Skip to main content

Risk factors of preoperative Hirschsprung-associated enterocolitis

Abstract

Background

Hirschsprung-associated enterocolitis (HAEC) is a life-threatening complication of Hirschsprung disease (HSCR), that might occur preoperatively. We investigated the risk factors of preoperative HAEC.

Method

We retrospectively reviewed all medical records of HSCR patients admitted at Dr. Sardjito Hospital, Indonesia from March 2012 until March 2015. Diagnosis of HAEC was determined using the Delphi scoring system.

Results

Sixty-one HSCR patients were involved in this study, of whom 48 were males and 13 females. Eighteen percent (11/61) patients had a preoperative HAEC. The most common findings of the HAEC score found in our patients were distended abdomen (100%) and dilated loops of bowel (100%), followed by lethargy (72.7%), cut-off sign in rectosigmoid with absence of distal air (72.7%), leukocytosis (72.7%), and shift to left (63.6%). There was no association between gender, age of HSCR diagnosis, early/late diagnosis during neonatal period, aganglionosis type, albumin level nor body mass index with preoperative HAEC (pā€‰=ā€‰0.69, 0.76, 0.33, 1.0, 0.86, and 0.50, respectively). In addition, the maternal age, gestational age, and maternal education level also did not correlate with the development of preoperative HAEC (pā€‰=ā€‰0.71, 0.59, and 0.32, respectively).

Conclusion

The incidence of preoperative HAEC in our hospital is considered relatively moderate, with the most common findings of distended abdomen and dilated loops of bowel. None of the identified risk factors have an association with the development of HAEC in our patients.

Background

Hirschsprung disease (HSCR) is a complex genetic disorder characterized by an absence of ganglion cells in the intestines, resulting in a functional obstruction of the bowels [1]. Its incidence varies among populations ranging from 1:5000 to 1:3250 live-births in European and Indonesian, respectively [1, 2].

Hirschsprung-associated enterocolitis (HAEC) is a life-threatening complication of HSCR [3]. It might occur preoperatively or following pull-through procedure [3,4,5,6]. We have shown that the frequency of HAEC following Soave and Duhamel procedures are 10 and 28%, respectively [4], while HAEC occurs preoperatively in 6ā€“60% HSCR patients [3].

There are several risk factors known for preoperative HAEC, however, are still show conflicting findings [3, 5,6,7,8]. Therefore, we investigated the risk factors of preoperative HAEC in Indonesia.

Material and methods

Subjects

The inclusion criteria of our study were HSCR patients of <ā€‰18ā€‰years of age who were admitted to Dr. Sardjito Hospital, Indonesia, from March 2012 until March 2015 and underwent a histopathological examination [4, 9], while the exclusion criteria were incomplete medical record. All HSCR patients received a rectal washout while waiting for the surgery.

The Ethical Committee of Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital gave prior approval for this study (KE/FK/713/EC/2015). A written informed consent has been given by the parentsā€™ patients before joining the study.

HAEC

HAEC was determined using the Delphi scoring system, consisting of 16 criteria including clinical history, physical examination, radiologic and laboratory findings. HAEC is determined when the score is ā‰„10 [4, 10].

Statistical analysis

Data are presented as number and percentages for categorical variables. The chi-square or Fisher exact test was used to evaluate the differences of prognostic factors and maternal factors of the preoperative HAEC between groups. IBM SPSS Statistics version 21 (Chicago, USA) was used for statistical analysis.

Results

Baseline characteristics

Sixty-one HSCR patients were included in final analysis, involving 48 males and 13 females. Most HSCR patients were diagnosed during the neonate period (54%) and showed short-segment aganglionosis (88.5%) (TableĀ 1).

TableĀ 1 Clinical characteristics of HSCR patients admitted to Dr. Sardjito Hospital, Indonesia

Preoperative HAEC

Eighteen percent (11/61) of the patients had a preoperative HAEC. The most common findings of the HAEC score found in our patients were distended abdomen (100%) and dilated loops of bowel (100%), followed by lethargy (72.7%), cut-off sign in rectosigmoid with absence of distal air (72.7%), leukocytosis (72.7%), and shift to left (63.6%) (Table 2).

Table 2 HAEC scoring system findings in HSCR patients admitted to Dr. Sardjito Hospital, Indonesia

Association of prognostic factors and preoperative HAEC

There was no association between gender, age of HSCR diagnosis, early/late diagnosis during neonatal period, aganglionosis type, albumin level and body mass index with preoperative HAEC (pā€‰=ā€‰0.69, 0.76, 0.33, 1.0, 0.86, and 0.50, respectively) (TableĀ 3).

