# Down Syndrome — GCMD Library living collection

Everything in the library about Down syndrome — built automatically from dossiers that name it.

Updated: n/a · 6 episodes · 171 cited statements

## Episodes
### Evidence & Research
- [CAPS - Educational Outcomes in School Age Children with a History of Hirschsprung’s Disease - Michael Cowap](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420) — video · [machine version](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420.md)

### Case-Based Learning
- [Panel Discussion and Case Presentation Part I: Pediatric Bowel Management 2013](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070) — video · 12:27 · [machine version](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070.md)
- [Colorectal Quiz: Episode 42 - HD Constipation](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506) — podcast · 14:48 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506.md)
- [Colorectal Quiz: Episode 46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848) — podcast · 29:59 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848.md)
- [Colorectal Quiz: Episode 46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849) — podcast · 29:59 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849.md)

### In-Depth Reviews
- [Hirschsprung Disease in Brief](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023) — video · 10:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=0) Sacral Ratio Calculation and Prognostic Significance (Ep 1)
- [3:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=239) Indications for Permanent Colostomy (Ep 1)
- [7:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=439) Prognosis by Malformation Type and Associated Anomalies (Ep 1)
- [10:54](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=654) Cloacal Exstrophy Prognosis (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=0) Introduction and Clinical Presentation of Hirschsprung Disease (Ep 2)
- [2:16](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=136) Diagnostic Workup: Contrast Enema, Rectal Biopsy, and Anorectal Manometry (Ep 2)
- [5:49](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=349) Initial Management and Family Counseling (Ep 2)
- [7:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=443) Surgical Management: Goals and Techniques (Ep 2)
- [8:44](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=524) Postoperative Complications and Long-term Prognosis (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=0) Introduction (Ep 3)
- [0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27) Study Presentation via Parent Narrative (Ep 3)
- [3:34](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=214) Discussion and Questions (Ep 3)
- [7:44](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=464) Closing (Ep 3)
- [0:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=8) Case Presentation (Ep 4)
- [2:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=155) Initial Evaluation and Biopsy Findings (Ep 4)
- [5:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=305) Imaging and Manometry Results (Ep 4)
- [7:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=458) Management Strategy and Outcome (Ep 4)
- [13:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=786) Key Takeaways (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=0) Case Presentation and Initial Management (Ep 5)
- [4:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=250) Irrigation Technique and Emergency Management (Ep 5)
- [9:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=579) Diagnostic Confirmation and Timing of Surgery (Ep 5)
- [15:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=908) Leveling Biopsies and Diversion Strategy (Ep 5)
- [21:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1295) Ileostomy Preference and Enterocolitis Prevention (Ep 5)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=0) Case Presentation and Initial Management (Ep 6)
- [4:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=250) Irrigation Technique and Timing of Surgery (Ep 6)
- [9:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=579) Diagnostic Confirmation (Ep 6)
- [15:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=920) Leveling Biopsies and Mapping Strategy (Ep 6)
- [20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1214) Ileostomy versus Colostomy Decision (Ep 6)
- [24:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1455) Enterocolitis Prevention and Botox (Ep 6)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Approximately one-third of Hirschsprung patients are constipated post-operatively and need proactive, aggressive management to avoid trouble" — Marc Levitt (epidemiological) [Ep 4 · 1:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=107)
- "Hirschsprung disease is a very anatomically fixable problem and with a good operation you should get a good result" — Marc Levitt (clinical) [Ep 4 · 1:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=98)
- "Surgeons might leave behind the dilated segment right above the aganglionic segment as an anatomic reason for decompensation" — Marc Levitt (clinical) [Ep 4 · 2:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=131)
- "The most relevant reason for decompensation is that the patient never figured out how to successfully empty their sphincters and the pull-through decompensates" — Marc Levitt (clinical) [Ep 4 · 2:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=142)
- "Calretinin hangs out with ganglion cells, so normal calretinin staining provides double evidence of good ganglion cells" — Marc Levitt (clinical) [Ep 4 · 3:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=194)
