Neuro-Immune Interactions in the Gut (NIG)

The Enteric Nervous System as Modulator of Mucosal Immune Cells

Hirschsprung's disease (HD) is diagnosed shortly after birth and is characterized by the presence of megacolon. HD is caused when ganglion cells of the enteric nervous system (ENS) in the wall of the large intestine do not develop before birth. This results in a lack of gastrointestinal motility and leads to stool obstruction. It is known that ablation of enteric nerves is associated with intestinal infection and inflammation. Indeed the most severe complication in HD is Hirschsprung's associated enterocolitis (HAEC), characterized by explosive diarrhea, abdominal distension, fever and impending septic shock. Bacteria overgrowth and changes in colonic mucosal immune cell populations during HAEC suggest a possible defect in mucosal immune homeostasis. Under steady state conditions, the mucosal immune system must be tightly controlled to avoid harmful reactions against commensal flora and food antigens, while allowing protective immune responses against invading pathogens. This balance between tolerance and defense is influenced by the mucosal microenvironment, which in turn determines the phenotype and stability of mucosal immune cell populations. The goal of this project is to understand if the enteric nervous system plays a role in regulating mucosal immunity and how this might contribute to the development of HAEC.

Study Overview

• Status: Completed
• Conditions: Hirschsprung's Disease Associated Enterocolitis

Detailed Description

Hirschsprung's disease (HD) is diagnosed shortly after birth and is characterized by the absence of enteric nerves in parts of colon [Amiel et al.]. Following surgical correction many patients develop HD-associated enterocolitis (HAEC), a condition distinguished by intestinal inflammation resulting in abdominal distension, severe diarrhea, fever and sepsis [Demehri et al.]. The underlying factors leading to HAEC remain poorly understood and likely involve a defect in epithelial barrier, including decreased mucin production and insufficient immunoglobulin translocation. The establishment of the epithelial barrier is dependent on epithelial recognition of microbial products by innate immune receptors, like toll-like receptors (TLRs) [Peterson et al.]. TLR-dependent epithelial recognition of microflora also coordinates the immune response away from harmless commensal bacteria and towards pathogenic invaders. Both innate and adaptive effector cell functions are influenced by epithelial-derived signals. Under homeostatic conditions commensal bacteria induce anti-inflammatory cytokines in epithelial cells which trigger a tolerogenic phenotype in mucosal antigen presenting cells (APC) resulting in generation of commensal-specific regulatory T cells (Tregs) [Curotto de Lafaille et al.]. During infection, recognition of pathogenic organisms by epithelial cells leads to secretion of inflammatory cytokines thereby inducing an inflammatory APC phenotype which promotes T effector cell (Th1, Th17) generation. The enteric nervous system is directly located underneath the epithelium and controls epithelial cell function. Ablation of enteric glia cells, one of the two cell types of the ENS, in mice is associated with inflammation and enterocolitis [Cornet et al.]. In a study from 2011 Flamant and co-workers demonstrate that enteric glia cells protect from a shigella flexneri invasion by preventing lesions in the epithelial barrier mediated by the glia cell derived neurothrophic factor S-nitrosoglutathione (GSNO) [Flamant et al.]. We hypothesize that the lack of an enteric nervous system in HD patients modulates the microbial recognition of epithelial cells and thereby the phenotype of underlying mucosal APCs and effector T cells; this might be associated with the manifestation of HAEC.

• Study Type: Observational
• Enrollment (Actual): 103

Contacts and Locations

Study Locations

• Germany
  • Heidelberg, Germany, 69120
    • Kinderchirurgie Universität Heidelberg
• Switzerland
  • Bellinzona, Switzerland, 6500
    • Ospedale Regionale di Bellinzona e Valli
  • Bern, Switzerland, 3010
    • Inselspital Universität Bern
  • Geneva, Switzerland, 1205
    • Hôpitaux Universitaires Genève
  • Lausanne, Switzerland, 1011
    • Bâtiment Hospitalier CHUV
  • Luzern, Switzerland, 6000
    • Luzerner Kantonsspital
  • Saint Gallen, Switzerland, 9000
    • Kinderspital St. Gallen
  • Zürich, Switzerland, 8032
    • Kinderspital Zürich

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 year to 16 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

patients between 0 and 18 years undergoing bowel resection

Description

Inclusion Criteria:

Informed consent

Exclusion Criteria:

No signed informed consent No blood from patients with weak general state of health

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Hirschsprung's disease patients; Children diagnosed with Hirschsprung's disease or Hirschsprung's disease associated enterocolitis
control patients; Children diagnosed and treated for miscellaneous bowel diseases

