Abstract
The concept of internal anal sphincter achalasia (IASA) was first described by Davidson and Bauer in 1958. Their reported three cases with constipation since birth and presented with fecal impaction and soiling had moderately dilated rectum without any zone of narrowing in barium enemas. Injection of acetylbetamethylcholine (Mecholyl®), a potent parasympathetic drug, displayed the proximal relaxation but no relaxation distally, which indicated that they would have aganglionosis in the terminal rectum. However, histological study of the specimen revealed the presence of ganglia in all areas, and they described the condition as “achalasia of the distal rectal segment.” Although they did not use the term “ultrashort Hirschsprung’s disease” in the paper, a short area of achalasia proximal to the anus was considered as a very short segment of aganglionosis, and the diagnostic label of ultrashort Hirschsprung’s disease prevailed since, and this entity has been reported in many literatures as ultrashort Hirschsprung’s disease. However, since the authors arbitrarily included patients into this category, there has been some confusion on this entity. And it has been proposed that the term ultrashort Hirschsprung’s disease should be replaced by internal anal sphincter achalasia. In the consensus workshop on “Criteria for Classification and Diagnosis of Dysganglionoses” held in 2004, participants agreed on the issue of Internal Anal Sphincter Neurogenic Achalasia that the diagnosis of the entity is the result of clinical, manometric, and histochemical studies, and none excluded manometry as enzymatic histochemistry, and histology alone cannot provide the diagnosis. Now the diagnosis of IASA is based on (1) anorectal manometry that shows the absence of rectosphincteric reflex on rectal balloon inflation and the presence of marked rhythmic activity of the internal anal sphincter and (2) the presence of ganglion cells and normal acetylcholinesterase (AChE) activity in the rectal suction biopsy as proposed by Doodnath and Puri. However, one should cautiously make the diagnosis of the disease considering technical aspects of anorectal manometry with anatomical investigations on the terminal rectum. Only when one could not demonstrate rectosphincteric reflex in a relaxed or sedated child with ample distention of the rectum by a balloon, and only when no nerve fibers with increased AChE activity are observed in the lamina propria with the presence of ganglion cells in the rectal mucosal biopsy, the disease of IASA can be diagnosed. One should also recognize that the entity may contain several unclarified pathogeneses of this condition and that very few cases are reported in a large cohort of patients with Hirschsprung’s disease and allied disorders in Japan.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Neilson IR, Yazbeck S. Ultrashort Hirschsprung’s disease: myth or reality. J Pediatr Surg. 1990;25(11):1135–8.
Swenson O, Bill AH Jr. Resection of rectum and rectosigmoid with preservation of the sphincter for benign spastic lesions producing megacolon An experimental study. Surgery. 1948;24(2):212–20.
Swenson O, Fisher JH, Macmahon HE. Rectal biopsy as an aid in the diagnosis of Hirschsprung’s disease. N Engl J Med. 1955;253(15):632–5.
Tobon F, Reid NC, Talbert JL, Schuster MM. Nonsurgical test for the diagnosis of Hirschsprung’s disease. N Engl J Med. 1968;278(4):188–93.
Schnaufer L, Talbert JL, Haller JA, Reid NCRW, Tobon F, Schuster MM. Differential sphincteric studies in the diagnosis of ano-rectal disorders of childhood. J Pediatr Surg. 1967;2(6):538–43.
Aaronson I, Nixon HH. A clinical evaluation of anorectal pressure studies in the diagnosis of Hirschsprung’s disease. Gut. 1972;13(2):138–46.
Iwai N, Ogita S, Kida M, Nishioka B, Fujita Y, Majima S. A manometric assessment of anorectal pressures and its significance in the diagnosis of Hirschsprung’s disease and idiopathic megacolon. Jpn J Surg. 1979;9(3):234–40.
Vela AR, Rosenberg AJ. Anorectal manometry: a new simplified technique. Am J Gastroenterol. 1982;77(7):486–90.
Davidson M, Bauer CH. Studies of distal colonic motility in children. IV. Achalasia of the distal rectal segment despite presence of ganglia in the myenteric plexuses of this area. Pediatrics. 1958;21(5):746–61.
Holschneider A. Electromyographic studies of the external and internal anal sphincter in relation to the anorectal manometry. Langenbecks Arch Chir. 1974;333(4):303–16.
Holschneider AM. Anal sphincter achalasia. In: Holschneider AM, editor. Hirschsprung’s disease. New York, NY: Thieme Medical Publishers; 1982. p. 203–18.
Meister HP. Morphologic findings in chronic constipation in children. Monatsschr Kinderheilkd. 1976;124(5):354–6.
