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Rectal biopsy as an aid in the diagnosis of diseases of infants and children
T h e Journal o/ P E D I A T R I C S
197
Rectal biopsy as an aid in the diagnosis of diseases of infants and children Rectal biopsy may be of aid in establishing the diagnosis o[ several congenital, hereditary, and acquired disorders, as well as Hirschsprung's disease. It is an especially valuable diagnostic tool in cases of suspected neural lipidosis, amaurotic idiocies, unexplained degenerative neurological disorders; and it may be o] value in the diagnosis o[a long list of other conditions which have associated histologie changes in the various layers in the wall of the rectum. The technique employed for rectal biopsy in small in[ants is described.
Lester W. Martin, M.D., ~ Benjamin H. Landing, M.D., and Hisayo Nakai, M.D. CINCINNATI,
OHIO
E x P ~ R I E N C E with rectal biopsy for the diagnosis Of aganglionic megacolon has proved the safety, feasibility, and simplicity of the procedureY Nakai and Landing 1 have recently proposed that such a biopsy be employed for the diagnosis of the neural lipidoses, in which group of disorders the myenteric plexus nerve cells of the rectum show diagnostic, histologic, and histochemical abnormalities similar to those of the central nervous system. In addition to being the most easily accessible site for biopsy of nerve cells, the rectal From the Departments o[ Surgery, Pathology, and Pediatrics o[ the University o[ Cincinnati College o[ Medicine, and the Divisions of Surgery, Pathology, and Pediatrics o[ the Children's Hospital o[ Cincinnati. eAddress, Director o] Pediatric Surgery, -The Children's Hospital, Etland and Bethesda Avenues, Cincinnati 29, Ohio.
wall is also readily available as a source of smooth muscle, intestinal epithelium, connective tissue, blood vessels, and reticuloendothelial cells, abnormalities of which m a y be recognizable upon microscopic examination. The purpose of this paper is to call attention to the diagnostic potential of rectal biopsy for several conditions other than Hirschsprung's disease; to present our experience from the Children's Hospital of Cincinnati over a 3 year period; and to describe modifications of the technique which we feel simplify the procedure, particularly in small infants.
POSSIBLE APPLICATIONS Tables I, II, and I I I list conditions amenable to diagnosis by rectal biopsy under the categories of disease involving the epithelium,
19 8
February 1963
Martin, Landing, and Nakai
Table I. Diseases involving epithelium Genetic disease Disease Comments regarding technique Lesion Definite lesions Epithelial atypia Formalin or Zenker fixation, paraffin 1. Pellagra, megaloblastic section anemia, pernicious anemia, folio acid antagonist effect, etc. Epithelial atypia Formalin or Zenker fixation, paraffin 2. Acute radiation and nitrosection gen mustard effect Noninflammatory ulceration Formalin or Zenker fixation, paraffin 3. Uremic colitis section Deep ulcers Formalin or Zenker fixation, paraffin 4. Ulcerative colitis section Ulcers with or without Formalin or Zenker fixation, paraffin 5. Dysenteries amebae section -
Possible lesions 1. Fibrocystic disease
x
"Mucosis" of glands
2. Hartnup disease
x
? Epithelial atypia
3. Gamble's hypochloremic alkalosis
?
the mesenchymal components of the colonic wall (lamina propria, submucosa, smooth muscle layers, or blood vessels), or the myenteric plexus: U n d e r each heading, the diseases are grouped as follows: 1. Conditions in which a lesion is known to be present in the colon in some or all patients with the disease. 2. Conditions in which a lesion demonstrable in other organs m a y occur in the colon, but for which colonic involvement in children is not clearly described in the literature we have surveyed, or disorders involving tissues found in the colonic wall, but for which a lesion is not, regularly demonstrable by current m e t h o d s ; T h e list is given in some detail with brief comments on the p~thologic findings and the appropriate fixi~Ig and staining methods, both to e m p h a s i z e the range of potential uses of rectal biopsy, and to provide guidance when unexpected findings are encountered in such specimens. The tables are not intended to irfipty that rectal biopsy is the diagnostic procedure of choice in all these disorders, although it certainly is for some (e.g., aganglionic megacolon), and m a y well prolze to be for others (e.g., the amaurotic idiocies). Rather, these lists are intended to emphasize that rectal biopsy
Formalin or Zenker fixation, paraffin section Formalin or Zenker fixation, paraffin section
m a y aid in establishing the diagnosis if other biopsy approaches (e.g., bone m a r r o w for the diagnosis of Gaucher's disease or cystinosis) are for some reason not appropriate to certain patients. Also, confirmation of diagnosis m a y be possible when unrelated rectal surgery is performed on patients considered on other grounds to have one of the diseases included. T o illustrate some possible uses of the procedure in the sphere of adult medicine, a few conditions have been included which are also typical of adults. T h e indications for rectal biopsy must be determined for each individual patient, since in several of the conditions listed it m a y be more desirable to confirm the diagnosis by other means. Certain generalizations, however, m a y be made on the basis of our limited experience and the data available: 1. For the megacolon symptom complex, rectal biopsy is the diagnostic maneuver of choice in instances where roentgenographic interpretation is vague or otherwise not conclusively diagnostic. 2. For suspected neural lipidosis, it m a y well prove to be the method of choice, although m u c h of the experience with this group to date has been with autopsy material. For this reason, the age at which the
Volume 62 Number 2
Rectal biopsy
19 9
T a b l e I I . D i s e a s e s i n v o l v i n g m e s e n c h y m a l c o m p o n e n t s of r e c t a l w a l l ( l a m i n a p r o p r i a , s u b m u c o s a , s m o o t h m u s c l e , a n d vessels)
Disease Definite lesions
t Genetic disease
Lesion
Comments regarding technique
9. Melanosis coli 10. Niemann-Pick disease 11. "Adult" Niemann-Pick disease 12. "Adolescent" NiemannPick disease 13. "Periarticular" NiemannPick-like disease (lipogranulomatosis) 14. "Debrancher deficiency" glycogen storage disease 15. Schistosomiasis
x ?