Table 3 Association of prognostic factors and preoperative HAEC in Dr. Sardjito Hospital, Indonesia

Association of maternal risk factors and preoperative HAEC

In addition, the maternal age, gestational age, and maternal education level also did not correlate with the development of preoperative HAEC (pā€‰=ā€‰0.71, 0.59, and 0.32, respectively) (TableĀ 4).

Table 4 Association of maternal risk factors and preoperative HAEC in Dr. Sardjito Hospital, Indonesia

Discussion

Here, we show that the incidence of preoperative HAEC in our institution was relatively moderate (18%). It is similar with previous studies [11,12,13]. This might be related to the fact that most of our patients were diagnosed during the neonatal period (~ā€‰60%). Previous study revealed that the incidence of HAEC is lower in patients who were diagnosed with HSCR within the first week of life (11%) compared with those infants who were diagnosed with HSCR after the first of week of life (24%) [14]. Another study also presented a similar pattern (early diagnosis: 12% vs. late diagnosis: 63%) [15]. Interestingly, the incidence of preoperative HAEC and its mortality was gradually decreased in Japan from previous decade to current one of HSCR patients group (1978ā€“1982 vs. 1988ā€“1992 vs. 1998ā€“2002: 29.2%/6.5% vs. 29.1%/4.9% vs. 17.3%/0.7%, respectively). These findings might be due to an earlier diagnosis for the current HSCR patients in Japan [16]. However, our study did not show any difference in HAEC incidence between patients with late diagnosis (2/21, 9.5%) and early diagnosis of HSCR (3/12, 25%) (pā€‰=ā€‰0.33) (TableĀ 3). Our findings are compatible with previous report [17]. Interestingly, the incidence of HAEC was found declining after the neonatal period [5, 12], as a result of the improvement of mucosal defenses or HSCR variants [12].

Diagnosis of HSCR is established according to clinical features, contrast enema, manometry, and histopathology as gold standard [1, 9]. For histopathological staining, hematoxylin and eosin and S100 are the most common staining used in many institutions to assess the presence of ganglion cell and hypertrophic of nerve trunks [9]. Molecular genetic has becoming popular to diagnose an HSCR at molecular level [1]. Most HSCR patients show a variant in RET gene [1]. Early definitive diagnosis of HSCR is very important as a key element in further accurate treatment to avoid complications, such as HAEC [18].

Trisomy 21 has been known as a risk factor for HAEC in infants with HSCR [7, 12, 19, 20]. Since the maternal age of ā‰„35-year-old has a higher risk for having an infant with trisomy 21 [21], we expected older maternal age had more infants with HAEC, however, our findings may support the hypothesis trisomy 21 is not a risk factor for HAEC [5]. Since we retrospectively extracted data from medical records, unfortunately, we do not have a complete data on HAEC infants with trisomy 21.

Only one (1.6%) long-segment patient developed HAEC in our study. We did not find any association between aganglionosis length and HAEC. Previous studies presented that the incidence of HAEC is higher in HSCR long-segment than short-segment patients [22, 23]. This discrepancy might be due to a small sample size in our report. Female gender might increase the risk for HAEC [7], however, the evidence is still lacking [22]. Our study results support the assumption that gender does not affect the incidence of HAEC [22] (TableĀ 3).

There are several intervention methods to prevent HAEC, such as routine washout and probiotics. Our moderate incidence of preoperative HAEC (18%) might relate to our administering routine washout to HSCR patients. Washout procedure decreases fecal stasis and bacterial load, resulting in preventing colonic distension [12]. Regarding probiotics to prevent HAEC, it is not our routine procedure yet, therefore, it is necessary to perform a clinical trial to clarify the role of probiotics in HAEC. How the probiotics can prevent the development HAEC, however, is still controversy [12].

Most HAEC patients showed distended abdomen (100%) and lethargy (72.7%). These clinical findings are considered as ā€œclassicā€ diagnostic criteria [22]. There are several attempts to standardize the diagnostic criteria of HAEC [6, 10]. The current one is developed not only to easily diagnose a HAEC, but also to allow a consistent approach to the HAEC management [3].

Given the fact that hypoalbuminemia has been detected in HAEC Ednrbāˆ’/āˆ’ rats [24] and might affect the mortality of HSCR mouse model [25], we hypothesized hypoalbuminemia as one of the risk factors for HAEC. We failed to prove those hypotheses (TableĀ 3).

Since premature infants have a higher risk for having necrotizing enterocolitis [26], we considered premature birth as a risk factor for HAEC. Unfortunately, we did not find any difference in HAEC incidence between premature and aterm/postterm infants. We also speculated that higher educated mothers will show more awareness of early diagnosis of HSCR, thus, preventing HAEC for their infants. However, this hypothesis was not proved.

