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Erythrocyte acetylcholinesterase activity in Hirschsprung's disease in Israel
Erythrocyte Acetylcholinesterase Activity in Hirschsprung’s Disease in Israel By0.
Atias, R. Finaly, N. Meyerstein,
and A.J. Mares
Beer Sheva, Israel l Hirschsprung’s disease is a relatively prevalent disorder in newborn babies and young children. Acetylcholinesterase (AChE) activity is augmented locally, in the neural plexus of the affected gut segment. It has been suggested that this enzyme will also be increased in red blood cells (RBCs) of affected children. Thus, we studied AChE activity in newborn babies and children, as well as age-adjusted data. This Israeli study consisted of healthy and affected Bedouins as well as Ashkenari and Sephardic Jews. This study supports the Japanese study in that the RBC AChE is not augmented in Hirschsprung’s disease. However, final conclusions cannot yet be drawn, because of the small sample. Copyright o 1997 by W.B. Saunders Company INDEX WORDS: Erythrocyte Hirschsprung’s disease.
acetylcholinesterase
activity;
H
IRSCHSPRUNG’S disease (HD) is a congenital anomaly, characterized by partial to complete colonic obstruction associated with absence of intramural ganglionic cells in the distal alimentary tract.’ The disease incidence is approximately one in 5,000 live births, and primarily affects males (80%).2 The pathogenesis is an abnormal interference with the craniocaudal migration of the neuroblasts. It has been noticed that local acethylcholinesterase (AChE) is increased in the neural plexus of the affected gut segment. 3.4This enzyme has also been found to be significantly increased in red blood cells (RBCs) of 12 children who had HD in South Africa.’ Therefore, we have further studied the possibility that RBC AChE could serve as an easy diagnostic procedure for HD and compared the results with age-adjusted data, because AChE activity changes with age.‘.’ MATERIALS
AND METHODS
Subjects All patients with HD during a 2-year period were examined. Ninety healthy newborn babies, children, and adults were examined; the newborn babies were mature healthy newborns in the Neonatal Department of the Hospital. The blood samples were
From the Dr Joseph Kaufmann HematotogV Laboratory, Physiology Unit, and the Department of Pediatric Surgery, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. Date accepted: December 13, 1989. Address reprint requests to A.J. Mares, MD, Head, Department of Pediatric Surgery, Soroka Medical Center, Box 151, Ben Gurion University Beer Shwa, Israel 84101. Copyright b 1991 by K B. Saunders Company 0022-3468/91/2602-0018$03.0010 190
taken in heparinized capillaries during routine hematological examination. The older children were hospitalized for elective minor surgery, such as correction of inguinal hernias, undescended testes, etc.
Method The blood samples were taken from the children as 1-mL samples, during routine presurgical examinations. The healthy adults were hospital personnel. The determination of AChE activity in the red cells was performed according to Ellman’s method, on whole RBCs suspended as 6% hematocrit in isotonic saline.” RESULTS
The control population of healthy children and adults included 89 controls (23% females and 77% males) to resemble the prevalent males among the patients. Origin, according to father’s country: 27% Jews born in Israel, 21% Jews born in Near East countries (Sephardic Jews), 11% Jews born in Western countries (Ashkenazi Jews), and 14% Bedouins from local Negev tribes. The results of AChE according to age are given in Fig 1. The known low AChE activity in newborn RBCs is noted to be 49.55 + 1.25 U/mL cells (average + standard error). AChE activity increased significantly with age, reaching normal adult values, 67.28 +- 8.39, at 5 months of age. HD Patients Eleven children with HD were examined. Ten were male and one was female. Their origin was as follows: six Bedouins (55%) three Sepharadic Jews (27%), and two Ashkenazi Jews. Four of the patients (all Bedouins) have relatives with diagnosed HD (usually first cousins). In two patients, other minor associated congenital defects were detected. The final diagnosis of HD was confirmed in all the patients by rectal biopsy. All the blood samples were examined before resection of the aganglionic segment and abdominoperineal pullthrough; in three patients AChE levels also were examined following the operative procedure. All the children had normal hematological values (including reticulocyte counts). The results of AChE activity of the patients, compared with age-adjusted controls, are presented in Fig 1 and Table 1. The newborn babies with HD have low activity of AChE, similar to that of the age-adjusted controls. Statistical evaluation (t test) did not show any difference between the patients and JournalofPediatric Surgery, Vol 26, No 2 (February), 1991: pp 190-191
ACETYLCHOLINESTERASE
IN HIRSCHSPRUNG’S
191
DkC4SE
their age-adjusted controls. The same pattern of initial low AChE values and gradual increase to adult values, attained at 5 months of age, was observed. The presence of the affected segment or its absence following resection did not influence the AChE levels. When the HD children with known affected relatives were separated from the rest of the group, it was found that in both groups the existence of affected relatives did not influence the AChE values.