Histiocytes with pigment Histiocytes with lipid Histioeytes with lipid
Formalin or Zenker fixation, paraffin section Fat stain stronger in frozen section than in paraffin section. Acid phosphatase strong in histiocytes Toluidine blue stain after fixation in acetone tetrahydrofurane Polarization of frozen section Fat stain persists in paraffin section Fat dissolves in fat solvents Formalin or Zenker fixation, paraffin section Formalin or Zenker fixation, paraffin section Pigment PAS positive, not lipid Fat stain persists in paraffin section Fat stain persists in paraffin section
x
Histiocytes with lipid
Lipid soluble in fat solvents
x
Histiocytes with lipid
Fat stain persists in paraffin section
x
Histiocytes with polysaccharide Iodine stains substance blue
-
16. Letterer-Siwe disease
-
Ova with foreign body reaction Formalin or Zenker fixation, paraffin section Usually nonlipid histiocytes Formalin or Zenker fixation, paraffin section Ceroid pigment in smooth Formalin or Zenker fixation, parafmuscle fin section
I. Agammaglobulinemia
x
Absent plasma cells
2. Gaucher's disease
x
Histiocytes with glycollpid
3. Hurler's disease (gargoylism) 4. Cystinosis 5. "Ceroid storage disease"
x
6. Xanthomatosis 7. Primary amyloidosis
x orx
Acid mucopolysaccharide in connective tissue Histlocytes with crystals Histiocytes with pigmented lipid Vacuolated hi3tiocytes Amyloid in walls of vessels
8. Hemosiderosis
x or-
Histiocytes with iron pigment
x x
17. Fibrocystic disease, sprue, x o r other chronic malabsorption syndromes (vitamin E deficiency) ? 18. Perivascular demyelination x 19. Polysaccharide histiocytosis of colon x 20. Multiple polyposis 21. Varicella
Vacuolated histiocytes
Fat and carbohydrate stains negative Histiocytes with polysaccharide Histiocytes nonlipid, PAS positive Polyps Pox with inclusions
-
22. Measles
-
23. Cytomegalie inclusion disease 24. Chronic radiation effect
-
Warthin-Finkeldly cells in lymphoid follicles Inclusions in lamina propria
-
Telangieetasia, fibrosis
25. Granuloma inguinale
-
26. Lymphogranuloma venereum 27. Rickettsial infection
-
Histiocytes with bacteria (Donovan bodies) Inflammation, scarring
-
Organisms in vessel walls
Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section
fixation, paraffixation, paraffixation, paraffixation, paraffixation, paraffixation, paraffixation, paraffixation, paraf-
2 O0
Martin, Landing, and Nakai
February 1963
Table II. Cont'd
Disease
I Genetic disease
28. Collagen diseases (anaphylactoid purpura, periarteritis nodosa, seleroderma, dermatomyositis, thrombotic thrombocytopenic purpura) 29. Tuberculosis
Lesion
Comments regarding technique
Vasculitis, thrombl, or scarring Formalin or Zenker fixation, paraffin section
Tubercle in lamina propria
Formalin or Zenker fixation, paraffin section
Possible lesions 1. "Generalized" glycogen storage disease 2. Peutz-Jeghers syndrome
x
3. Addison's disease
•
4. Oxalosis
x
5. Gout
x
6. Ehlers-Danlos disease
x
7. Pseudoxanthoma elasticure 8. Whipple's disease
•
x
x
9. Fabry's anglokeratoma corporis diffusum 10. Hypophosphatasia
x
11. Chediak-Higashi syndrome
x
12. Fibrodysplasia ossificans progresiva 13. Argyria
x
14. 15. 16. 17.
