, failure of the intestinal barrier, and impaired immunity. Common manifestations include fever, abdominal distension, lethargy, vomiting, and diarrhea. Given the non-specific signs and symptoms of HAEC, high clinical suspicion is warranted, especially in patients with risk factors. Diagnosis and management of HAEC depend on the severity of disease presentation. Several preoperative and postoperative modalities have been explored to prevent HAEC. The current review elaborates on the risk factors, pathogenesis, diagnosis, treatment, and prevention of HAEC.

Exploring the Spectrum of Long Non-Coding RNA CARMN in Physiological and Pathological Contexts

Cardiac mesoderm enhancer-associated non-coding RNA (CARMN), an evolutionarily conserved long non-coding RNA (lncRNA), serves as the host gene for the miR143/145 cluster. It plays a crucial role in cardiovascular cell differentiation and the maintenance of vascular smooth muscle cell (VSMC) homeostasis, which are vital for normal physiological processes. Specifically, CARMN is associated with the pathological progression of cardiovascular diseases such as atherosclerosis, abdominal aortic aneurysm, and chronic heart failure. Moreover, it acts as a tumor suppressor in various cancers, including hepatocellular carcinoma, bladder cancer, and breast cancer, highlighting its potential as a beneficial biomarker and therapeutic target. This review provides a detailed examination of the roles of CARMN, its evolutionary conservation, expression patterns, and regulatory mechanisms. It also outlines its significant implications in the diagnosis, prognosis, and treatment of these diseases, underscoring the need for further translational research to exploit its clinical potential.

ZEB2 alleviates Hirschsprung's-associated enterocolitis by promoting the proliferation and differentiation of enteric neural precursor cells via the Notch-1/Jagged-2 pathway

BACKGROUND

Hirschsprung's-associated enterocolitis (HAEC) is a prevalent complication of Hirschsprung's disease (HSCR). Zinc finger E-box binding homeobox 2 (ZEB2) and Notch-1/Jagged-2 are dysregulated in HSCR, but their role in HAEC progression remains poorly understood. We aimed to explore the role and underlying mechanism of enteric neural precursor cells (ENPCs) and the ZEB2/Notch-1/Jagged-2 pathway in HAEC development.

METHODS

Colon tissues were collected from HSCR and HAEC patients. ENPCs were isolated from the HAEC group and stimulated by lipopolysaccharide (LPS). The expressions of ZEB2/Notch-1/Jagged-2 were measured using RT-qPCR and Western blot. Immunofluorescence and cell counting kit-8 assays were performed to assess the differentiation and proliferation of ENPCs. Inflammatory factors were measured by ELISA kits. Co-immunoprecipitation and bioinformatic analysis were used to explore the interaction between ZEB2 and Notch-1. Small interfering RNA and overexpression vectors were used to investigate the role and mechanism of ZEB2 and Notch-1 in regulating ENPCs' proliferation and differentiation during HAEC progression.

RESULTS

We observed increased LPS in the colon tissues of HAEC, with downregulated ZEB2 expression and upregulated Notch-1/Jagged-2 expression. ZEB2 interacts with Notch-1. LPS treatment downregulated ZEB2 expression, upregulated Notch-1/Jagged-2 expression, and induced proliferation and differentiation disorders in ENPCs, which were reversed by the knockdown of Notch-1. Furthermore, overexpression of ZEB2 inhibited Notch-1/Jagged-2 signaling and ameliorated inflammation and dysfunction in LPS-induced ENPCs. Notch-1 overexpression enhanced LPS-induced dysfunction, but this effect was antagonized by the overexpression of ZEB2.

CONCLUSION

Overexpression of ZEB2 ameliorates LPS-induced ENPCs' dysfunction via the Notch-1/Jagged-2 pathway, thus playing a role in HAEC.

Clinical characteristics and influence of postoperative Hirschsprung-associated enterocolitis: retrospective study at a tertiary children's hospital

PURPOSE

To explore the influence of postoperative Hirschsprung-associated enterocolitis (post-HAEC) on long-term outcomes and to identify risk factors of post-HAEC.

METHODS

The medical records of 304 eligible patients diagnosed with Hirschsprung's disease (HSCR) were reviewed. We analyzed the clinical characteristics of post-HAEC and its influence on long-term outcomes. Furthermore, risk factors for early and recurrent HAEC were identified separately.

RESULTS

The overall incidence of post-HAEC was 29.9% (91/304). We categorized early HAEC as occurring within postoperative 3 months (n = 39) and recurrent HAEC as occurring ≥ 3 episodes within postoperative 6 months (n = 25). Patients with early HAEC were more likely to experience worse nutritional status, defecation function, and quality of life compared to those with late or no episodes (P < 0.05). Similarly, the adverse influences of recurrent HAEC on these outcomes were also significant (P < 0.05). The risk factors for early HAEC included preoperative undernutrition, long-segment HSCR, and postoperative Grade 3-4 complications within 30 days. For recurrent HAEC, risk factors were preoperative malnutrition, non-parental caregivers, long-segment HSCR, and postoperative Grade 3-4 complications within 30 days.

CONCLUSION

Classification of post-HAEC based on the first episode time and frequency was necessary. The earlier or more frequent episodes of post-HAEC have detrimental influences on long-term outcomes. Furthermore, risk factors for early and recurrent HAEC were different.