Lack of Mucosal Cholinergic Innervation Is Associated With Increased Risk of Enterocolitis in Hirschsprung's Disease

Cell Mol Gastroenterol Hepatol. 2021;12(2):507-545. doi: 10.1016/j.jcmgh.2021.03.004. Epub 2021 Mar 16.


Background & aims: Hirschsprung's disease (HSCR) is a congenital intestinal motility disorder defined by the absence of enteric neuronal cells (ganglia) in the distal gut. The development of HSCR-associated enterocolitis remains a life-threatening complication. Absence of enteric ganglia implicates innervation of acetylcholine-secreting (cholinergic) nerve fibers. Cholinergic signals have been reported to control excessive inflammation, but the impact on HSCR-associated enterocolitis is unknown.

Methods: We enrolled 44 HSCR patients in a prospective multicenter study and grouped them according to their degree of colonic mucosal acetylcholinesterase-positive innervation into low-fiber and high-fiber patient groups. The fiber phenotype was correlated with the tissue cytokine profile as well as immune cell frequencies using Luminex analysis and fluorescence-activated cell sorting analysis of colonic tissue and immune cells. Using confocal immunofluorescence microscopy, macrophages were identified in close proximity to nerve fibers and characterized by RNA-seq analysis. Microbial dysbiosis was analyzed in colonic tissue using 16S-rDNA gene sequencing. Finally, the fiber phenotype was correlated with postoperative enterocolitis manifestation.

Results: The presence of mucosal nerve fiber innervation correlated with reduced T-helper 17 cytokines and cell frequencies. In high-fiber tissue, macrophages co-localized with nerve fibers and expressed significantly less interleukin 23 than macrophages from low-fiber tissue. HSCR patients lacking mucosal nerve fibers showed microbial dysbiosis and had a higher incidence of postoperative enterocolitis.

Conclusions: The mucosal fiber phenotype might serve as a prognostic marker for enterocolitis development in HSCR patients and may offer an approach to personalized patient care and new therapeutic options.

Keywords: Cholinergic Nerve Fibers; Enterocolitis; Macrophages; Microbiome; Neuroimmunology; Th17 Cells.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acetylcholinesterase / metabolism
  • Child
  • Child, Preschool
  • Cholinergic Neurons / pathology*
  • Cohort Studies
  • Cytokines / metabolism
  • Dysbiosis / immunology
  • Dysbiosis / microbiology
  • Dysbiosis / pathology
  • Enterocolitis / etiology*
  • Epithelial Cells / metabolism
  • Epithelial Cells / pathology
  • Female
  • Hirschsprung Disease / complications*
  • Hirschsprung Disease / pathology
  • Hirschsprung Disease / surgery
  • Humans
  • Infant
  • Infant, Newborn
  • Inflammation / immunology
  • Intestinal Mucosa / innervation*
  • Intestinal Mucosa / pathology*
  • Lipopolysaccharide Receptors / metabolism
  • Macrophages / metabolism
  • Male
  • Phenotype
  • RNA, Messenger / genetics
  • RNA, Messenger / metabolism
  • Risk Factors


  • Cytokines
  • Lipopolysaccharide Receptors
  • RNA, Messenger
  • Acetylcholinesterase