Conclusion

The incidence of preoperative HAEC in our hospital is considered relatively moderate, with the most common findings of distended abdomen and dilated loops of the bowel. None of the identified risk factors have an association with the development of HAEC in our patients. It might be due to the small sample size, becoming limitation of our study.

Availability of data and materials

All data generated or analyzed during this study are included in the submission. The raw data are available from the corresponding author on reasonable request.

Abbreviations

HAEC:

Hirschsprung-associated enterocolitis

HSCR:

Hirschsprung disease

References

  1. Amiel J, Sproat-Emison E, Garcia-Barcelo M, Lantieri F, Burzynski G, Borrego S, et al. Hirschsprung disease, associated syndromes and genetics: a review. J Med Genet. 2008;45:1ā€“14.

    ArticleĀ  CASĀ  Google ScholarĀ 

  2. Gunadi, Karina SM, Dwihantoro A. Outcomes in patients with Hirschsprung disease following definitive surgery. BMC Res Notes. 2018;11:644.

    ArticleĀ  CASĀ  Google ScholarĀ 

  3. Gosain A, Frykman PK, Cowles RA, Horton J, Levitt M, Rothstein DH, et al. Guidelines for the diagnosis and management of Hirschsprung-associated enterocolitis. Pediatr Surg Int. 2017;33:517ā€“21.

    ArticleĀ  Google ScholarĀ 

  4. Parahita IG, Makhmudi A, Gunadi. Comparison of Hirschsprung-associated enterocolitis following Soave and Duhamel procedures. J Pediatr Surg. 2018;53:1351ā€“4.

    ArticleĀ  Google ScholarĀ 

  5. Haricharan RN, Seo JM, Kelly DR, Mroczek-Musulman EC, Aprahamian CJ, Morgan TL, et al. Older age at diagnosis of Hirschsprung disease decreases risk of postoperative enterocolitis, but resection of additional ganglionated bowel does not. J Pediatr Surg. 2008;43:1115ā€“23.

    ArticleĀ  Google ScholarĀ 

  6. El-Sawaf M, Siddiqui S, Mahmoud M, Drongowski R, Teitelbaum DH. Probiotic prophylaxis after pullthrough for Hirschsprung disease to reduce incidence of enterocolitis: a prospective, randomized, double-blind, placebo-controlled, multicenter trial. J Pediatr Surg. 2013;48:111ā€“7.

    ArticleĀ  Google ScholarĀ 

  7. Teitelbaum DH, Qualman SJ, Caniano DA. Hirschsprungā€™s disease. Identification of risk factors for enterocolitis. Ann Surg. 1988;207:240ā€“4.

    ArticleĀ  CASĀ  Google ScholarĀ 

  8. Le-Nguyen A, Righini-Grunder F, PichĆ© N, Faure C, Aspirot A. Factors influencing the incidence of Hirschsprung associated enterocolitis (HAEC). J Pediatr Surg. 2019;54:959ā€“63.

    ArticleĀ  Google ScholarĀ 

  9. Setiadi JA, Dwihantoro A, Iskandar K, Heriyanto DS, Gunadi. The utility of the hematoxylin and eosin staining in patients with suspected Hirschsprung disease. BMC Surg. 2017;17:71.

    ArticleĀ  Google ScholarĀ 

  10. Pastor AC, Osman F, Teitelbaum DH, Caty MG, Langer JC. Development of a standardized definition for Hirschsprungā€™s-associated enterocolitis: a Delphi analysis. J Pediatr Surg. 2009;44:251ā€“6.

    ArticleĀ  Google ScholarĀ 

  11. Vieten D, Spicer R. Enterocolitis complicating Hirschsprungā€™s disease. Semin Pediatr Surg. 2004;13:263ā€“72.

    ArticleĀ  Google ScholarĀ 

  12. Frykman PK, Short SS. Hirschsprung-associated enterocolitis: prevention and therapy. Semin Pediatr Surg. 2012;21:328ā€“35.

    ArticleĀ  Google ScholarĀ 

  13. Austin KM. The pathogenesis of Hirschsprungā€™s disease-associated enterocolitis. Semin Pediatr Surg. 2012;21:319ā€“27.

    ArticleĀ  Google ScholarĀ 

  14. Surana R, Quinn FMJ, Puri P. Evaluation of risk factors in the development of enterocolitis complicating Hirschsprungā€™s disease. Pediatr Surg Int. 1994;9:234ā€“6.

    ArticleĀ  Google ScholarĀ 

  15. Lee CC, Lien R, Chiang MC, Chian MC, Yang PH, Chu SM, et al. Clinical impacts of delayed diagnosis of Hirschsprungā€™s disease in newborn infants. Pediatr Neonatol. 2012;53:133ā€“7.