Bentley JFR. Some new observations on megacolon in infancy and childhood with special reference to the management of megasigmoid and megarectum. Dis Colon Rect. 1964;7(5):462–70.
Aldridge RT, Campbell PE. Ganglion cell distribution in the normal rectum and anal canal A basis for the diagnosis of Hirschsprung’s disease by anorectal biopsy. J Pediatr Surg. 1968;3(4):475–90.
Chow CW, Campbell PE. Short segment Hirschsprung’s disease as a cause of discrepancy between histologic, histochemical, and clinical features. J Pediatr Surg. 1983;18(2):167–71.
Swenson O, Sherman JO, Fisher JH. Diagnosis of congenital megacolon: an analysis of 501 patients. J Pediatr Surg. 1973;8(5):587–94.
Orr JD, Scobie WG. Presentation and incidence of Hirschsprung’s disease. Br Med J. 1983;287(6406):1671.
Meier-Ruge W. Ultrashort Hirschsprung’s disease: a bioptically safely substantiated disease. Eur J Pediatr Surg. 1985;40(3):146–50.
Meier-Ruge W, Schärli AF. The epidemiology and enzyme histotopochemical characterization of ultrashort-segment Hirschsprung’s disease. Pediatr Surg Int. 1986;1(1):37–42.
Fadda B, Welskop J, Müntefering H, Meier-Ruge W, Engert J. Achalasia of the anal sphincter - enzyme-histotopochemical studies of internal sphincter muscle biopsies. Pediatr Surg Int. 1987;2(2):81–5.
Martucciello G, Prato AP, Puri P, Holschneider AM, Meier-Ruge W, Jasonni V, et al. Controversies concerning diagnostic guidelines for anomalies of the enteric nervous system: a report from the fourth International Symposium on Hirschsprung’s disease and related neurocristopathies. J Pediatr Surg. 2005;40(10):1527–31.
Doodnath R, Puri P. Internal anal sphincter achalasia. Semin Pediatr Surg. 2009;18(4):246–8.
Baumgarten HG, Holstein AF, Stelzner F. Nervous elements in the human colon of Hirschsprung’s disease - with comparative remarks on neuronal profiles in the normal human and monkey colon and sphincter ani internus. Virchows Arch A Pathol Pathol Anat. 1973;358(2):113–36.
Ariel I, Hershlag A, Lernau OZ, Nissan S, Rosenmann E. Hypoganglionosis of the myenteric plexus with normal Meissner’s plexus: a new variant of colonic ganglion cell disorders. J Pediatr Surg. 1985;20(1):90–2.
Ueno S, Sato T, Yokoyama S, Soeda J, Tajima T, Mitomi T. Granular-cell tumorlike Schwann cell degeneration in the anal sphincter of an infant suspected of having ultrashort Hirschsprung’s disease. Pediatr Surg Int. 1995;10(2-3):196–8.
Fujimoto T, Puri P, Miyano T. Abnormal peptidergic innervation in internal sphincter achalasia. Pediatr Surg Int. 1992;7(1):12–7.
Hirakawa H, Kobayashi H, Sean O’Briain D, Puri P. Absence of nadph-diaphorase activity in internal anal sphincter (Ias) achalasia. J Pediatr Gastroenterol Nutr. 1995;20(1):54–8.
Kobayashi H, Hirakawa H, Puri P. Abnormal internal anal sphincter innervation in patients with Hirschsprung’s disease and allied disorders. J Pediatr Surg. 1996;31(6):794–9.
Oue T, Puri P. Altered intramuscular innervation and synapse formation in internal sphincter achalasia. Pediatr Surg Int. 1999;15(3-4):192–4.
Rolle U, Piaseczna-Piotrowska A, Puri P. Interstitial cells of Cajal in the normal gut and in intestinal motility disorders of childhood. Pediatr Surg Int. 2007;23(12):1139–52.
Nissan S, Bar-Maor JA. Changing trends in presentation and management of Hirschsprung’s disease. J Pediatr Surg. 1971;6(1):10–5.
Clayden GS, Lawson JON. Investigation and management of long-standing chronic constipation in childhood. Arch Dis Child. 1976;51(12):918–23.
De Caluwé D, Yoneda A, Akl U, Puri P. Internal anal sphincter achalasia: outcome after internal sphincter myectomy. J Pediatr Surg. 2001;36(5):736–8.
Bagdzevicius R, Vaicekauskas V, Bagdzeviciute S. Experience of acetylcholinesterase histochemistry application in the diagnosis of chronic constipation in children. Medicina (Kaunas). 2007;43(5):376–84.
Ohashi S, Okamoto E, Toyosaka A, Suguro M, Kashitani M, Fujimoto A, et al. Pathophysiology of defecatory disturbance in the patient with Hirschsprung’s disease and chronically constipated patients with simple megarectum. Nippon Geka Gakkai Zasshi. 1985;86(9):1277–80.