Muscular dystrophies Osteogenesis imperfecta Marfan's disease Ochronosis
x
-
Glycogen in smooth muscle
Formalin or Zenker fixation, paraffin section Pigment in epithelium Formalin or Zenker fixation, paraffin section Pigment in epithelium Formalin or Zenker fixation, paraffin section Crystals in submucosa Formalin or Zenker fixation, paraffin section Crystals in submueosa Formalin or Zenker fixation, paraffin section Deficient elastic tissue Formalin or Zenker fixation, paraffin section "Elastosis" of collagen Formalin or Zenker fixation, paraffin section Histiocytes with polysaccharlde Formalin or Zenker fixation, paraffin section. Cells PAS positive, metachromatic Lipid in smooth muscle cells Formalin fixation, frozen section Absent capillary endothelial alkaline phosphatase Cytoplasmic inclusions in nayeloid cells Calcification of connective tissue Granular silver deposits in basement membrane
Short cold formalin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section
fixation, frozen fixation, paraffixation, paraffixation, paraf-
• X X X
diagnostic changes in the m y e n t e r i c plexus occur is unknown. Presumably, t h e y occur at the same time as the changes in the brain, and, if so, t h e n rectal biopsy w o u l d be equally as diagnostic as b r a i n biopsy. 3. R e c t a l biopsy m a y welt prove to p l a y a significant role in the diagnosis of otherwise u n e x p l a i n e d instances of d e g e n e r a t i v e neurologic disorder. 4. R e c t a l biopsy m i g h t f u r t h e r be indic a t e d when suspicion of one of the o t h e r diseases listed makes diagnostic or confirmat o r y biopsy desirable, a n d o t h e r bioPsY sites are for some reason c o n t r a i n d i c a t e d o r are less desirable.
CLINICAL
EXPERIENCE
D u r i n g the 3 y e a r p e r i o d ending J u l y 1, 1961, 75 rectal biopsy specimens have been s u b m i t t e d to the D e p a r t m e n t of P a t h o l o g y of the C h i l d r e n ' s Hospital. T h i r t y - o n e were o b t a i n e d because of possible H i r s c h s p r u n g ' s disease. O f these, 17 h a d n o r m a l ganglion cells a n d 13 were diagnostic of aganglionic megacolon on the basis of absence of ganglion cells. O n e specimen was i n a d e q u a t e in t h a t m u c o s a only was submitted. T w e n t y - f i v e specimens were s u b m i t t e d as tissue r e m o v e d i n c i d e n t a l l y to o p e r a t i o n for i m p e r f o r a t e anus. N o r m a l findings were rep o r t e d i n 19. I n 6 instances, no n o r m a l
Volume 62
Number 2
Rectal biopsy
20 1
S u b s e q u e n t b r a i n biopsy s h o w e d changes suggestive of p e r i v a s c u l a r d e m y e l i n a t i o n . T h e o t h e r positive biopsy was r e p o r t e d as a p o l y s a c c h a r i d e histiocytosis. T h i s child was t h o u g h t to b e n o r m a l u n t i l 21 m o n t h s of age, w h e n the p a r e n t s n o t e d difficulty in w a l k i n g a n d a t e n d e n c y to "stiffness of the legs." She s u b s e q u e n t l y ceased w a l k i n g entirely. H e r v o c a b u l a r y g r a d u a l l y regressed. A t the age of 29 naonths, she c o u l d n e i t h e r walk n o r talk. O n e x a m i n a t i o n , she could n e i t h e r s t a n d n o r sit. T h e r e was n o m u s c u l a r
g a n g l i o n cells were identified. T w o of these c h i l d r e n h a v e s u b s e q u e n t l y p r o v e d to h a v e m i l d s y m p t o m s suggestive of H i r s c h s p r u n g ' s disease. I n 11 instances, biopsy was o b t a i n e d because of a n u n d i a g n o s e d n e u r o l o g i c disorder. N o r m a l findings w e r e r e c o r d e d i n 8,' a n d a b n o r m a l findings i n 3 instances. O f the 3 a b n o r m a l biopsies, 2 were f r o m t h e same p a t i e n t , a 15-year-old b o y w i t h c e r e b r a l deg e n e r a t i o n . M a n y n o n l i p i d v a c u o l a t e d histiocytes w e r e p r e s e n t i n the l a m i n a p r o p r i a . T a b l e I I I . Diseases i n v o l v i n g m y e n t e r i c plexus
Disease Definite lesions 1. Amaurotic idiocies: a. Infantile (Tay-Sachs) b. Early juvenile (JanskyBielschowsky) c. Late juvenile (Spielmeyer-Vogt) d. Adult (Kufs) 2. I-Iurler's disease 3. Niemann-Pick complex 4. Pseudo-Hurler ("TaySachs with visceral involvement" ) 5. Generalized glycogen storage disease 6. Megacolon complex: a. Aganglionic megacolon b. Total aganglionosis of intestine c. Acquired aganglionic megaeolon 7. Neuronal necrosis
Possible lesions 1. Myoclonus epilepsy with amyloid degeneration of nerve ceils 2. Kernicterus
Genetic disease
Lesion
Comments regardinq technique
x x
Ballooned nerve cells with lipid Ballooned nerve ceils with lipid
Lipid relatively soluble Lipid persists in paraffin section
x
Ballooned nerve cells with lipid
Lipid persists in paraffin section
x x x x
Ballooned Ballooned Ballooned Ballooned
Lipid Lipid Lipid Lipid
x
Ballooned nerve cells with glycogen
Formalin or Zenker fixation, PAS
?