    ArticleĀ  Google ScholarĀ 

  16. Suita S, Taguchi T, Ieiri S, Nakatsuji T. Hirschsprungā€™s disease in Japan: analysis of 3852 patients based on a nationwide survey in 30 years. J Pediatr Surg. 2005;40:197ā€“201.

    ArticleĀ  Google ScholarĀ 

  17. Hackam DJ, Filler RM, Pearl RH. Enterocolitis after the surgical treatment of Hirschsprungā€™s disease: risk factors and financial impact. J Pediatr Surg. 1998;33:830ā€“3.

    ArticleĀ  CASĀ  Google ScholarĀ 

  18. Martucciello G. Hirschsprungā€™s disease, one of the most difficult diagnoses in pediatric surgery: a review of the problems from clinical practice to the bench. Eur J Pediatr Surg. 2008;18:140ā€“9.

    ArticleĀ  CASĀ  Google ScholarĀ 

  19. Morabito A, Lall A, Gull S, Mohee A, Bianchi A. The impact of Downā€™s syndrome on the immediate and long-term outcomes of children with Hirschsprungā€™s disease. Pediatr Surg Int. 2006;22:179ā€“81.

    ArticleĀ  Google ScholarĀ 

  20. Menezes M, Puri P. Long-term clinical outcome in patients with Hirschsprungā€™s disease and associated Downā€™s syndrome. J Pediatr Surg. 2005;40:810ā€“2.

    ArticleĀ  Google ScholarĀ 

  21. Newberger DS. Down syndrome: prenatal risk assessment and diagnosis. Am Fam Physician. 2000;62(825ā€“832):837ā€“8.

    Google ScholarĀ 

  22. Elhalaby EA, Teitelbaum DH, Coran AG, Heidelberger KP. Enterocolitis associated with Hirschsprungā€™s disease: a clinical histopathological correlative study. J Pediatr Surg. 1995;30:1023ā€“7.

    ArticleĀ  CASĀ  Google ScholarĀ 

  23. Lacher M, Fitze G, Helmbrecht J, Schroepf S, Berger M, Lohse P, et al. Hirschsprung-associated enterocolitis develops independently of NOD2 variants. J Pediatr Surg. 2010;45:1826ā€“31.

    ArticleĀ  Google ScholarĀ 

  24. Dembowski C, Hofmann P, Koch T, Kamrowski-Kruck H, Riedesel H, Krammer HJ, et al. Phenotype, intestinal morphology, and survival of homozygous and heterozygous endothelin B receptor--deficient (spotting lethal) rats. J Pediatr Surg. 2000;35:480ā€“8.

    ArticleĀ  CASĀ  Google ScholarĀ 

  25. Jiao CL, Chen XY, Feng JX. Novel insights into the pathogenesis of Hirschsprungā€™s-associated enterocolitis. Chin Med J. 2016;129:1491.

    ArticleĀ  Google ScholarĀ 

  26. Salzman NH, Underwood MA, Bevins CL. Paneth cells, defensins, and the commensal microbiota: a hypothesis on intimate interplay at the intestinal mucosa. Semin Immunol. 2007;19:70ā€“83.

    ArticleĀ  CASĀ  Google ScholarĀ 

Download references

Acknowledgments

We are thankful to all those who offered excellent technical help during the study. Some results for the manuscript are from Dicky Yuliandaā€™s and Andy Indra Saitiā€™s theses.

About this supplement

This article has been published as part of BMC Proceedings Volume 13 Supplement 11, 2019: Selected articles from the 3rd International Symposium on Congenital Anomaly and Developmental Biology 2019 (ISCADB 2019). The full contents of the supplement are available online at https://bmcproc.biomedcentral.com/articles/supplements/volume-13-supplement-11 .

Funding

This study was supported by the grant from the Indonesia Ministry Research, Technology and Higher Education (#2545/UN1.DITLIT/DIT-LIT/LT/2019). Publication costs are funded by the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada.

Author information

Authors and Affiliations

Authors

Contributions

DY, AIS and G conceived the study. DY drafted the manuscript and G critically revised the manuscript for important intellectual content. DY, AIS, AM and G facilitated all project-related tasks. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gunadi.

Ethics declarations

Ethics approval and consent to participate

The Institutional Review Board of Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital approved this study (KE/FK/713/EC/2015). A written informed consent has been given by the parentsā€™ patients before joining the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisherā€™s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yulianda, D., Sati, A.I., Makhmudi, A. et al. Risk factors of preoperative Hirschsprung-associated enterocolitis. BMC Proc 13 (Suppl 11), 18 (2019). https://doi.org/10.1186/s12919-019-0172-y

Download citation

  • Published:

  • DOI: https://doi.org/10.1186/s12919-019-0172-y

Keywords