Hirschsprung's disease overview: Difference between revisions

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{{Hirschsprung's disease}}
{{Hirschsprung's disease}}
{{CMG}}; {{AE}}{{AY}} {{ADG}}
{{CMG}}; {{AE}} {{AY}}, {{ADG}}
==Overview==
==Overview==
Hirschsprung's disease involves an enlargement of the [[colon (anatomy)|colon]], caused by [[bowel obstruction]], resulting from an [[ganglion|aganglionic]] section of [[bowel]]. The condition in which the normal [[Enteric nervous system|enteric nerves]] is absent; begins from anus and progresses proximally. The length of affected bowel varies, rarely extended more than one foot or so.
Hirschsprung's disease involves an enlargement of the [[colon (anatomy)|colon]] caused by a [[bowel obstruction]] resulting from an [[ganglion|aganglionic]] section of [[bowel]]. The condition, in which the normal [[Enteric nervous system|enteric nerves]] are absent, begins from the [[anus]] and progresses proximally. The length of affected bowel varies, rarely extending more than approximately one [[foot]]
 
==Historical perspective==
==Historical perspective==
The disease is named after [[Harald Hirschsprung]], the Danish [[physician]] who first described the disease in 1886; describing two infants who had died with swollen bellies. The autopsies showed identical pictures with a pronounced dilatation and hypertrophy of the colon as the dominant features.
The disease is named after [[Harald Hirschsprung]], the Danish [[physician]] who first described the disease in 1886 when describing two infants who had died with swollen bellies. The autopsies showed identical pictures with pronounced dilatation and [[hypertrophy]] of the [[colon ]]as dominant features.
==Classification==
==Classification==
Hirschsprung's disease may be classified based on the extent of [[Colon (anatomy)|colon]] involvement: rectosigmoid disease, long segment disease, and ultrashort segment disease.
Hirschsprung's disease may be classified as rectosigmoid disease, long segment disease, or ultrashort segment disease based on the extent of [[Colon (anatomy)|colon]] involvement.
==Pathophysiology==
==Pathophysiology==
Hirschsprung’s disease is a [[congenital]] disorder of colon in which certain nerve cells, known as ganglion cells, are absent; which may lead to chronic constipation. <ref>Worman and Ganiats 1995, Am Fam Physician 51, 487-494 [http://www.ncbi.nlm.nih.gov/pubmed/7840044]</ref>
Hirschsprung’s disease is a [[congenital]] disorder of colon in which certain nerve cells, called [[ganglion cells]], are absent. This may lead to [[chronic]] constipation.<ref>Worman and Ganiats 1995, Am Fam Physician 51, 487-494 [http://www.ncbi.nlm.nih.gov/pubmed/7840044]</ref>
==Causes==
==Causes==
Hirschsprung's disease is caused by failure of myentric and [[submucosal]] [[Nerve plexus|nerve plexuses]] craniocaudal migration into the distal [[colon]].
Hirschsprung's disease is caused by a failure of the myentric and [[submucosal]] [[Nerve plexus|nerve plexuses]] to complete craniocaudal migration into the distal [[colon]].
==Differentiating Hirschsprung's dieases from other diseases==
==Differentiating Hirschsprung's diseases from other diseases==
Hirschsprung's disease must be differentiated from other diseases that cause [[meconium]] pass failure and also [[abdominal distension]] in infants; such as [[meconium plug syndrome]], [[small left colon syndrome]], and [[congenital hypothyroidism]].
Hirschsprung's disease must be differentiated from other diseases that cause [[meconium]] pass failure and [[abdominal distension]] in infants, such as [[meconium plug syndrome]], [[small left colon syndrome]], or [[congenital hypothyroidism]].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence of Hirschsprung's disease is 20 per 100,000 newborns. It is three times more common in Asian Americans. Males are more commonly affected than females.
The [[incidence]] of Hirschsprung's disease is 20 per 100,000 newborns. Hirschsprung's disease is three times more common in Asian Americans than the rest of the population. Males are more commonly affected than females.