Absent nerve cells
?
Absent nerve ceils
?
Absent nerve cells
Formalin or Zenker fixation, zen or paraffin section Formalin or Zenker fixation, zen or paraffin section Formalin or Zenker fixation, zen or paraffin section Formalin or Zenker fixation, zen or paraffin section
nerve nerve nerve nerve
cells cells cells cells
with with with with
lipid lipid lipid lipid
Acidophilic hyalinization of nerve cells
-
persists in paraffin section persists in paraffin section persists in paraffin section relatively soluble
frofrofrofro-
x
"Amyloid" in nerve cells
Formalin or Zenker fixation, frozen or paraffin section
-
Formalin or Zenker fixation, frozen or paraffin section Formalin fixation, frozen section
3. Leukodystrophies
x
4. Neurofibromatosis
x
Neuronal necrosis with bile staining Abnormal "myelin" in nerve trunks Nenrofibroma
5. Epiloia (Bourneville's disease) 6. Hoffmann-Werdnig infantile spinal muscular atrophy 7. Dawson's subacute inclusion encephalitis 8. Viral encephalitides 9. Friedreich's ataxia
x
Abnormal glial cells
x
x
Formalin or Zenker fixation, paraffin section Formalin or Zenker fixation, paraffin section
2 0 2 Martin, Landing, and Nakai
atrophy. An older sister has the same condition: is ahnost completely "rigid," has to be fed, is totally incontinent of stool and urine, and does not talk. The diagnosis was polysaccharide histiocytosis of the colon. Suspected Hurler's syndrome was ruled out on 2 occasions on the basis of a normal rectal biopsy. Marked eosinophilic infiltration of the lamina propria w a s noted in one biopsy from a child who subsequently developed rheumatoid arthritis, and a diagnosis of leukemia was made on one specimen. We have experienced no complications from rectal biopsy in the 75 patients in our series. TECHNIQUE The procedure is generally performed under general anesthesia, but m a y well be done without anesthesia, since it causes little or no discomfort (no anesthesia was employed in 8 of our cases). The patient is placed in the lithotomy position and the anus gently dilated. The lateral rectal wall is grasped with a Babcock or Allis clamp approximately 2.0 era. above the white line of Hilton, and this segment of rectal wall is withdrawn through the anus. A hemostatlc No. 3-0 chromic catgut suture ligature is placed above and below the biopsy site, and the intervening 5.0 to 10 mm. of rectal wall (including mucosa and muscularis) is excised for biopsy. Hemostasis is obtained by means
February 1963
of transfixion suture ligatures of No. 3-0 catgut. The mucosal defect is left open to prevent infection. We have had no complications from this procedure. SUMMARY
Rectal biopsy represents an addition to the diagnostic a r m a m e n t a r i u m available to the pediatrician for the diagnosis of a number of congenital, hereditary, and acquired disorders. In questionable cases of congenital megacolon, its value has previously been demonstrated and is reconfirmed by our experience. For the neural lipidoses, it m a y be as reliable as brain biopsy and m a y well prove to be the most convenient means of establishing the diagnosis. It probably should be considered in the diagnostic investigation of any otherwise unexplained degenerative neurologic disorder of childhood. A list of additional diseases is presented in which rectal biopsy m a y aid in establishing the diagnosis. Its true role, however, in these conditions must await further investigation and clinical experience.
REFERENCES
1. Nakai, H., and Landing, B. H.: Suggested use of rectal biopsy in the diagnosis of neural lipidoses, Pediatrics 26" 225, 1960. 2. Swenson, O., Fisher, J. H., and McMahon, I-I. E.: Rectal biopsy as an aid in the diagnosis of Hirsehsprung's disease, New England J. Med. 253: 632, 1955.