Table 1. AChE Activity in Erythrocytes of HD Patients and Normal Population
Healthy newborns Newborns with HD Healthy children and adults HD children (l-2 yr)
NO.
AChE (U/mLcells)
5
49.55 2 1.25
4
41.40 k 9.6
81
67.26 t 8.39
7
67.82 2 5.05
r Test’
P > .I P > .l
NOTE. Values are expressed as means t SD. *The difference from normal controls.
DISCUSSION
The determination of RBC AChE has been suggested as a diagnostic aid for HD.5 If successful, it may provide a relatively simple way of supporting the diagnosis by means of a routine blood test. This may be particularly relevant in newborn babies, in whom diagnosis is sometime difficult. In 17 Japanese children, no change in RBC AChE was found, but the plasma pseudocholinesterase was found to be increased.’ A more recent Chinese study has again demonstrated increased RBC AChE in 31 HD patients, including newborns.” These authors have found good correlation between the increase in RBC AChE and the length of the aganglionic segment.” The Chinese group studied 31 patients, between 3 months and 12 years of age, and six newborn babies, and compared them with the appropriate age-groups. They did not find any difference between patients and controls in plasma pseudocholinesterase. Surgery did not affect these values. They did find significantly higher AChE levels in the patients’ RBCs, and suggest that this augmented AChE could simulate the augmented AChE activity in the mucosa. The present study relates to geneti-
0 : : 012345
;
MONTHS Fig 1.
:
; :;
;
:
I
234
: YEARS
;
: ;;
;
5 ADULTS
Erythrocyte AChE in healthy (0) and HD (0) patients.
tally different populations than those studied in South Africa, China, and Japan. We examined several known different genetic populations among the Jewish population (Ashkenazi v Sephardic Jews), as well as the local Bedouin population. The Jewish group was similar in its subdivision in the control group and in the patients. However, in this study the Bedouin patients constituted 55% of the total group, compared with only 14% of the general population. This correlates well with an increased incidence of HD in the Bedouin population. None of the groups affected showed any increase in RBC AChE. The length of the involved segment had no effect on the RBC AChE activity either. In summary, the present study, as well as the Japanese study, speak against the use of RBC AChE for diagnosis of HD. However, this small sample should be continued and enlarged before final conclusions may be drawn. REFERENCES 1. Sieber
WK: Problems
Hirschprung’s disease, in Ravitch MM (ed): in Surgery. Chicago, IL, Year Book, 1978, pp
Current 1-93 2. Passarge E: Genetics of Hirschprung’s disease. Clin Gasteroenterol2:507-511. 1973 3. Meier-Ruge W, Lutterbeck PM, Herzog B, et al: Acetylcholine esterase activity in suction biopsies of the rectum in the diagnosis of Hirschprung’s disease. J Pediatr Surg 7:11-17, 1972 4. Boston VE, Dale G, Riley KWA: Diagnosis of Hirschsprung’s disease by quantitative biochemical assay of AChE in rectal tissue. Lancet 2:951-953, 1975 5. Boston VE, Cywes S, Davis Q: Serum and erythrocyte AChE activity in Hirschprung’s disease. J Pediatr Surg 13:407-410, 1978 6. Burman D: Red cell cholinesterase in infancy and childhood. Arch Dis Child 36:362-365, 1961 7. Herz F, Kaplan E: A review: Human erythrocyte acltylcholinesterase. Pediatr Res 7:204-214, 1973 8. Ellman GL, Courtney KD, Andres V, et al: A new and rapid calorimetric determination of AChE activity. Biochem Pharmacol 7:88-95,196l 9. Okasora T, Okamoto E. Kuwata K. et al: Serum and erythrocyte AChE in Hirschprung’s disease. Z Kinderchir 38:298-300. 1983 10. Ya-Xiong S, Cheng-Ren S, Jia-Zhou C, et al: Observations on erythrocyte AChE activity of infants and children in Hirschprung’s disease. J Pediatr Surg 19:281-284, 1984
Atias, R. Finaly, N. Meyerstein,
and A.J. Mares
Beer Sheva, Israel l Hirschsprung’s disease is a relatively prevalent disorder in newborn babies and young children. Acetylcholinesterase (AChE) activity is augmented locally, in the neural plexus of the affected gut segment. It has been suggested that this enzyme will also be increased in red blood cells (RBCs) of affected children. Thus, we studied AChE activity in newborn babies and children, as well as age-adjusted data. This Israeli study consisted of healthy and affected Bedouins as well as Ashkenari and Sephardic Jews. This study supports the Japanese study in that the RBC AChE is not augmented in Hirschsprung’s disease. However, final conclusions cannot yet be drawn, because of the small sample. Copyright o 1997 by W.B. Saunders Company INDEX WORDS: Erythrocyte Hirschsprung’s disease.