==Risk Factors==
==Risk Factors==
The most potent risk factor for Hirschsprung's disease is strong family history (i.e., multiple family members involvement). Other risk factors include: family history of long segment disease running in the family or the probation of being a female.
The most potent [[risk factor]] for the development of Hirschsprung's disease is a strong [[family history]] (i.e. involvement of multiple family members). Other risk factors include a [[family history]] of long segment disease and the [[proband]] being female.


==Screening==
==Screening==
According to the USPSTF, screening is not recommended for Hirschsprung's disease.
According to the [[USPSTF]], screening is not recommended for Hirschsprung's disease.


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, Hirschsprung's disease can lead to [[enterocolitis]] and even death. Common complications include: [[enterocolitis]], [[intestinal perforation]], and [[short bowel syndrome]]. After appropriate surgical intervention, [[Mortality rate|mortality]] drops significantly.
If left untreated, Hirschsprung's disease can lead to [[enterocolitis]] and even death. Common [[complications]] include [[enterocolitis]], [[intestinal perforation]], and [[short bowel syndrome]]. After appropriate surgical intervention, the odds of mortality drop significantly.


==Diagnosis==
==Diagnosis==
===History and Symptoms===
===History and Symptoms===
Hirschsprung's disease is commonly diagnosed in the neonatal period. The cardinal symptoms of Hirschsprung's disease include [[abdominal distension]], delayed passage of [[meconium]] (not occurring in the first 24 to 48 hours of life) and [[vomiting]]. <ref name="pmid28601177">{{cite journal |vauthors=Stanescu AL, Liszewski MC, Lee EY, Phillips GS |title=Neonatal Gastrointestinal Emergencies: Step-by-Step Approach |journal=Radiol. Clin. North Am. |volume=55 |issue=4 |pages=717–739 |year=2017 |pmid=28601177 |doi=10.1016/j.rcl.2017.02.010 |url=}}</ref><ref name="pmid28600660">{{cite journal |vauthors=Das K, Mohanty S |title=Hirschsprung Disease - Current Diagnosis and Management |journal=Indian J Pediatr |volume= |issue= |pages= |year=2017 |pmid=28600660 |doi=10.1007/s12098-017-2371-8 |url=}}</ref>
Hirschsprung's disease is commonly diagnosed during the neonatal period. The cardinal symptoms of Hirschsprung's disease include [[abdominal distension]], delayed passage of [[meconium]] (i.e., after 24-48 hours from birth), and [[vomiting]]. <ref name="pmid28601177">{{cite journal |vauthors=Stanescu AL, Liszewski MC, Lee EY, Phillips GS |title=Neonatal Gastrointestinal Emergencies: Step-by-Step Approach |journal=Radiol. Clin. North Am. |volume=55 |issue=4 |pages=717–739 |year=2017 |pmid=28601177 |doi=10.1016/j.rcl.2017.02.010 |url=}}</ref><ref name="pmid28600660">{{cite journal |vauthors=Das K, Mohanty S |title=Hirschsprung Disease - Current Diagnosis and Management |journal=Indian J Pediatr |volume= |issue= |pages= |year=2017 |pmid=28600660 |doi=10.1007/s12098-017-2371-8 |url=}}</ref>


===Physical Examination===
===Physical Examination===
Physical examination is nondiagnostic in newborns. it may reveal a [[distended abdomen]] and/or [[anal spasm]]. In older children, [[abdominal distension]] may result from the inability to release [[flatus]].<ref name="pmid28600660">{{cite journal |vauthors=Das K, Mohanty S |title=Hirschsprung Disease - Current Diagnosis and Management |journal=Indian J Pediatr |volume= |issue= |pages= |year=2017 |pmid=28600660 |doi=10.1007/s12098-017-2371-8 |url=}}</ref>
Physical examination is nondiagnostic in newborns. It may reveal a [[distended abdomen]] and/or [[anal spasm]]. In older children, [[abdominal distension]] may result from the inability to release [[flatus]].<ref name="pmid28600660">{{cite journal |vauthors=Das K, Mohanty S |title=Hirschsprung Disease - Current Diagnosis and Management |journal=Indian J Pediatr |volume= |issue= |pages= |year=2017 |pmid=28600660 |doi=10.1007/s12098-017-2371-8 |url=}}</ref>