197
Rectal biopsy as an aid in the diagnosis of diseases of infants and children Rectal biopsy may be of aid in establishing the diagnosis o[ several congenital, hereditary, and acquired disorders, as well as Hirschsprung's disease. It is an especially valuable diagnostic tool in cases of suspected neural lipidosis, amaurotic idiocies, unexplained degenerative neurological disorders; and it may be o] value in the diagnosis o[a long list of other conditions which have associated histologie changes in the various layers in the wall of the rectum. The technique employed for rectal biopsy in small in[ants is described.
Lester W. Martin, M.D., ~ Benjamin H. Landing, M.D., and Hisayo Nakai, M.D. CINCINNATI,
OHIO
E x P ~ R I E N C E with rectal biopsy for the diagnosis Of aganglionic megacolon has proved the safety, feasibility, and simplicity of the procedureY Nakai and Landing 1 have recently proposed that such a biopsy be employed for the diagnosis of the neural lipidoses, in which group of disorders the myenteric plexus nerve cells of the rectum show diagnostic, histologic, and histochemical abnormalities similar to those of the central nervous system. In addition to being the most easily accessible site for biopsy of nerve cells, the rectal From the Departments o[ Surgery, Pathology, and Pediatrics o[ the University o[ Cincinnati College o[ Medicine, and the Divisions of Surgery, Pathology, and Pediatrics o[ the Children's Hospital o[ Cincinnati. eAddress, Director o] Pediatric Surgery, -The Children's Hospital, Etland and Bethesda Avenues, Cincinnati 29, Ohio.
wall is also readily available as a source of smooth muscle, intestinal epithelium, connective tissue, blood vessels, and reticuloendothelial cells, abnormalities of which m a y be recognizable upon microscopic examination. The purpose of this paper is to call attention to the diagnostic potential of rectal biopsy for several conditions other than Hirschsprung's disease; to present our experience from the Children's Hospital of Cincinnati over a 3 year period; and to describe modifications of the technique which we feel simplify the procedure, particularly in small infants.
POSSIBLE APPLICATIONS Tables I, II, and I I I list conditions amenable to diagnosis by rectal biopsy under the categories of disease involving the epithelium,
19 8
February 1963
Martin, Landing, and Nakai
Table I. Diseases involving epithelium Genetic disease Disease Comments regarding technique Lesion Definite lesions Epithelial atypia Formalin or Zenker fixation, paraffin 1. Pellagra, megaloblastic section anemia, pernicious anemia, folio acid antagonist effect, etc. Epithelial atypia Formalin or Zenker fixation, paraffin 2. Acute radiation and nitrosection gen mustard effect Noninflammatory ulceration Formalin or Zenker fixation, paraffin 3. Uremic colitis section Deep ulcers Formalin or Zenker fixation, paraffin 4. Ulcerative colitis section Ulcers with or without Formalin or Zenker fixation, paraffin 5. Dysenteries amebae section -
Possible lesions 1. Fibrocystic disease
x
"Mucosis" of glands
2. Hartnup disease
x
? Epithelial atypia
3. Gamble's hypochloremic alkalosis
?
the mesenchymal components of the colonic wall (lamina propria, submucosa, smooth muscle layers, or blood vessels), or the myenteric plexus: U n d e r each heading, the diseases are grouped as follows: 1. Conditions in which a lesion is known to be present in the colon in some or all patients with the disease. 2. Conditions in which a lesion demonstrable in other organs m a y occur in the colon, but for which colonic involvement in children is not clearly described in the literature we have surveyed, or disorders involving tissues found in the colonic wall, but for which a lesion is not, regularly demonstrable by current m e t h o d s ; T h e list is given in some detail with brief comments on the p~thologic findings and the appropriate fixi~Ig and staining methods, both to e m p h a s i z e the range of potential uses of rectal biopsy, and to provide guidance when unexpected findings are encountered in such specimens. The tables are not intended to irfipty that rectal biopsy is the diagnostic procedure of choice in all these disorders, although it certainly is for some (e.g., aganglionic megacolon), and m a y well prolze to be for others (e.g., the amaurotic idiocies). Rather, these lists are intended to emphasize that rectal biopsy
Formalin or Zenker fixation, paraffin section Formalin or Zenker fixation, paraffin section
m a y aid in establishing the diagnosis if other biopsy approaches (e.g., bone m a r r o w for the diagnosis of Gaucher's disease or cystinosis) are for some reason not appropriate to certain patients. Also, confirmation of diagnosis m a y be possible when unrelated rectal surgery is performed on patients considered on other grounds to have one of the diseases included. T o illustrate some possible uses of the procedure in the sphere of adult medicine, a few conditions have been included which are also typical of adults. T h e indications for rectal biopsy must be determined for each individual patient, since in several of the conditions listed it m a y be more desirable to confirm the diagnosis by other means. Certain generalizations, however, m a y be made on the basis of our limited experience and the data available: 1. For the megacolon symptom complex, rectal biopsy is the diagnostic maneuver of choice in instances where roentgenographic interpretation is vague or otherwise not conclusively diagnostic. 2. For suspected neural lipidosis, it m a y well prove to be the method of choice, although m u c h of the experience with this group to date has been with autopsy material. For this reason, the age at which the
Volume 62 Number 2
Rectal biopsy
19 9
T a b l e I I . D i s e a s e s i n v o l v i n g m e s e n c h y m a l c o m p o n e n t s of r e c t a l w a l l ( l a m i n a p r o p r i a , s u b m u c o s a , s m o o t h m u s c l e , a n d vessels)
Disease Definite lesions
t Genetic disease
Lesion
Comments regarding technique
9. Melanosis coli 10. Niemann-Pick disease 11. "Adult" Niemann-Pick disease 12. "Adolescent" NiemannPick disease 13. "Periarticular" NiemannPick-like disease (lipogranulomatosis) 14. "Debrancher deficiency" glycogen storage disease 15. Schistosomiasis
x ?
