PEDIATRIC GASTROINTESTINAL DISEASES – A

CLINICO HISTOPATHOLOGICAL STUDY

 INTRODUCTION:

• Children are vulnerable to a vast number of diseases

including gastrointestinal disorders, which may be
associated with life threatening complications.

• There are few studies documented in literature

regarding the overview of lesions involving the
gastrointestinal tract in pediatric age group.
 Aims of the study

• To know the distribution of various gastrointestinal

lesions in pediatric age group with respect to age and
sex.

• To know the role of histopathology, special stains and

immunohistochemistry in diagnosing Hirshsprung’s
disease.
 STUDY DESIGN
• Type of study: Observational study.
• Duration of study: 2 years from July 2017 to June
2019.

• Inclusion criteria: Gastrointestinal Specimens

received for histopathological examination in the
department of pathology in the age group ≤ 18 years
will be included in the study.

• Exclusion criteria: Cases on therapy, recurrent lesions

and above 18 years will be excluded from study.
 Methodology

• Complete clinical data was recorded as per

protocol.

• The excised histopathology specimens were

thoroughly grossed and data recorded.

• In cases of Hirschsprung’s disease we received

both ganglionic and aganglionic segment for HPE

• Tissues routinely processed as per paraffin

embedded processing and stained with H&E.
 Methodology

In cases with clinical diagnosis of Hirshsprung’s

disease: All cases were subjected to special
stains
• 1% Cresyl violet stain to see ganglion cells.
• 1% Toluidine blue stain to see mast cells in
submucosa
 Methodology
The mast cells in the submucosa was graded as per
Hadeel A.Yasseen et al (Toulidine blue stain) in both
ganglionic and aganglionic segment

• 1+ some what easy to identify

• 2+ Easy to identify
• 3+ Very easy to identify
 Methodology
Statistical analysis:
• Mean,Percentage distribution was analysed using
Excel sheet.

• Accuracy of calretinin expression in diagnosing

Hirshsprung’s disease.

• Chi square test where ever applicable.

RESULTS
• Total number of cases analysed :443
• Non neoplastic lesions :433
• Neoplastic lesion : 10

Neoplastic lesion 10

Non neoplastic lesions 433

Total number of cases analysed 443

0 50 100 150 200 250 300 350 400 450 500

Distribution of lesions of GIT in
Pediatric age group-443
Number of cases -443
10
22
31 Inflammatory lesions

Disorders of motility

Developmental
abnormalities
Neoplastic lesions
380
 Distribution of GIT lesions in relevance with Age and Sex
distribution-443
GIT lesion (HPE) No of lesion <5Years >5Years Male Female
NON NEOPLASTIC LESIONS -443
INFLAMMATORY LESIONS -380
APPENDICITIS 372 12 360 253 119
Tuberculous ileitis 2 0 2 1 1
Lymphocytic 2 0 2 2 0
enterocolitis

Inflammatory 3 0 3 3 0
Bowel Disease

Gangrenous 1 0 1 1 0
intestine
DISORDERS OF INTESTINAL MOTILITY
Hirschsprung 31 24 7 24 7
disease
 Distribution of GIT lesions in relevance with Age and Sex
distribution
DEVELOPMENTAL ABNORMALITIES- 22
GIT lesion (HPE) No of lesion <5Years >5Years Male Female
Intestinal atresia 13 13 0 8 5
Beningn mesenteric 1 0 1 1 0
cyst
Chylolymphatic cyst 2 2 0 1 1

Enteric duplication 1 1 0 0 1
cyst
Hamartoma 1 0 1 1 0
Meckel's 3 2 1 2 1
diverticulum
Meconium 1 1 0 1 0
pseudocyst
Total 22 19 3 14 8
NEOPLASTIC LESIONS -10
CARCINOID in 1 0 1 1 0
appendix
JUVENILE POLYP 9 5 4 4 5
TOTAL 10 5 5 5 5
 Distribution of Types of Appendicitis
Number of cases-372
350
299
300
250
200
150
Number of cases
100
50 36 35
2
0
Acute Chronic Acute on Eosinophilic
suppurative appendicitis Chronic appendicitis
appendicitis appendicitis
Male :Female Ratio:2.1:1
 Clinical features in GIT lesions
Lesions No of Pain Abdominal Perforation Intestinal
lesions abdomen distension obstruction

Inflammatory 380 375 - 3 2

Lesions
Disorders of 31 - 5 - 26
intestinal
motility

Developmental 22 - - - 22
anomalies

Neoplastic 10 1 - - 9
lesions

Total 443 376(84.87%) 5 3 59(13.31%)

Age and Sex distribution of Hirschsprung’s disease(HD)
and Non Hirschsprung’ disease(Non HD) – 44 cases
Age and Sex HD(months) Non HD(months) P value
N=31 N=13
Age in months
Mean age 31.33(2.5y) 20.15(1.6y) 0.964
SD 30.88 19.96 >0.05 (not
significant)
Minimum 1 2
Maximum 90(7.5y) 72(6y)

Sex
Male 23 6 .0498
Female 7 8 <0.05 (significant)
 Samples subjected to special stain
(Cresyl violet stain& Toulidine blue stain)

• 31 cases with clinical diagnosis of

Hirschsprung’ disease
• 13 cases with clinical diagnosis of ileal atresia
to rule out Hirschsprung’ disease
 Results of special stain
(Cresyl violet stain& Toulidine blue stain)
• In 27 cases with clinical diagnosis of Hirschsprung’ disease: HPE and
Cresyl violet showed absence of ganglion cells

• In 4 cases with clinical diagnosis of Hirschsprung’ disease: HPE

showed suspicious ganglion cells and cresyl violet showed absence
of ganglion cells.