Obata S, Fukahori S, Yagi M, Suzuki M, Ueno S, Ushijima K, et al. Internal anal sphincter achalasia: data from a nationwide survey of allied disorders of Hirschsprung’s disease in Japan. Surg Today. 2017;47(12):1429–33.
Taguchi T, Obata S, Ieiri S. Current status of Hirschsprung’s disease: based on a nationwide survey of Japan. Pediatr Surg Int. 2017;33(4):497–504.
Zani A, Eaton S, Morini F, Puri P, Rintala R, Heurn EV, et al. European Paediatric Surgeons’ Association Survey on the management of Hirschsprung disease. Eur J Pediatr Surg. 2017;27(1):096–101.
Ikawa H, Kim SH, Hendren WH, Donahoe PK. Acetylcholinesterase and manometry in the diagnosis of the constipated child. Arch Surg. 1986;121(4):435–8.
Jarvi K, Koivusalo A, Rintala RJ, Pakarinen MP. Anorectal manometry with reference to operative rectal biopsy for the diagnosis/exclusion of Hirschprung’s disease in children under 1 year of age. Int J Colorectal Dis. 2009;24(4):451–4.
Martelli H, Faverdin C, Devroede G, Goulet O, Jais JP, Hambourg M, et al. Can functional constipation begin at birth? Gastroenterol Int. 1998;11(1):1–11.
De Lorijn F, Kremer LCM, Reitsma JB, Benninga MA. Diagnostic tests in hirschsprung disease: a systematic review. J Pediatr Gastroenterol Nutr. 2006;42(5):496–505.
Ricciardi R, Counihan TC, Banner BF, Sweeney WB. What is the normal aganglionic segment of anorectum in adults? Dis Colon Rectum. 1999;42(3):380–2.
Ohi R, Yamaguchi M, Komatsu K, Kato H, Kasai M. Histochemical diagnosis of Hirschsprung’s disease and 2 point rectal mucosal biopsies for selection of surgical treatment. Nippon Geka Gakkai Zasshi. 1985;86(9):1281–3.
Tafazzoli K, Soost K, Wessel L, Wedel T. Topographic pecularities of the submucous plexus in the human anorectum - consequences for histopathologic evaluation of rectal biopsies. Eur J Pediatr Surg. 2005;15(3):159–63.
Knowles CH, Veress B, Kapur RP, Wedel T, Farrugia G, Vanderwinden JM, et al. Quantitation of cellular components of the enteric nervous system in the normal human gastrointestinal tract - report on behalf of the Gastro 2009 International Working Group. Neurogastroenterol Motil. 2011;23(2):115–24.
Taguchi T, Ieiri S, Miyoshi K, Kohashi K, Oda Y, Kubota A, et al. The incidence and outcome of allied disorders of Hirschsprung’s disease in Japan: Results from a nationwide survey. Asian J Surg. 2017;40(1):29–34.
Heikkinen M, Lindahl H, Rintala RJ. Long-term outcome after internal sphincter myectomy for internal sphincter achalasia. Pediatr Surg Int. 2005;21(2):84–7.
Doodnath R, Puri P. Long-term outcome of internal sphincter myectomy in patients with internal anal sphincter achalasia. Pediatr Surg Int. 2009;25(10):869–71.
Gui D, Rossi S, Runfola M, Macalini SC. Review article: Botulinum toxin in the therapy of gastrointestinal motility disorders. Aliment Pharmacol Ther. 2003;18(1):1–16.
Schäppi MG, Staiano A, Milla PJ, Smith VV, Dias JA, Heuschkel R, et al. A practical guide for the diagnosis of primary enteric nervous system disorders. J Pediatr Gastroenterol Nutr. 2013;57(5):677–86.
Friedmacher F, Puri P. Comparison of posterior internal anal sphincter myectomy and intrasphincteric botulinum toxin injection for treatment of internal anal sphincter achalasia: a meta-analysis. Pediatr Surg Int. 2012;28(8):765–71.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Singapore Pte Ltd.
About this chapter
Cite this chapter
Ueno, S. (2019). Internal Anal Sphincter Achalasia (IASA). In: Taguchi, T., Matsufuji, H., Ieiri, S. (eds) Hirschsprung’s Disease and the Allied Disorders. Springer, Singapore. https://doi.org/10.1007/978-981-13-3606-5_41
Download citation
DOI: https://doi.org/10.1007/978-981-13-3606-5_41
Published:
Publisher Name: Springer, Singapore
Print ISBN: 978-981-13-3605-8
Online ISBN: 978-981-13-3606-5
eBook Packages: MedicineMedicine (R0)