Histiocytes with pigment Histiocytes with lipid Histioeytes with lipid
Formalin or Zenker fixation, paraffin section Fat stain stronger in frozen section than in paraffin section. Acid phosphatase strong in histiocytes Toluidine blue stain after fixation in acetone tetrahydrofurane Polarization of frozen section Fat stain persists in paraffin section Fat dissolves in fat solvents Formalin or Zenker fixation, paraffin section Formalin or Zenker fixation, paraffin section Pigment PAS positive, not lipid Fat stain persists in paraffin section Fat stain persists in paraffin section
x
Histiocytes with lipid
Lipid soluble in fat solvents
x
Histiocytes with lipid
Fat stain persists in paraffin section
x
Histiocytes with polysaccharide Iodine stains substance blue
-
16. Letterer-Siwe disease
-
Ova with foreign body reaction Formalin or Zenker fixation, paraffin section Usually nonlipid histiocytes Formalin or Zenker fixation, paraffin section Ceroid pigment in smooth Formalin or Zenker fixation, parafmuscle fin section
I. Agammaglobulinemia
x
Absent plasma cells
2. Gaucher's disease
x
Histiocytes with glycollpid
3. Hurler's disease (gargoylism) 4. Cystinosis 5. "Ceroid storage disease"
x
6. Xanthomatosis 7. Primary amyloidosis
x orx
Acid mucopolysaccharide in connective tissue Histlocytes with crystals Histiocytes with pigmented lipid Vacuolated hi3tiocytes Amyloid in walls of vessels
8. Hemosiderosis
x or-
Histiocytes with iron pigment
x x
17. Fibrocystic disease, sprue, x o r other chronic malabsorption syndromes (vitamin E deficiency) ? 18. Perivascular demyelination x 19. Polysaccharide histiocytosis of colon x 20. Multiple polyposis 21. Varicella
Vacuolated histiocytes
Fat and carbohydrate stains negative Histiocytes with polysaccharide Histiocytes nonlipid, PAS positive Polyps Pox with inclusions
-
22. Measles
-
23. Cytomegalie inclusion disease 24. Chronic radiation effect
-
Warthin-Finkeldly cells in lymphoid follicles Inclusions in lamina propria
-
Telangieetasia, fibrosis
25. Granuloma inguinale
-
26. Lymphogranuloma venereum 27. Rickettsial infection
-
Histiocytes with bacteria (Donovan bodies) Inflammation, scarring
-
Organisms in vessel walls
Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section
fixation, paraffixation, paraffixation, paraffixation, paraffixation, paraffixation, paraffixation, paraffixation, paraf-
2 O0
Martin, Landing, and Nakai
February 1963
Table II. Cont'd
Disease
I Genetic disease
28. Collagen diseases (anaphylactoid purpura, periarteritis nodosa, seleroderma, dermatomyositis, thrombotic thrombocytopenic purpura) 29. Tuberculosis
Lesion
Comments regarding technique
Vasculitis, thrombl, or scarring Formalin or Zenker fixation, paraffin section
Tubercle in lamina propria
Formalin or Zenker fixation, paraffin section
Possible lesions 1. "Generalized" glycogen storage disease 2. Peutz-Jeghers syndrome
x
3. Addison's disease
•
4. Oxalosis
x
5. Gout
x
6. Ehlers-Danlos disease
x
7. Pseudoxanthoma elasticure 8. Whipple's disease
•
x
x
9. Fabry's anglokeratoma corporis diffusum 10. Hypophosphatasia
x
11. Chediak-Higashi syndrome
x
12. Fibrodysplasia ossificans progresiva 13. Argyria
x
14. 15. 16. 17.
