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University of Groningen Genetics Dissection and Functional University of Groningen Genetics dissection and functional studies in Hirschsprung disease Sribudiani, Yunia IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2011 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Sribudiani, Y. (2011). Genetics dissection and functional studies in Hirschsprung disease Groningen: s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 11-02-2018 Genetic Dissection and Functional Studies in Hirschsprung Disease Yunia Sribudiani Genetic Dissection and Functional Studies in Hirschsprung Disease Y. Sribudiani PhD Thesis – Department of Genetics University Medical Center Groningen, University of Groningen Groningen, the Netherlands This study was financially supported by University of Groningen and Research Institute GUIDE. ISBN/EAN: 978-94-6182-039-6 Cover Ilustration: Ella Elviana, www.ellasworks.blogspot.com Cover & book layout: Briyan B Hendro, www.brianos.daportfolio.com Printed by: Off Page, Amsterdam, www.offpage.nl Printing of this thesis was financially supported by: University of Groningen, GUIDE and Department of Genetics - UMCG. Copyright ©2011 Y.Sribudiani. All rights reserved. No part of this book may be reproduced, stored in retrieval system, or transmitted in any form or by any means, without prior permission of the author. RIJKSUNIVERSITEIT GRONINGEN Genetic Dissection and Functional Studies in Hirschsprung Disease Proefschrift ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. E. Sterken, in het openbaar te verdedigen op woensdag 21 december 2011 om 14.30 uur door Yunia Sribudiani geboren op 28 juni 1977 te Bandung, Indonesië Promotor : Prof. dr. R.M.W. Hofstra Beoordelingscommissie : Prof. dr. I. Ceccherini Prof. dr. U.L.M. Eisel Prof. dr. H.W.G.M. Boddeke CONTENTS Chapter 1 General Introduction 1 Chapter 2 Fine mapping of the 9q31 Hirschsprung disease locus 23 Hum Genet, 2010 Jun; 127(6):675-83 Chapter 3 Exome sequencing in a family with Hirschsprung disease 45 Manuscript in preparation Chapter 4 Variant in RET associated with Hirschsprung disease 59 affect binding of transcription factor and gene expression Gastroenterology, 2011 Feb; 140(2):572-582.e2 Chapter 5 RET mediated gene expression in ENS precursors 83 shows involvement of RET in innate immune response Submitted Chapter 6 General discussions and future perspective 123 Appendices Summary 138 Samenvatting 141 Ringkasan 145 List of Abbreviations 149 Acknowledgments 151 General Introduction 1. Hirschsprung Disease: Diagnosis and Treatment 1.1 Diagnosis Hirschsprung (HSCR) disease, also known as congenital megacolon, is characterized by the absence of enteric ganglia (aganglionosis) in the submucosal and myenteric plexuses of the gastrointestinal (GI) tract leading to a life-threatening bowel distention which presents itself usually shortly after birth.1 HSCR disease was first recognized in 1887 by the Danish pediatri- cian Harald Hirschsprung. He described two boys who died at age 8 and 11 years with severe constipation. HSCR is clinically characterized by a failure to pass meconium (the first stool) within 48 hours after birth, abdominal distention, vomiting or neonatal enterocoilitis.2 In par- ticular, enterocolitis can prove life-threatening in HSCR. The mortality rate of HSCR disease due to enterocolitis ranges from 0-30%. The variation is most likely due to differences in di- agnosing Hirschsprung-associated enterocolitis (HAEC).3,4 The gold standard for diagnosing HSCR disease is the histopathology of a full-thickness rectal biopsy in which the neurons and glial cells (ganglia) are absent in both the myenteric and submucosal plexus of the GI tract of HSCR patients.5 Measurement of the pressures in the rectum (rectal manometry) and X-rays made with a barium enema are methods that can provide extra information to the physi- cian for an accurate diagnosis. The dilated (mega)colon is proximal to the aganglionic region, which narrows towards the distal part and an empty rectum is a common finding.1 In 75% of cases, the diagnoses is made within six weeks of birth and in 90% of cases, the disease is diagnosed before the age of five years.6 The length of the aganglionic region varies and based on this HSCR disease is classified into short-segment HSCR (S-HSCR), long-segment HSCR (L-HSCR) and total