===Laboratory Findings===
===Laboratory Findings===
There are no specific laboratory findings associated with hirschsprungs disease. All the blood tests and coagulation tests if done prior to surgery will be within the reference range.<ref name="pmid28600660">{{cite journal |vauthors=Das K, Mohanty S |title=Hirschsprung Disease - Current Diagnosis and Management |journal=Indian J Pediatr |volume= |issue= |pages= |year=2017 |pmid=28600660 |doi=10.1007/s12098-017-2371-8 |url=}}</ref>
There are no specific laboratory finding associated with Hirschsprung's disease. All the pre-operation blood tests and coagulation tests will be within the reference range.<ref name="pmid28600660">{{cite journal |vauthors=Das K, Mohanty S |title=Hirschsprung Disease - Current Diagnosis and Management |journal=Indian J Pediatr |volume= |issue= |pages= |year=2017 |pmid=28600660 |doi=10.1007/s12098-017-2371-8 |url=}}</ref>


===Xray===
===X-ray===
X-ray abdomen is the primary modality of choice in diagnosing Hirschsprung's disease. Findings include decreased bowel caliber of the involved segment along with colonic distension.
Abdominal X-ray is the modality of choice in diagnosing Hirschsprung's disease. Major findings on abdominal X-rays in patients affected by Hirschsprung's disease are decreased bowel caliber of the involved segment and [[colon]] distension.


===CT Scan===
===CT Scan===
There are no specific CT findings associated with Hirschsprung's disease.
There are no specific CT scan findings associated with Hirschsprung's disease.


===MRI===
===MRI===
There are no specific CT findings associated with Hirschsprung's disease.
There are no specific MRI finding associated with Hirschsprung's disease.


===Other Imaging Findings===
===Other Imaging Findings===
A [[barium enema]] is the mainstay of diagnosis of Hirschsprung’s disease.
A [[barium enema]] is the mainstay of Hirschsprung’s disease diagnosis.
 
===Other Diagnostic Studies===
===Other Diagnostic Studies===
A rectal [[biopsy]] showing the lack of ganglion cells is the only certain method of diagnosis.
A rectal [[biopsy]] showing the absence of [[ganglion cells]] is the only definitive method of diagnosis.