Muscular dystrophies Osteogenesis imperfecta Marfan's disease Ochronosis
x
-
Glycogen in smooth muscle
Formalin or Zenker fixation, paraffin section Pigment in epithelium Formalin or Zenker fixation, paraffin section Pigment in epithelium Formalin or Zenker fixation, paraffin section Crystals in submucosa Formalin or Zenker fixation, paraffin section Crystals in submueosa Formalin or Zenker fixation, paraffin section Deficient elastic tissue Formalin or Zenker fixation, paraffin section "Elastosis" of collagen Formalin or Zenker fixation, paraffin section Histiocytes with polysaccharlde Formalin or Zenker fixation, paraffin section. Cells PAS positive, metachromatic Lipid in smooth muscle cells Formalin fixation, frozen section Absent capillary endothelial alkaline phosphatase Cytoplasmic inclusions in nayeloid cells Calcification of connective tissue Granular silver deposits in basement membrane
Short cold formalin section Formalin or Zenker fin section Formalin or Zenker fin section Formalin or Zenker fin section
fixation, frozen fixation, paraffixation, paraffixation, paraf-
• X X X
diagnostic changes in the m y e n t e r i c plexus occur is unknown. Presumably, t h e y occur at the same time as the changes in the brain, and, if so, t h e n rectal biopsy w o u l d be equally as diagnostic as b r a i n biopsy. 3. R e c t a l biopsy m a y welt prove to p l a y a significant role in the diagnosis of otherwise u n e x p l a i n e d instances of d e g e n e r a t i v e neurologic disorder. 4. R e c t a l biopsy m i g h t f u r t h e r be indic a t e d when suspicion of one of the o t h e r diseases listed makes diagnostic or confirmat o r y biopsy desirable, a n d o t h e r bioPsY sites are for some reason c o n t r a i n d i c a t e d o r are less desirable.
CLINICAL
EXPERIENCE
D u r i n g the 3 y e a r p e r i o d ending J u l y 1, 1961, 75 rectal biopsy specimens have been s u b m i t t e d to the D e p a r t m e n t of P a t h o l o g y of the C h i l d r e n ' s Hospital. T h i r t y - o n e were o b t a i n e d because of possible H i r s c h s p r u n g ' s disease. O f these, 17 h a d n o r m a l ganglion cells a n d 13 were diagnostic of aganglionic megacolon on the basis of absence of ganglion cells. O n e specimen was i n a d e q u a t e in t h a t m u c o s a only was submitted. T w e n t y - f i v e specimens were s u b m i t t e d as tissue r e m o v e d i n c i d e n t a l l y to o p e r a t i o n for i m p e r f o r a t e anus. N o r m a l findings were rep o r t e d i n 19. I n 6 instances, no n o r m a l
Volume 62
Number 2
Rectal biopsy
20 1
S u b s e q u e n t b r a i n biopsy s h o w e d changes suggestive of p e r i v a s c u l a r d e m y e l i n a t i o n . T h e o t h e r positive biopsy was r e p o r t e d as a p o l y s a c c h a r i d e histiocytosis. T h i s child was t h o u g h t to b e n o r m a l u n t i l 21 m o n t h s of age, w h e n the p a r e n t s n o t e d difficulty in w a l k i n g a n d a t e n d e n c y to "stiffness of the legs." She s u b s e q u e n t l y ceased w a l k i n g entirely. H e r v o c a b u l a r y g r a d u a l l y regressed. A t the age of 29 naonths, she c o u l d n e i t h e r walk n o r talk. O n e x a m i n a t i o n , she could n e i t h e r s t a n d n o r sit. T h e r e was n o m u s c u l a r
g a n g l i o n cells were identified. T w o of these c h i l d r e n h a v e s u b s e q u e n t l y p r o v e d to h a v e m i l d s y m p t o m s suggestive of H i r s c h s p r u n g ' s disease. I n 11 instances, biopsy was o b t a i n e d because of a n u n d i a g n o s e d n e u r o l o g i c disorder. N o r m a l findings w e r e r e c o r d e d i n 8,' a n d a b n o r m a l findings i n 3 instances. O f the 3 a b n o r m a l biopsies, 2 were f r o m t h e same p a t i e n t , a 15-year-old b o y w i t h c e r e b r a l deg e n e r a t i o n . M a n y n o n l i p i d v a c u o l a t e d histiocytes w e r e p r e s e n t i n the l a m i n a p r o p r i a . T a b l e I I I . Diseases i n v o l v i n g m y e n t e r i c plexus
Disease Definite lesions 1. Amaurotic idiocies: a. Infantile (Tay-Sachs) b. Early juvenile (JanskyBielschowsky) c. Late juvenile (Spielmeyer-Vogt) d. Adult (Kufs) 2. I-Iurler's disease 3. Niemann-Pick complex 4. Pseudo-Hurler ("TaySachs with visceral involvement" ) 5. Generalized glycogen storage disease 6. Megacolon complex: a. Aganglionic megacolon b. Total aganglionosis of intestine c. Acquired aganglionic megaeolon 7. Neuronal necrosis
Possible lesions 1. Myoclonus epilepsy with amyloid degeneration of nerve ceils 2. Kernicterus
Genetic disease
Lesion
Comments regardinq technique
x x
Ballooned nerve cells with lipid Ballooned nerve ceils with lipid
Lipid relatively soluble Lipid persists in paraffin section
x
Ballooned nerve cells with lipid
Lipid persists in paraffin section
x x x x
Ballooned Ballooned Ballooned Ballooned
Lipid Lipid Lipid Lipid
x
Ballooned nerve cells with glycogen
Formalin or Zenker fixation, PAS
?