colonic/intesti- nal aganglionosis (TCA/TIA). S-HSCR is the most common type (80% of cases) and the length of the aganglionic region does not extend beyond the upper sigmoid. Fifteen percent of the patients have L-HSCR in which the aganglionic region extends beyond the upper sigmoid. In about 5% of cases, the TCA/TIA is diagnosed. In these patients the complete colon and the terminal part of the ileum show an absence of ganglia and in rare cases even the whole bowel can lack ganglia, which is a lethal condition.1, 7-9 HSCR is the most common developmental disorder of the enteric nervous system (ENS) with a prevalence of 1 in 5000 newborns, although variation of the prevalence is observed be- tween ethnic populations.10 Interestingly, a sex-dependent penetrance is observed in S-HSCR with a male:female ratio of 4:1. With respect to these findings, it is interesting to report that the transmission of disease-causing alleles in this group is also disturbed, as 78% of the com- monly shared RET allele, the major risk factor for HSCR development, are maternally de- 2 Chapter 1 rived.11, 12 Whether the male:female ratio is caused by these differences in the transmission of associated alleles is not yet known. HSCR most commonly presents sporadically, although in approximately 20% of cases, several members in a family are affected (familial HSCR). In 70% of cases, HSCR occurs as an isolated trait and in the other 30% HSCR is associated with other congenital malformation or syndromes. A B http://radiopaedia.org/images/135545 http://praanadah-hospital.com/procedures/hirschsprung_disease Figure 1 - A) Barium enema X-ray of HSCR patient’s bowel, the arrows shows the beginning of the agan- glionic region. B) Treatment of HSCR patient with pull-through surgery to remove the aganglionic region and rejoin the healthy ganglionated colon to the anus. 1.2 Treatment Current treatment of HSCR is surgical resection of the aganglionic part of the gastro- intestinal (GI) tract. These operations, so called pull-through operations, are mostly based on the procedures developed by Swenson, Duhamel or Soave. In this surgical procedure the affected region of the colon is removed and the healthy ganglionated region of the colon is rejoined with the anus.13-15 A one-stage procedure (one operation) is possible when the diag- nosis of HSCR is made before the colon dilates. Otherwise a primary colostomy is temporarily required before the patient has the second pull-through surgery to remove the aganglionic region. Although the surgical procedure relieves the patient’s constipation and has proven life-saving, the long-term outcome remains rather poor, irrespective of the length of the agan- glionic region. A retrospective study performed by Catto-Smith and colleagues showed that fecal incontinence is very common and episodic constipations have also been reported.16 These clinical findings have led researchers to think about developing alternative treat- ments for HSCR disease. One method that seems promising is ENS replacement therapy. 3 General Introduction Metzger and colleagues showed that enteric nervous system stem cells (ENSSCs) can be iso- lated from postnatal human gut mucosal biopsy and used to generate neurosphere-like bod- ies (NLBs). More importantly, they showed that these NLBs have the same stem cell plasticity as those generated from embryonic human gut tissue and, when grafted onto aganglionic chick hindgut, these NLBs have the ability to migrate and differentiate into glial cells and dif- ferent types of ENS neurons. Whether these grafted cells function correctly and whether they repair the ENS system needs further investigation. These preliminary results show, however, that ENSSCs transplantation might have therapeutic potential and could, in the future, be considered as an additional therapy for HSCR disease.17 2. Pathogenesis of Hirschsprung Disease: Genetic Background 2.1 Genes involved in the development of HSCR disease The genetic dissection of HSCR has led to the identification of 12 genes and five susceptibil- ity loci implicated in the development of HSCR disease. These 12 genes are expressed either in the enteric neural crest cells (ENCCs) or in other cells in the gut along the path of ENCCs migration during ENS development. The inheritance of HSCR is considered to be complex. The disease can be
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