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
Medical therapy only plays a supportive role in the management of Hirschsprung's disease. Medical therapy is indicated to prevent complications of Hirschsprung disease, to prevent infections during reconstructive surgery, and to manage postoperative bowel function. Intravenous fluid resuscitation and maintenance, nasogastric decompression, and administration of intravenous antibiotics (as indicated) remain the cornerstones of initial medical management.<ref name="pmid28180937">{{cite journal |vauthors=Langer JC, Rollins MD, Levitt M, Gosain A, Torre L, Kapur RP, Cowles RA, Horton J, Rothstein DH, Goldstein AM |title=Guidelines for the management of postoperative obstructive symptoms in children with Hirschsprung disease |journal=Pediatr. Surg. Int. |volume=33 |issue=5 |pages=523–526 |year=2017 |pmid=28180937 |doi=10.1007/s00383-017-4066-7 |url=}}</ref><ref name="pmid24002048">{{cite journal |vauthors=Burkardt DD, Graham JM, Short SS, Frykman PK |title=Advances in Hirschsprung disease genetics and treatment strategies: an update for the primary care pediatrician |journal=Clin Pediatr (Phila) |volume=53 |issue=1 |pages=71–81 |year=2014 |pmid=24002048 |doi=10.1177/0009922813500846 |url=}}</ref>
Medical therapy only plays a supportive role in the management of Hirschsprung's disease. Medical therapy indications include preventing disease complications, preventing post-operative [[infections]], and managing post-operative bowel function. [[Intravenous]] fluid resuscitation and maintenance, nasogastric decompression, and the administration of [[intravenous]] [[antibiotics]] (as indicated) remain the cornerstones of initial medical management.<ref name="pmid28180937">{{cite journal |vauthors=Langer JC, Rollins MD, Levitt M, Gosain A, Torre L, Kapur RP, Cowles RA, Horton J, Rothstein DH, Goldstein AM |title=Guidelines for the management of postoperative obstructive symptoms in children with Hirschsprung disease |journal=Pediatr. Surg. Int. |volume=33 |issue=5 |pages=523–526 |year=2017 |pmid=28180937 |doi=10.1007/s00383-017-4066-7 |url=}}</ref><ref name="pmid24002048">{{cite journal |vauthors=Burkardt DD, Graham JM, Short SS, Frykman PK |title=Advances in Hirschsprung disease genetics and treatment strategies: an update for the primary care pediatrician |journal=Clin Pediatr (Phila) |volume=53 |issue=1 |pages=71–81 |year=2014 |pmid=24002048 |doi=10.1177/0009922813500846 |url=}}</ref>


===Surgery===
===Surgery===
The usual treatment is pull-through surgery where the portion of the colon that does have nerve cells is pulled through and sewn over the part that lacks nerve cells (National Digestive Diseases Information Clearinghouse).
The usual treatment is pull-through surgery, in which the portion of the [[colon]] that has [[nerve cells]] is pulled through and sewn over the portion that lacks [[nerve cells]] (National Digestive Diseases Information Clearinghouse).
 
===Primary Prevention===
===Primary Prevention===


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===Secondary Prevention===
===Secondary Prevention===
Diagnosis of Hirschsprung's disease is required to prevent complications. Secondary preventive measures include administration of laxatives to prevent obstruction and administration of antibiotics to prevent infection.
To prevent complications of Hirschsprung's disease, diagnosis is required. Secondary preventive measures include the administration of [[laxatives]] and [[antibiotics]] to prevent [[obstruction]] and [[infection]], respectively.


==References==
==References==

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [3], Aditya Ganti M.B.B.S. [4]

Overview

Hirschsprung's disease involves an enlargement of the colon caused by a bowel obstruction resulting from an aganglionic section of bowel. The condition, in which the normal enteric nerves are absent, begins from the anus and progresses proximally. The length of affected bowel varies, rarely extending more than approximately one foot

Historical perspective

The disease is named after Harald Hirschsprung, the Danish physician who first described the disease in 1886 when describing two infants who had died with swollen bellies. The autopsies showed identical pictures with pronounced dilatation and hypertrophy of the colon as dominant features.

Classification

Hirschsprung's disease may be classified as rectosigmoid disease, long segment disease, or ultrashort segment disease based on the extent of colon involvement.

Pathophysiology

Hirschsprung’s disease is a congenital disorder of colon in which certain nerve cells, called ganglion cells, are absent. This may lead to chronic constipation.[1]

Causes

Hirschsprung's disease is caused by a failure of the myentric and submucosal nerve plexuses to complete craniocaudal migration into the distal colon.

Differentiating Hirschsprung's diseases from other diseases

Hirschsprung's disease must be differentiated from other diseases that cause meconium pass failure and abdominal distension in infants, such as meconium plug syndrome, small left colon syndrome, or congenital hypothyroidism.

Epidemiology and Demographics

The incidence of Hirschsprung's disease is 20 per 100,000 newborns. Hirschsprung's disease is three times more common in Asian Americans than the rest of the population. Males are more commonly affected than females.