Absent nerve cells
?
Absent nerve ceils
?
Absent nerve cells
Formalin or Zenker fixation, zen or paraffin section Formalin or Zenker fixation, zen or paraffin section Formalin or Zenker fixation, zen or paraffin section Formalin or Zenker fixation, zen or paraffin section
nerve nerve nerve nerve
cells cells cells cells
with with with with
lipid lipid lipid lipid
Acidophilic hyalinization of nerve cells
-
persists in paraffin section persists in paraffin section persists in paraffin section relatively soluble
frofrofrofro-
x
"Amyloid" in nerve cells
Formalin or Zenker fixation, frozen or paraffin section
-
Formalin or Zenker fixation, frozen or paraffin section Formalin fixation, frozen section
3. Leukodystrophies
x
4. Neurofibromatosis
x
Neuronal necrosis with bile staining Abnormal "myelin" in nerve trunks Nenrofibroma
5. Epiloia (Bourneville's disease) 6. Hoffmann-Werdnig infantile spinal muscular atrophy 7. Dawson's subacute inclusion encephalitis 8. Viral encephalitides 9. Friedreich's ataxia
x
Abnormal glial cells
x
x
Formalin or Zenker fixation, paraffin section Formalin or Zenker fixation, paraffin section
2 0 2 Martin, Landing, and Nakai
atrophy. An older sister has the same condition: is ahnost completely "rigid," has to be fed, is totally incontinent of stool and urine, and does not talk. The diagnosis was polysaccharide histiocytosis of the colon. Suspected Hurler's syndrome was ruled out on 2 occasions on the basis of a normal rectal biopsy. Marked eosinophilic infiltration of the lamina propria w a s noted in one biopsy from a child who subsequently developed rheumatoid arthritis, and a diagnosis of leukemia was made on one specimen. We have experienced no complications from rectal biopsy in the 75 patients in our series. TECHNIQUE The procedure is generally performed under general anesthesia, but m a y well be done without anesthesia, since it causes little or no discomfort (no anesthesia was employed in 8 of our cases). The patient is placed in the lithotomy position and the anus gently dilated. The lateral rectal wall is grasped with a Babcock or Allis clamp approximately 2.0 era. above the white line of Hilton, and this segment of rectal wall is withdrawn through the anus. A hemostatlc No. 3-0 chromic catgut suture ligature is placed above and below the biopsy site, and the intervening 5.0 to 10 mm. of rectal wall (including mucosa and muscularis) is excised for biopsy. Hemostasis is obtained by means
February 1963
of transfixion suture ligatures of No. 3-0 catgut. The mucosal defect is left open to prevent infection. We have had no complications from this procedure. SUMMARY
Rectal biopsy represents an addition to the diagnostic a r m a m e n t a r i u m available to the pediatrician for the diagnosis of a number of congenital, hereditary, and acquired disorders. In questionable cases of congenital megacolon, its value has previously been demonstrated and is reconfirmed by our experience. For the neural lipidoses, it m a y be as reliable as brain biopsy and m a y well prove to be the most convenient means of establishing the diagnosis. It probably should be considered in the diagnostic investigation of any otherwise unexplained degenerative neurologic disorder of childhood. A list of additional diseases is presented in which rectal biopsy m a y aid in establishing the diagnosis. Its true role, however, in these conditions must await further investigation and clinical experience.
REFERENCES
1. Nakai, H., and Landing, B. H.: Suggested use of rectal biopsy in the diagnosis of neural lipidoses, Pediatrics 26" 225, 1960. 2. Swenson, O., Fisher, J. H., and McMahon, I-I. E.: Rectal biopsy as an aid in the diagnosis of Hirsehsprung's disease, New England J. Med. 253: 632, 1955.