Total intestinal aganglionosis presenting as duodenal obstruction

Autosomal-recessive neural crest syndrome with albinism, black lock, cell migration disorder of the neurocytes of the gut, and deafness: ABCD syndrome

We report on a macrosomic newborn girl with albinism, a black lock at the right temporo-occipital region, and retinal depigmentation. Bilateral deafness was confirmed by brainstem auditory-evoked potentials. In addition, the infant had a severe defect of intestinal innervation. Biopsy showed aganglionosis of the large intestine, and total absence of neurocytes and nerve fibers in the small intestine, indicating a total lack of sympathetic and parasympathetic innervation. The infant died of intestinal dysfunction at 5 weeks. She was the 14th child of consanguineous Kurdish parents. Four sibs of our patient had the same syndrome and died a few days after birth. The other 9 sibs are well, with an unremarkable phenotype. A syndrome of albinism, black lock, deafness, and a total lack of intestinal neural innervation has not yet been reported. It represents a new neural crest syndrome with autosomal-recessive inheritance.

A 3-year survivor of near-total intestinal aganglionosis

A newborn girl had no ganglion cells beyond 2 cm distal to the ligament of Treitz. The proximal jejunum was dilated. A jejunostomy constructed 46 cm distal to the ligament of Treitz functioned. A 28-cm jejunal segment was myectomized to augment enteral feeding. For almost 1 year she has been on enteral feedings only, and her body size has been in the 75th percentile.

Absence of the enteric nervous system in the newborn: presentation of three patients and review of the literature

Three patients suffering from an absence of the enteric nervous system are reported. Two sisters presented with severe vomiting shortly after birth and dilatation of the intestine proximal to a stenosis. There was an absence of the enteric nervous system throughout the entire length of the intestine distal to the duodenum. A boy presenting an ileus was found to suffer from an aganglionosis of the entire colon. There was also an absence of neuronal bodies and nerve fibers in the small intestine. The final diagnosis was made by histochemical and immunocytochemical stains for acetylcholinesterase, lactate hydrogenase, neuron-specific enolase, protein S-100, and substance P. In the literature, 13 other patients have been reported. On the basis of differences of symptoms, incidence, sex ratio, genetics, and, presumably, pathogenesis between absence of the enteric nervous system and aganglionosis, it is assumed that the two diseases are separate entities.

Total intestinal aganglionosis

Total Intestinal Aganglionosis is a rare, uniformly fatal condition with absence of ganglia from the duodenum to the rectum. A neonate with this extreme form of Hirschsprung's disease is presented with a review of 12 previously reported cases. Smooth muscle strips from this infant's gastrointestinal tract demonstrated viable cholinergic receptors, absence of intrinsic neuronal innervation, and colonic contractile activity to the purported peptidergic neurotransmitter cholecystokinin. Four aspects of total intestinal aganglionosis are noteworthy: (1) one-third of patients presented between four and eight days of age after passing meconium on the first day of life; (2) at laparotomy, no intestinal distention, obstruction, or transition zone was evident; (3) hypertrophic nerve fibers seen in classic Hirschsprung's disease were absent in one-quarter of patients; and (4) a high incidence of affected siblings occurred in the previously reported cases. This form of Hirschsprung's disease may represent a distinct entity with autosomal recessive inheritance and significant risk for recurrence.

Aganglionosis of the colon. Morphologic investigations in 524 patients

2014 biopsies and surgical specimens of 524 patients with suspected aganglionosis of the colon were analyzed using enzyme histochemical techniques for acetylcholinesterase and lactate dehydrogenase. The diagnosis could be confirmed in 70 patients. Hypoganglionosis was found in 6, neuronal dysplasia (or hyperganglionosis) in 2, and a complete lack of intramural neurons and nerve fibers in 1 patient. The disease was found to occur most often during the first year of life (65.7%) and to be more common in males than females (3.3:1). Enzyme histochemistry is useful for the final diagnosis of aganglionosis provided the biopsy contains mucosa and parts of the submucosa of the colon.

Total colonic aganglionosis. Analysis of 16 cases

Sixteen of 116 infants (14 percent) with Hirschsprung's disease had total colonic aganglionosis. Treatment was delayed in 6 of 16 patients because the condition was not recognized. Diagnosis was eventually achieved by rectal biopsy and the extent of aganglionosis was documented after multiple intestinal biopsies. All patients were initially managed by diverting enterostomy. Ileoanal pull-through operation was performed in nine patients at 12 to 24 months of age with no operative mortality. The overall mortality rate was 25 percent, including the deaths of two infants with diagnostic delay. Survivors had normal growth and satisfactory bowel function, Hirschsprung's disease should be suspected and rectal biopsy performed in infants with persistent or intermittent abdominal distention and constipation. Instances of total colonic aganglionosis can be documented by appropriate biopsies at the time of laparotomy. The modified Duhamel operation is an acceptable procedure for this condition. A ganglionic antimesenteric patch enteroplasty may prove a useful adjunct in infants with extensive aganglionosis involving the proximal small bowel.

Modified endorectal procedure for management of long-segment aganglionosis

During the past five years, 65 patients with Hirschsprung's disease have been treated at our institution. Ten of these patients had long-segment aganglionosis, five with total colonic involvement, four with aganglionosis to the midtransverse colon, and one child with Hirschsprung's disease extending to the distal jejunum. There are six females and four males in the series, which is a reversal of the normal sex ratio for aganglionosis. An extensive literature review of long-segment Hirschsprung's disease has revealed a total of 489 reported cases. The mean frequency of long-segment aganglionosis in the literature is 12% of all cases of aganglionosis. Our series is comparable, with an incidence of 15%. The overall mortality rate in the literature of 54% indicates the poor therapeutic results obtained with this disease in the past. All ten of our patients have been definitively treated with a modified endorectal pull-through procedure. The mortality rate with this procedure has been zero. There has been one major complication (incorrect pathologic diagnosis of the level of aganglionosis) and four minor complications. The average follow-up period is 42.6 months. The functional results have been excellent with an average of three to four soft bowel movements per day. All of the children over 3 years of age are completely toilet trained. The remaining two patients are too young to be toilet trained, but are continent in the sense that they do not soil between bowel movements. Awareness of this entity of long-segment aganglionosis should lead to earlier diagnosis, appropriate operative therapy, and lower mortality rates.

Idiopathic late-onset immunoglobulin deficiency with associated defect in cell-mediated immunity

An 8-year-old boy presented with idiopathic late-onset immunoglobulin deficiency manifested principally by recurrent suppurative chest infections and chronic diarrhoea with malabsorption. Nodular lymphoid hyperplasia and giardiasis were shown on small bowel biopsy. Investigation of the immune system showed low serum levels of IgG, IgM, and IgA, negative skin tests to four recall antigens, absent mixed lymphocyte reactivity, and impared lymphocyte responses to mitogens in vitro. Serum complement and granulocyte function studies were normal. Maintenance therapy with gammaglobulin and antibiotics gave a good response.

Total intestinal aganglionosis. An autosomal recessive condition?

A case of total intestinal aganglionosis in a sib of a previously recorded patient is presented. The number of cases now reported is 9 in six families. The possibility that this condition is a distinct entity inherited in an autosomal recessive manner is discussed.