• In 13 cases with clinical diagnosis of Ileal atresia to rule out

Hirschsprung’ disease: HPE and and Cresyl violet stain showed
presence of ganglion cells confirming the diagnosis of Ileal atresia.

• Toulidine blue stain:In the present study there is increased

number of mast cells in the aganglionic segment when
compared to ganglionic segment in Hirschsprung’ disease
 Results of special stain
(Cresyl violet stain& Toulidine blue stain)
No of cases Clinical HPE Cresyl violet Final
diagnosis (Ganglion cells) stain diagnosis
(Ganglion cells)
27 HD Absent Absent HD
4 HD Suspicious of Absent HD
ganglion cells
13 ILEAL ATRESIA Present Present ILEAL
to rule out ATRESIA
Hirschsprung’
disease

Toulidine blue stain:In the present study there is increased

number of mast cells in the aganglionic segment when
compared to ganglionic segment in Hirschsprung’ disease
 Samples subjected to
(CALRETININ IHC )
• Due to cost effectiveness the following 17 samples were
subjected to Calretenin IHC

• 4 cases with clinical diagnosis of Hirschsprung’ disease,HPE

showing suspicious ganglion cells and cresyl violet showing
absence of ganglion cells.

• 13 cases with clinical diagnosis of Ileal atresia to rule out

Hirschsprung’ disease:HPE and Cresyl violet stain showing
presence of ganglion cells
 Results of CALRETININ Expression
• 4 cases with clinical diagnosis of Hirschsprung’ disease,HPE
showing suspicious ganglion cells and cresyl violet showing
absence of ganglion cells: CALRETININ NEGATIVE FOR
GANGLION CELLS confirming the diagnosis of HD

• 13 cases with clinical diagnosis of Ileal atresia to rule out

Hirschsprung’ disease,HPE and Cresyl violet stain showing
presence of ganglion cells:CALRETININ POSITIVE FOR
GANGLION CELLS ruling out HD

• Accuracy of Calretinin expression in diagnosing HD is 100%

 Results of CALRETININ Expression

No of Clinical HPE Cresyl violet CALRETININ Final

cases diagnosis (Ganglion stain Ganglion diagnosis
cells) (Ganglion cells
cells)
4 HD Suspicious of Absent Absent HD
ganglion cells
13 ILEAL ATRESIA Present Present Present ILEAL
to rule out ATRESIA
Hirschsprung’
disease

Accuracy of Calretinin expression in diagnosing HD is

100%
Photographs
Ganglion cells in Muscularis propria(H&E,400X)

Ganglion cell
 Ganglion cells in Muscularis propria (H&E,400X)

Ganglion cell
Control (Brain)1% Cresyl violet stain for Ganglion cells(CV,400X)

Ganglion cell
1% Cresyl violet stain Positive for Ganglion cells in muscularis
propria (CV,400X)

Ganglion cells
1% Toulidine blue stain for mast cells in submucosa
(Perivascular)(TB,400X)

Mast cells
Calretinin,positive ganglion cells in
submucosa(IHC,400X)
Calretinin,positive ganglion cells in Muscularis Propria
(IHC,400X)
Hirschsprung disease:Hypertrophic nerve fibres with absence of
ganglion cells(H&E,400X)
Hirschsprung disease:Calretinin stain :Absence of ganglion cells in all layers of
intestine (IHC,100X)
 Discussion
Abudu Emmanuel Kunle et al Present study

Appendiceal lesions common (39.2%) Appendiceal lesions common (83%)

Hirschsprung’s disease, enterocolitis and Hirschsprung’s disease, enterocolitis and

jejunal atresia accounted for 29.7%, 6.8% jejunal atresia accounted for 6.99%, 1.8%
and 4.1% of cases respectively. and 2.9% of cases respectively
Mean age of 8.6years Mean age of 10.6years

M:F ratio= 1.6:1.0 M:F ratio= 2.2:1.0

Acute suppurative appendicitis was the Acute suppurative appendicitis was the
most prevalent lesion of the most prevalent lesion of the
appendix(44.82%) appendix(79.56%)
 Discussion
Studies Present study

Zaidoon A.Musa et al: The mean age for HD The mean age for HD cases was 31.33
cases was 19.43 months,statistically not months,statistically not significant. Male-to-
significant. Male-to-female ratio in HD cases female ratio in HD cases was 2.1:1
was 2.34:1

Nasser Rakhshani et al, Specificity of Specificity of calretinin in diagnosing HD

calretinin in diagnosing HD was 96.2% was 80%
Torabizadeh et al Specificity of calretinin in
diagnosing HD was 84.2%

Hadeel A. Yasseen, Kobayashi et al, Increased number of mast cells in the

Demirbilek et al and Amit et al described an aganglionic segment of the colon
increased number of mast cells in the
aganglionic segment of the colon
 Conclusion
• Acute suppurative appendicitis was the
predominant pediatric gastrointestinal disease.
• Cresyl violet stain should to be used as the
routine stain to highlight the ganglion cells in
suspected Hirschsprung’s disease cases.
• Calretinin IHC is a very reliable adjunctive test in
identification of ganglion cells and differentiating
between pure Ileal atresia from HD, reducing the
requirement for repetitive biopsies and
unnecessary sectioning .
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 References
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