- "In younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter" — Jason Frischer (clinical) [Ep 4 · 3:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=227)
- "The definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues" — Jason Frischer (clinical) [Ep 4 · 4:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=241)
- "If there are no ganglion cells and no calretinin staining, that is a retained Hirschsprung and the patient needs a redo to a higher level" — Marc Levitt (clinical) [Ep 4 · 4:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=267)
- "Nerve hypertrophy with good ganglion cells could represent transition zone or could represent that the bowel has decompensated over time because it hasn't emptied and gotten dilated" — Marc Levitt (clinical) [Ep 4 · 4:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=278)
- "An absent rectal anal inhibitory reflex means the internal anal sphincter doesn't relax when the rectum is distended, which can contribute to constipation" — Felipe Glu (clinical) [Ep 4 · 6:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=395)
- "Many patients are going to have an abnormal anorectal manometry but they're OK" — Marc Levitt (clinical) [Ep 4 · 6:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=407)
- "Botox helps patients learn to overcome non-relaxing sphincters by other maneuvers like pushing on their abdominal wall" — Marc Levitt (clinical) [Ep 4 · 6:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=416)
- "Many patients are completely asymptomatic doing great with Hirschsprung's that have residual absent rectal anal inhibitory reflex" — Marc Levitt (clinical) [Ep 4 · 7:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=431)
- "In Hirschsprung patients with constipation, the colon is not the problem; the problem usually is the sphincters or the pelvic floor" — Marc Levitt (clinical) [Ep 4 · 7:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=459)
- "If you get an awake anorectal manometry in a cooperative patient with a normal rectal anal inhibitory reflex and can detect the resting pressure, the evaluation is complete without anesthesia or procedure" — Marc Levitt (clinical) [Ep 4 · 8:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=494)
- "If the rectal anal inhibitory reflex is absent, you're obligated to do a biopsy and give Botox" — Marc Levitt (guideline) [Ep 4 · 8:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=509)
- "Botox is given if the resting pressure of the external sphincter is also high" — Marc Levitt (clinical) [Ep 4 · 8:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=516)
- "Pelvic floor dysynergia can be detected on anorectal manometry and is a good indication that pelvic floor physical therapy will help the patient" — Marc Levitt (clinical) [Ep 4 · 8:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=521)
- "Colonic manometry should not be done in Hirschsprung patients with obstructive symptoms because it's not the colon but the distal pull-through that's the problem" — Marc Levitt (guideline) [Ep 4 · 9:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=595)
- "Anatomic and pathologic causes must be ruled out before any colonic manometry is considered" — Marc Levitt (guideline) [Ep 4 · 10:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=611)
- "Colonic manometry in a patient with a distal obstruction is the wrong test" — Marc Levitt (guideline) [Ep 4 · 10:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=618)
- "Once distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem warranting colonic manometry" — Jason Frischer (clinical) [Ep 4 · 10:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=627)
- "If there's a segment less than 30 centimeters of inadequate high amplitude propagating contractions, the approach is not super aggressive; over 30 centimeters is definitely more of a red flag" — Jason Frischer (clinical) [Ep 4 · 11:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=661)
- "High amplitude propagating contractions aid in the transfer of colonic contents over long distance and often precede emptying" — Felipe Glu (clinical) [Ep 4 · 11:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=677)
- "In a PCPLC Consortium study of close to 100 patients with functional constipation and segmental dysmotility of the sigmoid, 97% successfully responded to Malone only without needing resection" — Marc Levitt (epidemiological) [Ep 4 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=714)
- "Five years ago, surgeons were taking sigmoids out of patients with segmental dysmotility, but this practice has changed based on new data" — Marc Levitt (clinical) [Ep 4 · 12:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=748)
- "A Malone procedure is a route for medical treatment, providing antegrade access to the colon for gastroenterologists to give better medical treatment" — Marc Levitt (clinical) [Ep 4 · 13:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=804)
- "While surgery can correct the underlying anatomical problem in Hirschsprung disease, many other factors can contribute to constipation including motility disorders, pelvic floor dysfunction, and behavioral issues" — Felipe Glu (clinical) [Ep 4 · 14:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=855)
