Hirschsprung’s disease : problems with false –negative biopsies Yasmine Houas, Yosra Kerkeni, Sondes Sahli,Fatma Fitouri,Nada Sghairoun,Manef Gasmi ,Mourad Hamzaoui Pediatric surgery department “A”, Children Hospital , Tunis , Tunisia

Introduction The diagnosis of Hirschsprung ‘s disease (HD) : * Clinical manifestations *Radiological findings *Manometry * Biopsy

Introduction Patients who clinically ressemble HD with quite similar histological findings

Aim of the study To report cases misdiagnosed preoperatively with a HD Individual patient analysis and strategy of management will be discussed.

Between the 1st of January 2011 and the 30th of June 2016 Methods A retrospective study Between the 1st of January 2011 and the 30th of June 2016 The sex The age The revealing symptoms The result of the histology the findings during surgery The follow-up

Methods: Same histopathologist Standard H & E staining Rapid cholinesterase staining was not available Rectal suction biopsy 3, 5cm above the dentate line

Results Three patients were misdiagnosed preoperatively with a HD

Case one Male infant 16 months old First meconium bowel within the first 24 hours Chronic constipation : one bowel movement per week Contrast enema : transition zone in the rectosigmoid region

Case one Manometry not performed Rectal suction biopsy : absence of ganglion cells in the colonic submucosa Transanal pull-through Histopathological findings : presence of ganglion cells in the whole colon resected

Case one Still suffering from constipation partially improved with laxatives Contrast enema Final diagnosis is yet to establish

Case two Rectal suction biopsies Male infant Neonatal intestinal obstruction Bowel decompression not possible with high bowel wash Surgery : transition zone at the splenic flexure right loop colostomy First : Low number of ganglion cells Second: absence of ganglion cells Rectal suction biopsies

Case two Surgery : staged full-thickness biopsies presence of ganglion cells closure of the stoma Patient is doing well Final histopathological findings : hypoganglionosis

Case three Rectal suction biopsy : absence of ganglion cells Male infant Neonatal intestinal obstruction Bowel decompression not possible with high bowel wash Surgery : transition zone at the splenic flexure right loop colostomy Rectal suction biopsy : absence of ganglion cells

Case three Surgery multiple staged biopsies : presence of ganglion cells colonic atresia Resection of the atretic portion of the colon closure of the stoma

Discussion High sensitivity 93 % of Rectal suction biopsy* High specificity 98 % *Rectal suction biopsy for the diagnosis of Hirschsprung's disease: a systematic review of diagnostic accuracy and complications. Friedmacher F, Puri P,Pediatric surgery Int 2015 Sep;31(9):821-30

Problems with Rectal suction biopsy for HD Variants of HD and pitfalls Intestinal neuronal dysplasia Hypoganglionosis Internal anal sphincter neurogenic achalasia Smooth muscle disorders Immature ganglia Too superficial ( ganglion cells in the deep parts of the submucosa) Physiologic hypoganglionosis ( less than 3cm of the dentate line) Degree of experience of histopathologist Calretenin vs.Acetylcholinesterase Age (immature cells neonate ) Technical problems Variants of HD and pitfalls

To conclude Errors in reading rectal biopsies in HD are rare but can have significant results in children. New methods, such as calretinin staining, must be considered to achieve better effectiveness of the RSB for diagnosing HD. Special attention must be given to intestinal dysganglionoses that can mimic a HD