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Phenotypic analysis of immune and nervous cell populations	Determining cell frequencies and subtypes using fluorescence-activated cell sorting (FACS) and FlowJo software	5 years
Expression profil	RNA expression profile of whole colon tissue and single cell populations	5 years
Histological analysis	Microscopic analysis of colonic tissue using immunofluorescence and immunohistochemistry	5 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Microbial metagenomics sequencing	16S/18S/ITS Amplicon	5 years
Identifying genetic defect	Targeted Sanger sequencing of known Hirschsprung's disease associated genes	5 years

Collaborators and Investigators

• Sponsor: University Children's Hospital Basel
• Collaborators: University Children's Hospital, Zurich; Luzerner Kantonsspital; Inselspital Universität Bern; Kinderspital St. Gallen; Bâtiment Hospitalier CHUV; Universität Klinikum Heidelberg; Hôpitaux Universitaires Genève; Ospedale Regionale di Bellinzona e Valli
• Investigators: Principal Investigator: Stefan Holland-Cunz, Prof, University Children's Hospital Basel

Publications and helpful links

General Publications

• Amiel J, Lyonnet S. Hirschsprung disease, associated syndromes, and genetics: a review. J Med Genet. 2001 Nov;38(11):729-39. doi: 10.1136/jmg.38.11.729.
• Demehri FR, Halaweish IF, Coran AG, Teitelbaum DH. Hirschsprung-associated enterocolitis: pathogenesis, treatment and prevention. Pediatr Surg Int. 2013 Sep;29(9):873-81. doi: 10.1007/s00383-013-3353-1.
• Peterson LW, Artis D. Intestinal epithelial cells: regulators of barrier function and immune homeostasis. Nat Rev Immunol. 2014 Mar;14(3):141-53. doi: 10.1038/nri3608.
• Curotto de Lafaille MA, Lafaille JJ. Natural and adaptive foxp3+ regulatory T cells: more of the same or a division of labor? Immunity. 2009 May;30(5):626-35. doi: 10.1016/j.immuni.2009.05.002.
• Cornet A, Savidge TC, Cabarrocas J, Deng WL, Colombel JF, Lassmann H, Desreumaux P, Liblau RS. Enterocolitis induced by autoimmune targeting of enteric glial cells: a possible mechanism in Crohn's disease? Proc Natl Acad Sci U S A. 2001 Nov 6;98(23):13306-11. doi: 10.1073/pnas.231474098. Epub 2001 Oct 30.
• Flamant M, Aubert P, Rolli-Derkinderen M, Bourreille A, Neunlist MR, Mahe MM, Meurette G, Marteyn B, Savidge T, Galmiche JP, Sansonetti PJ, Neunlist M. Enteric glia protect against Shigella flexneri invasion in intestinal epithelial cells: a role for S-nitrosoglutathione. Gut. 2011 Apr;60(4):473-84. doi: 10.1136/gut.2010.229237. Epub 2010 Dec 7.
• Rusmini M, Griseri P, Lantieri F, Matera I, Hudspeth KL, Roberto A, Mikulak J, Avanzini S, Rossi V, Mattioli G, Jasonni V, Ravazzolo R, Pavan WJ, Pini-Prato A, Ceccherini I, Mavilio D. Induction of RET dependent and independent pro-inflammatory programs in human peripheral blood mononuclear cells from Hirschsprung patients. PLoS One. 2013;8(3):e59066. doi: 10.1371/journal.pone.0059066. Epub 2013 Mar 18. Erratum In: PLoS One. 2013;8(4). doi:10.1371/annotation/d3a96ff5-2a66-4454-8d8d-932ad4cfe906.

Study record dates

Study Major Dates

• Study Start (Actual): February 28, 2015
• Primary Completion (Actual): February 28, 2022
• Study Completion (Actual): February 28, 2022

Study Registration Dates

• First Submitted: July 24, 2018
• First Submitted That Met QC Criteria: July 31, 2018
• First Posted (Actual): August 6, 2018

Study Record Updates

• Last Update Posted (Actual): November 4, 2022
• Last Update Submitted That Met QC Criteria: November 3, 2022
• Last Verified: November 1, 2022

More Information

Terms related to this study

• Keywords: Immune cells; enteric neuropathies; Nervous cells; Microbiom
• Additional Relevant MeSH Terms: Digestive System Diseases; Congenital Abnormalities; Gastrointestinal Diseases; Gastroenteritis; Colonic Diseases; Intestinal Diseases; Digestive System Abnormalities; Megacolon; Enterocolitis; Hirschsprung Disease
• Other Study ID Numbers: EKNZ 2015-049

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No