acetylcholinesterase
activity;
H
IRSCHSPRUNG’S disease (HD) is a congenital anomaly, characterized by partial to complete colonic obstruction associated with absence of intramural ganglionic cells in the distal alimentary tract.’ The disease incidence is approximately one in 5,000 live births, and primarily affects males (80%).2 The pathogenesis is an abnormal interference with the craniocaudal migration of the neuroblasts. It has been noticed that local acethylcholinesterase (AChE) is increased in the neural plexus of the affected gut segment. 3.4This enzyme has also been found to be significantly increased in red blood cells (RBCs) of 12 children who had HD in South Africa.’ Therefore, we have further studied the possibility that RBC AChE could serve as an easy diagnostic procedure for HD and compared the results with age-adjusted data, because AChE activity changes with age.‘.’ MATERIALS
AND METHODS
Subjects All patients with HD during a 2-year period were examined. Ninety healthy newborn babies, children, and adults were examined; the newborn babies were mature healthy newborns in the Neonatal Department of the Hospital. The blood samples were
From the Dr Joseph Kaufmann HematotogV Laboratory, Physiology Unit, and the Department of Pediatric Surgery, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. Date accepted: December 13, 1989. Address reprint requests to A.J. Mares, MD, Head, Department of Pediatric Surgery, Soroka Medical Center, Box 151, Ben Gurion University Beer Shwa, Israel 84101. Copyright b 1991 by K B. Saunders Company 0022-3468/91/2602-0018$03.0010 190
taken in heparinized capillaries during routine hematological examination. The older children were hospitalized for elective minor surgery, such as correction of inguinal hernias, undescended testes, etc.
Method The blood samples were taken from the children as 1-mL samples, during routine presurgical examinations. The healthy adults were hospital personnel. The determination of AChE activity in the red cells was performed according to Ellman’s method, on whole RBCs suspended as 6% hematocrit in isotonic saline.” RESULTS
The control population of healthy children and adults included 89 controls (23% females and 77% males) to resemble the prevalent males among the patients. Origin, according to father’s country: 27% Jews born in Israel, 21% Jews born in Near East countries (Sephardic Jews), 11% Jews born in Western countries (Ashkenazi Jews), and 14% Bedouins from local Negev tribes. The results of AChE according to age are given in Fig 1. The known low AChE activity in newborn RBCs is noted to be 49.55 + 1.25 U/mL cells (average + standard error). AChE activity increased significantly with age, reaching normal adult values, 67.28 +- 8.39, at 5 months of age. HD Patients Eleven children with HD were examined. Ten were male and one was female. Their origin was as follows: six Bedouins (55%) three Sepharadic Jews (27%), and two Ashkenazi Jews. Four of the patients (all Bedouins) have relatives with diagnosed HD (usually first cousins). In two patients, other minor associated congenital defects were detected. The final diagnosis of HD was confirmed in all the patients by rectal biopsy. All the blood samples were examined before resection of the aganglionic segment and abdominoperineal pullthrough; in three patients AChE levels also were examined following the operative procedure. All the children had normal hematological values (including reticulocyte counts). The results of AChE activity of the patients, compared with age-adjusted controls, are presented in Fig 1 and Table 1. The newborn babies with HD have low activity of AChE, similar to that of the age-adjusted controls. Statistical evaluation (t test) did not show any difference between the patients and JournalofPediatric Surgery, Vol 26, No 2 (February), 1991: pp 190-191
ACETYLCHOLINESTERASE
IN HIRSCHSPRUNG’S
191
DkC4SE
their age-adjusted controls. The same pattern of initial low AChE values and gradual increase to adult values, attained at 5 months of age, was observed. The presence of the affected segment or its absence following resection did not influence the AChE levels. When the HD children with known affected relatives were separated from the rest of the group, it was found that in both groups the existence of affected relatives did not influence the AChE values.
