Calretinin-Immunoreactive Mucosal Innervation in Very Short-Segment Hirschsprung Disease: A Potentially Misleading Observation

Abstract

Absent calretinin-immunoreactive (CRir) mucosal innervation in aganglionic rectal biopsies is considered a useful diagnostic finding for Hirschsprung disease. Analysis of a series of rectosigmoid resections from patients with short-segment (>2-cm aganglionic, n = 9) and very short-segment (≤2-cm aganglionic, n = 9) Hirschsprung disease demonstrates that CRir mucosal nerves extend into the proximal 1-2 cm of aganglionic bowel, where their presence in distal rectal biopsies could complicate diagnosis of very short-segment disease. Indeed, retrospective analysis of preoperative, aganglionic, distal rectal biopsies from 4 of 9 patients with very short-segment Hirschsprung disease revealed CRir mucosal innervation. Accurate diagnosis was possible based on generous histopathological submucosal sampling to exclude ganglion cells and the presence of abundant large-caliber submucosal nerves (more than 4 nerves >30 µm thick/×200 field or more than 2 nerves >40 µm thick/×200 field). Absent CRir mucosal innervation supports the diagnosis of Hirschsprung disease, but the presence of CRir mucosal nerves does not exclude aganglionosis, especially in distal rectal biopsies from patients with very short-segment Hirschsprung disease.

Two Cases of Chronic Intestinal Pseudo-obstruction: A Comparison of Staining Characteristics of Enteric Visceral Myopathy With Hirschsprung Disease

“…Calretinin immunoreactive mucosal innervation has been shown to be absent in the aganglionic segment of bowel in Hirschsprung disease. 26,27 Although the absence of calretinin staining in the muscularis has been previously described, the lack of peripherin-positive nerve fibers is a novel finding. 31 Peripherin is a neuronal intermediate filament protein required for axonal outgrowth and maintenance in developing neurons and a fairly reliable marker of peripheral nervous system mature ganglion cells.…”

Immunohistochemical panel for the diagnosis of Hirschsprung's disease using antibodies to MAP2, calretinin, GLUT1 and S100

“…Table 6 shows an evaluation of the expression or absence of expression of GLUT1 in perineurium around nerve fibres for all three zones. Expression was observed in 19 of 23 HD-affected tissue samples and about half the transition zone tissue samples (nine of 19), but only three of 27 normal tissue samples. Patient's age and gender did not influence the presence or absence of perineurium in submucosal nerve fibres.…”

“…Since the introduction of acetylcholinesterase staining, different types of neurones and ganglia in the submucosal and myenteric plexuses and various stains that mark neurones and nerve fibres have been identified . Immunohistochemical markers tested in cases of HD include: RET oncoprotein, neurone‐specific enolase, calretinin, MAP2, peripherin, NeuN and nNOS for the detection of ganglion cells; and GLUT1, S100, GFAP, NGFR and beta‐tubulin for the detection of nerve fibres . The aim of this study was to identify a method for the reliable diagnosis of HD using immunohistochemical staining that combined detection of ganglia (MAP2 and calretinin) and the evaluation of nerve fibres (S100 and GLUT1).…”

“…[8][9][10][11][12][13][14][15][16][17][18] Immunohistochemical markers tested in cases of HD include: RET oncoprotein, neurone-specific enolase, calretinin, MAP2, peripherin, NeuN and nNOS for the detection of ganglion cells; and GLUT1, S100, GFAP, NGFR and beta-tubulin for the detection of nerve fibres. [19][20][21][22][23][24][25][26][27][28][29] The aim of this study was to identify a method for the reliable diagnosis of HD using immunohistochemical staining that combined detection of ganglia (MAP2 and calretinin) and the evaluation of nerve fibres (S100 and GLUT1). Such an immunohistochemical diagnostic panel offers several advantages.…”

Comments on “A variant pattern of Calretinin immunohistochemistry on rectal suction-biopsies is fully specific of short-segment Hirschsprung’s disease”

“…Kapur had previously cautioned on the possibility of type II errors (false negative) when using Calretinin staining as a diagnostic tool in patients with very shortsegment Hirschsprung's disease [5]; this is attributed to the proximal segment of aganglionic bowel also staining positive with Calretinin. Instead of the P?…”