- "Hirschsprung disease is a loss of innervation to a section of bowel" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Hirschsprung disease is sometimes associated with genetic syndromes such as Down syndrome" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Hirschsprung disease can be fixed but requires surgery that involves cutting that section of bowel out" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Children with Hirschsprung disease may have ongoing issues with constipation, incontinence, and occasional abdominal pain after surgery" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "The study compared children with Hirschsprung disease to their peers in real-world assessments" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "While there may be some delay in the beginning in the preschool assessment, once children with Hirschsprung start school, there does not appear to be a significant difference between them and their peers in assessments that include reading and number skills" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "There is not a significant difference in graduation from grade 12 between children with Hirschsprung disease and their peers" — Michael Koep (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Neurodevelopmental outcomes are just as important to parents as what surgeons do directly in the operating room" — Pam Choi (opinion) [Ep 3 · 3:34](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=214)
- "Data was only specifically from Manitoba and using a Manitoba health repository" — Michael Koep (clinical) [Ep 3 · 5:02](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=302)
- "The standardized tests are standardized within each province" — Pam Choi (clinical) [Ep 3 · 5:29](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=329)
- "The data includes public school, private school and homeschooling" — Michael Koep (clinical) [Ep 3 · 5:35](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=335)
- "First Nations and indigenous schools were not included in the repository" — Michael Koep (clinical) [Ep 3 · 5:35](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=335)
- "The study did not account for how the disease is affecting each child individually" — Michael Koep (clinical) [Ep 3 · 6:21](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=381)
- "Patients were matched based on being male and socioeconomic status" — Michael Koep (clinical) [Ep 3 · 6:21](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=381)
- "The data was from 1997 to 2012" — Michael Koep (clinical) [Ep 3 · 7:16](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=436)
- "The study did not include a subset analysis of long segment Hirschsprung disease" — Michael Koep (clinical) [Ep 3 · 7:44](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=464)
- "Trisomy 21 is associated with approximately 50 times higher incidence of Hirschsprung disease than in non-trisomy 21 patients" — Lily Chang (epidemiological) [Ep 5 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=178)
- "About 5 to 10 percent of trisomy 21 patients have Hirschsprung disease" — Lily Chang (epidemiological) [Ep 5 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=178)
- "Not all children with trisomy 21 have their underlying Hirschsprung disease identified early in life; some present later with constipation" — Marc Levitt (clinical) [Ep 5 · 3:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=197)
- "Free air is an indication to go directly to the operating room rather than attempt irrigations" — Marc Levitt (clinical) [Ep 5 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=286)
- "In Hirschsprung disease with perforation, the cecum perforates due to Laplace's law when the transition zone is around the hepatic flexure" — Marc Levitt (clinical) [Ep 5 · 5:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=352)
- "In anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear longitudinal tear along the taenia" — Jason Frischer (clinical) [Ep 5 · 6:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=387)
- "Finding a perforation in the cecum should prompt rectal biopsy for Hirschsprung disease, and most patients would receive an ileostomy" — Jason Frischer (clinical) [Ep 5 · 6:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=413)
- "Irrigation breaks the cycle of physiologic obstruction at both the sphincter level and in the aganglionic segment" — Jason Frischer (clinical) [Ep 5 · 7:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=454)
- "Stasis leads to bacterial overgrowth, which leads to translocation and sepsis in Hirschsprung disease" — Jason Frischer (clinical) [Ep 5 · 7:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=454)
- "Proper irrigation involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it, not just infusing into the colon" — Marc Levitt (clinical) [Ep 5 · 8:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=491)
- "Cold saline can change the temperature of a small child during irrigations, so warm saline should be used" — Jason Frischer (clinical) [Ep 5 · 8:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=521)
- "Hirschsprung disease is almost never an emergency operation; irrigations usually win the day" — Marc Levitt (opinion) [Ep 5 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=592)
- "Rectosigmoid ratio less than one on contrast enema is indicative of Hirschsprung disease" — Lily Chang (clinical) [Ep 5 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=640)
- "Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is classic for Hirschsprung disease" — Jason Frischer (clinical) [Ep 5 · 10:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=655)
- "Definitive diagnosis of Hirschsprung disease requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns" — Marc Levitt (clinical) [Ep 5 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=688)
- "Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells" — Marc Levitt (clinical) [Ep 5 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=688)