Risk Factors

The most potent risk factor for the development of Hirschsprung's disease is a strong family history (i.e. involvement of multiple family members). Other risk factors include a family history of long segment disease and the proband being female.

Screening

According to the USPSTF, screening is not recommended for Hirschsprung's disease.

Natural History, Complications, and Prognosis

If left untreated, Hirschsprung's disease can lead to enterocolitis and even death. Common complications include enterocolitis, intestinal perforation, and short bowel syndrome. After appropriate surgical intervention, the odds of mortality drop significantly.

Diagnosis

History and Symptoms

Hirschsprung's disease is commonly diagnosed during the neonatal period. The cardinal symptoms of Hirschsprung's disease include abdominal distension, delayed passage of meconium (i.e., after 24-48 hours from birth), and vomiting. [2][3]

Physical Examination

Physical examination is nondiagnostic in newborns. It may reveal a distended abdomen and/or anal spasm. In older children, abdominal distension may result from the inability to release flatus.[3]

Laboratory Findings

There are no specific laboratory finding associated with Hirschsprung's disease. All the pre-operation blood tests and coagulation tests will be within the reference range.[3]

X-ray

Abdominal X-ray is the modality of choice in diagnosing Hirschsprung's disease. Major findings on abdominal X-rays in patients affected by Hirschsprung's disease are decreased bowel caliber of the involved segment and colon distension.

CT Scan

There are no specific CT scan findings associated with Hirschsprung's disease.

MRI

There are no specific MRI finding associated with Hirschsprung's disease.

Other Imaging Findings

A barium enema is the mainstay of Hirschsprung’s disease diagnosis.

Other Diagnostic Studies

A rectal biopsy showing the absence of ganglion cells is the only definitive method of diagnosis.

Treatment

Medical Therapy

Medical therapy only plays a supportive role in the management of Hirschsprung's disease. Medical therapy indications include preventing disease complications, preventing post-operative infections, and managing post-operative bowel function. Intravenous fluid resuscitation and maintenance, nasogastric decompression, and the administration of intravenous antibiotics (as indicated) remain the cornerstones of initial medical management.[4][5]

Surgery

The usual treatment is pull-through surgery, in which the portion of the colon that has nerve cells is pulled through and sewn over the portion that lacks nerve cells (National Digestive Diseases Information Clearinghouse).

Primary Prevention

There are no primary preventive measures for Hirschsprung's disease.

Secondary Prevention

To prevent complications of Hirschsprung's disease, diagnosis is required. Secondary preventive measures include the administration of laxatives and antibiotics to prevent obstruction and infection, respectively.

References

  1. Worman and Ganiats 1995, Am Fam Physician 51, 487-494 [1]
  2. Stanescu AL, Liszewski MC, Lee EY, Phillips GS (2017). "Neonatal Gastrointestinal Emergencies: Step-by-Step Approach". Radiol. Clin. North Am. 55 (4): 717–739. doi:10.1016/j.rcl.2017.02.010. PMID 28601177.
  3. 3.0 3.1 3.2 Das K, Mohanty S (2017). "Hirschsprung Disease - Current Diagnosis and Management". Indian J Pediatr. doi:10.1007/s12098-017-2371-8. PMID 28600660.
  4. Langer JC, Rollins MD, Levitt M, Gosain A, Torre L, Kapur RP, Cowles RA, Horton J, Rothstein DH, Goldstein AM (2017). "Guidelines for the management of postoperative obstructive symptoms in children with Hirschsprung disease". Pediatr. Surg. Int. 33 (5): 523–526. doi:10.1007/s00383-017-4066-7. PMID 28180937.
  5. Burkardt DD, Graham JM, Short SS, Frykman PK (2014). "Advances in Hirschsprung disease genetics and treatment strategies: an update for the primary care pediatrician". Clin Pediatr (Phila). 53 (1): 71–81. doi:10.1177/0009922813500846. PMID 24002048.

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