Table 1. AChE Activity in Erythrocytes of HD Patients and Normal Population
Healthy newborns Newborns with HD Healthy children and adults HD children (l-2 yr)
NO.
AChE (U/mLcells)
5
49.55 2 1.25
4
41.40 k 9.6
81
67.26 t 8.39
7
67.82 2 5.05
r Test’
P > .I P > .l
NOTE. Values are expressed as means t SD. *The difference from normal controls.
DISCUSSION
The determination of RBC AChE has been suggested as a diagnostic aid for HD.5 If successful, it may provide a relatively simple way of supporting the diagnosis by means of a routine blood test. This may be particularly relevant in newborn babies, in whom diagnosis is sometime difficult. In 17 Japanese children, no change in RBC AChE was found, but the plasma pseudocholinesterase was found to be increased.’ A more recent Chinese study has again demonstrated increased RBC AChE in 31 HD patients, including newborns.” These authors have found good correlation between the increase in RBC AChE and the length of the aganglionic segment.” The Chinese group studied 31 patients, between 3 months and 12 years of age, and six newborn babies, and compared them with the appropriate age-groups. They did not find any difference between patients and controls in plasma pseudocholinesterase. Surgery did not affect these values. They did find significantly higher AChE levels in the patients’ RBCs, and suggest that this augmented AChE could simulate the augmented AChE activity in the mucosa. The present study relates to geneti-
0 : : 012345
;
MONTHS Fig 1.
:
; :;
;
:
I
234
: YEARS
;
: ;;
;
5 ADULTS
Erythrocyte AChE in healthy (0) and HD (0) patients.
tally different populations than those studied in South Africa, China, and Japan. We examined several known different genetic populations among the Jewish population (Ashkenazi v Sephardic Jews), as well as the local Bedouin population. The Jewish group was similar in its subdivision in the control group and in the patients. However, in this study the Bedouin patients constituted 55% of the total group, compared with only 14% of the general population. This correlates well with an increased incidence of HD in the Bedouin population. None of the groups affected showed any increase in RBC AChE. The length of the involved segment had no effect on the RBC AChE activity either. In summary, the present study, as well as the Japanese study, speak against the use of RBC AChE for diagnosis of HD. However, this small sample should be continued and enlarged before final conclusions may be drawn. REFERENCES 1. Sieber
WK: Problems
Hirschprung’s disease, in Ravitch MM (ed): in Surgery. Chicago, IL, Year Book, 1978, pp
Current 1-93 2. Passarge E: Genetics of Hirschprung’s disease. Clin Gasteroenterol2:507-511. 1973 3. Meier-Ruge W, Lutterbeck PM, Herzog B, et al: Acetylcholine esterase activity in suction biopsies of the rectum in the diagnosis of Hirschprung’s disease. J Pediatr Surg 7:11-17, 1972 4. Boston VE, Dale G, Riley KWA: Diagnosis of Hirschsprung’s disease by quantitative biochemical assay of AChE in rectal tissue. Lancet 2:951-953, 1975 5. Boston VE, Cywes S, Davis Q: Serum and erythrocyte AChE activity in Hirschprung’s disease. J Pediatr Surg 13:407-410, 1978 6. Burman D: Red cell cholinesterase in infancy and childhood. Arch Dis Child 36:362-365, 1961 7. Herz F, Kaplan E: A review: Human erythrocyte acltylcholinesterase. Pediatr Res 7:204-214, 1973 8. Ellman GL, Courtney KD, Andres V, et al: A new and rapid calorimetric determination of AChE activity. Biochem Pharmacol 7:88-95,196l 9. Okasora T, Okamoto E. Kuwata K. et al: Serum and erythrocyte AChE in Hirschprung’s disease. Z Kinderchir 38:298-300. 1983 10. Ya-Xiong S, Cheng-Ren S, Jia-Zhou C, et al: Observations on erythrocyte AChE activity of infants and children in Hirschprung’s disease. J Pediatr Surg 19:281-284, 1984