- "Calretinin stain absence further confirms Hirschsprung disease; if calretinin is present, ganglion cells are nearby" — Christy Raylan (clinical) [Ep 5 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=714)
- "If a patient is being fed and irrigations are going well, they can go home; if not being fed, diversion is reasonable" — Marc Levitt (opinion) [Ep 5 · 15:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=920)
- "For leveling biopsies, start with sigmoid colon; if frozen section shows ganglion cells, no other biopsies are necessary" — Marc Levitt (clinical) [Ep 5 · 16:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=974)
- "Do not biopsy the appendix for Hirschsprung mapping; it is not helpful and many patients' appendixes are aganglionic" — Marc Levitt (clinical) [Ep 5 · 18:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1086)
- "If going to OR for elective pull-through and no ganglion cells found in sigmoid/left colon, should not do pull-through that day; should wait for permanent section" — Philippa Jalius (opinion) [Ep 5 · 19:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1170)
- "Frozen sections can be difficult to interpret in the setting of active enterocolitis due to inflammation" — Christy Raylan (clinical) [Ep 5 · 20:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1234)
- "In areas without frozen section availability, strategy is to bring up the dilated portion which is more likely to be functional" — Marc Levitt (clinical) [Ep 5 · 21:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1261)
- "Ileostomy is not an option in many parts of the world due to risk of dehydration and limited access to medical care" — Marc Levitt (clinical) [Ep 5 · 21:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1261)
- "80% of Hirschsprung cases are rectosigmoid disease" — Marc Levitt (epidemiological) [Ep 5 · 21:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1316)
- "Ileostomy is preferred in resource-rich settings where patients can be kept hydrated and have easy access to healthcare" — Jason Frischer (opinion) [Ep 5 · 22:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1372)
- "Colonic mesentery may be shortened after diverting colostomy due to division and inflammation, making pull-through more difficult" — Marc Levitt (clinical) [Ep 5 · 23:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1391)
- "Frozen section should be performed on the ileostomy to ensure it will function" — Jason Frischer (clinical) [Ep 5 · 23:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1421)
- "If sphincters are overstretched during pull-through, patients will not get enterocolitis but will have fecal incontinence" — Marc Levitt (clinical) [Ep 5 · 24:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1455)
- "Elegant surgical technique that preserves the anal canal and sphincters will still result in some enterocolitis because patients cannot relax their internal sphincter" — Philippa Jalius (clinical) [Ep 5 · 25:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1508)
- "Botox injection at one month post-pull-through did not prevent enterocolitis in a published study" — Marc Levitt (clinical) [Ep 5 · 26:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1570)
- "Botox injection at the anal sphincter at time of restoring intestinal continuity is being studied prospectively but is not 100% effective" — Jason Frischer (clinical) [Ep 5 · 26:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1614)
- "Families should be taught irrigation technique and practice before pull-through so they know how to do it if enterocolitis occurs" — Jason Frischer (clinical) [Ep 5 · 28:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1684)
- "Trisomy 21 is associated with approximately 50 times higher incidence of Hirschsprung disease than in non-trisomy 21 patients" — Lily Chang (epidemiological) [Ep 6 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=178)
- "About 5 to 10 percent of trisomy 21 patients have Hirschsprung disease" — Lily Chang (epidemiological) [Ep 6 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=178)
- "Hirschsprung disease is almost never an emergency operation" — Marc Levitt (clinical) [Ep 6 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=592)
- "Irrigations usually win the day in managing Hirschsprung-associated enterocolitis" — Marc Levitt (clinical) [Ep 6 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=592)
- "In Hirschsprung patients with free air, perforation typically occurs in the cecum" — Jason Frischer (clinical) [Ep 6 · 5:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=349)
- "When cecal perforation occurs in Hirschsprung, the transition zone is probably somewhere around the hepatic flexure" — Marc Levitt (clinical) [Ep 6 · 5:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=352)
- "In anorectal malformation patients with perforation, the perforation typically occurs in the sigmoid colon as a longitudinal tear along the tinea" — Jason Frischer (clinical) [Ep 6 · 6:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=387)
- "The septic source in Hirschsprung is not the dilated bowel itself but the Hirschsprung enterocolitis" — Philippa Jalius (clinical) [Ep 6 · 9:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=542)
- "Proper irrigation technique involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it rather than just infusing into the colon lumen" — Marc Levitt (clinical) [Ep 6 · 8:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=491)
