Diagnostic Role of Calretinin in Suspicious Cases of Hirschsprung's Disease

Abstract

Background Hirschsprung's disease (HD) is a developmental disorder of the intrinsic component of the enteric nervous system. It is characterized by the absence of ganglion cells in the myenteric and submucosal plexus. Histopathological diagnosis becomes difficult many times due to submucosal ganglionic cells are not easily identifiable. Aims and objective The aim of this study was to examine the clinical and histopathological features of HD and to establish the utility of calretinin staining to diagnose the case of suspicious HD. Materials and methods After taking necessary informed consent, we studied 41 cases in which clinical suspicion of HD had been made, in a study duration of three years (July 2017-June 2020). Open biopsies were taken from spastic segment, transition zone and dilated segment. Histopathological diagnosis had been made in three categories: HD, no Hirschsprung's disease (NHD) and suspicion of HD. Post histopathological diagnosis calretinin immunohistochemistry (IHC) was applied to all cases and interpretations were noted. Results On the basis of histopathological findings, 25 cases were diagnosed as HD, nine cases were marked for suspicion for HD and seven cases as NHD. After evaluating calretinin IHC on the suspicious case, total of 30 cases were confirmed as HD while the remaining 11 cases were confirmed as NHD. Twenty-four patients of HD were males while the remaining six cases were females. The age of patients ranged from four days to 10 years. Median age six days while 22 patients were in the neonatal period. Conclusion Calretinin immunostaining is a useful modality in diagnosing suspicious cases of HD. Its results are easy to interpret by less experienced pathologist with accuracy.

Keywords: abdominal distension; aganglionosis; congenital aganglionic megacolon; constipation; failure to thrive; functional intestinal obstruction; ganglion cells; immunohistochemistry.

Figure 1. Image showing radiological and surgical features of HD.

(A) Plain X-ray: paucity of air in the pelvic cavity (white arrow); (B) Contrast enema: sigmoid colon (star shape) is more dilated than rectum (reversal of rectosigmoid index) and 24-hour delayed film holding of dye in bowel (hexagonal shape); (C) intra-operative dilated sigmoid colon; (D) intra-operative retro rectal (white arrow retro rectal space) pull through (black arrow pull through bowel). HD: Hirschsprung’s disease.

Figure 2. Microphotograph of histopathological examination and Immunohistochemistry finding of HD.

(A) Micrograph 400X, H&E stain, ganglion cells (shown by black arrow) seen in NHD cases; (B) micrograph 100X, calretinin stain, ganglion cells (shown by white arrow) seen in NHD cases; (C) micrograph 400X, calretinin stain, ganglion cells (shown by white arrow) seen in suspected HD cases; (D) micrograph 100X, calretinin stain ganglion cells not seen in suspected HD cases. HD: Hirschsprung’s disease; NHD: non-Hirschsprung’s disease; H&E: hematoxylin and eosin.