EMR is superior to rectal suction biopsy for analysis of enteric ganglia in constipation and dysmotility

Published:September 08, 2017DOI:

      Background and Aims

      Patients with chronic constipation or motility disorders may be referred for rectal suction biopsy (RSB) to rule out Hirschsprung’s disease (HD). RSB may not be successful beyond infancy because of the increased thickness of the rectal mucosa. EMR could improve the diagnostic yield for HD when compared with traditional RSB because larger and deeper samples are acquired for analysis.


      In this prospective, single-center study, patients referred for RSB were offered enrollment for concurrent EMR. Specimens were analyzed pathologically for size, submucosal ganglionic tissue, and acetylcholinesterase or calretinin staining. Biopsy results were compared with transit studies, anorectal manometry, and constipation severity through validated questionnaires.


      Seventeen patients (2 male, 15 female; mean age, 35.8 years; range, 22-61 years) were enrolled in the study from 2008 to 2014. All patients underwent anorectal manometry (88% with anorectal dysfunction, 68% with outlet obstruction) and transit studies (41% with delayed transit). There were no reports of adverse events from the RSB and EMR procedures. The RSB sample volumes were significantly lower than the EMR sample volumes (0.023 cm3 vs 0.26 cm3, P = .001). There was diagnostic tissue for submucosal visualization by RSB in 53% (9/17) of cases compared with 100% (17/17) with EMR (P = .003). No cases of HD were diagnosed by RSB; one patient had rare ganglions observed by EMR.


      EMR provides greater tissue volume and can improve the characterization of ganglion cells in rectal tissue compared with RSB in patients with moderate to severe constipation with suspected HD.


      BSS (Bristol Stool Scale), GSRS (Gastrointestinal Symptom Rating Scale), HD (Hirschsprung’s disease), IBS-QOL (Irritable Bowel Syndrome Quality of Life), MGH (Massachusetts General Hospital), RSB (rectal suction biopsy)
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      Linked Article

      • Rectal EMR for enteric ganglia: Is deeper better?
        Gastrointestinal EndoscopyVol. 87Issue 3
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          Hirschsprung’s disease (HD) is characterized by the aberrant arrest of caudad migration of neural crest cells, resulting in the absence of ganglion cells within the submucosal and myenteric plexuses of the distal colorectum. The aganglionic segment extends proximally from the anorectum up to varying lengths of the colon. The loss of ganglion cells leads to a loss of peristalsis and neurotransmitter release, particularly nitric oxide and vasoactive intestinal peptide, causing a functional colonic obstruction.
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