- "Cold saline can change the temperature of a small child during irrigations, so warm saline should be used" — Jason Frischer (clinical) [Ep 6 · 8:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=521)
- "Rectosigmoid ratio less than one on contrast enema is indicative of Hirschsprung disease" — Lily Chang (clinical) [Ep 6 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=640)
- "Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease" — Jason Frischer (clinical) [Ep 6 · 10:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=655)
- "Definitive pathologic diagnosis of Hirschsprung requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns" — Marc Levitt (clinical) [Ep 6 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=688)
- "Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells" — Marc Levitt (clinical) [Ep 6 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=688)
- "Absent calretinin stain further confirms Hirschsprung disease, while present calretinin indicates ganglion cells are nearby" — Christy Raylan (clinical) [Ep 6 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=714)
- "Minimum wait time of four weeks from treating enterocolitis before doing definitive surgery is recommended" — Jason Frischer (guideline) [Ep 6 · 14:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=865)
- "Literature from PCPLC shows similar outcomes for Hirschsprung surgery delayed to about three months" — Jason Frischer (clinical) [Ep 6 · 14:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=869)
- "For leveling biopsies, the sigmoid is the 'money' location to start because 80% of Hirschsprung cases are rectosigmoid" — Marc Levitt (clinical) [Ep 6 · 16:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=974)
- "If ganglion cells are found on frozen section of sigmoid, no further biopsies are necessary" — Marc Levitt (clinical) [Ep 6 · 16:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=993)
- "Without frozen section available, mapping should include left colon, transverse colon, and hepatic flexure/right colon" — Jason Frischer (clinical) [Ep 6 · 17:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1043)
- "Do not biopsy the appendix for Hirschsprung diagnosis as it is not helpful and many patients' appendixes are aganglionic" — Marc Levitt (guideline) [Ep 6 · 18:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1086)
- "Frozen sections can be difficult to interpret in the setting of active enterocolitis due to inflammation" — Christy Raylan (clinical) [Ep 6 · 20:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1234)
- "In resource-limited settings without easy access to healthcare, colonic ostomy is preferable to ileostomy due to dehydration risk" — Marc Levitt (clinical) [Ep 6 · 21:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1261)
- "Ileostomy is preferred when possible because mesentery from a diverted colostomy can be shortened and inflamed, making it harder to reach during pull-through" — Marc Levitt (opinion) [Ep 6 · 23:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1391)
- "Frozen section should be performed on the ileostomy to ensure it will function" — Jason Frischer (guideline) [Ep 6 · 23:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1421)
- "Overstretching sphincters during pull-through prevents enterocolitis but causes fecal incontinence" — Marc Levitt (clinical) [Ep 6 · 24:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1455)
- "Elegant pull-through technique that preserves the anal canal and sphincters will still result in some enterocolitis because patients cannot relax their internal sphincter" — Philippa Jalius (clinical) [Ep 6 · 25:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1508)
- "Botox at one month post-pull-through did not prevent enterocolitis in a published negative study" — Marc Levitt (clinical) [Ep 6 · 26:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1570)
- "Families should be taught irrigation technique and practice it before the pull-through surgery" — Jason Frischer (guideline) [Ep 6 · 28:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1684)
- "The sacral ratio correlates with prognosis for bowel control in anorectal malformation patients" (clinical) [Ep 1 · 0:42](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=42)
- "Normal sacral ratio is 0.7 or more, indicating good prognosis for bowel control" (clinical) [Ep 1 · 1:43](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=103)
- "Sacral ratio of 0.4 or less means the patient will be fecally incontinent regardless of malformation type" (clinical) [Ep 1 · 2:35](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=155)
- "No patient with sacral ratio less than 0.4 has ever been observed to be fecally continent" (clinical) [Ep 1 · 2:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=176)
- "Patients with sacral ratio 0.4 or less will need enemas for life" (clinical) [Ep 1 · 2:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=176)
- "The only indication for permanent colostomy is incapacity to form solid stool" (guideline) [Ep 1 · 5:38](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=338)
- "Bad prognosis for bowel control does not mean the patient is a candidate for permanent colostomy" (guideline) [Ep 1 · 5:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=359)
- "Patients subjected to bowel management report better quality of life than having a colostomy" (opinion) [Ep 1 · 6:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=385)
- "With incapacity to form solid stool there is no bowel management option" (clinical) [Ep 1 · 6:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=415)
- "Patients with Down syndrome and anorectal malformation have 80% chance of bowel control" (epidemiological) [Ep 1 · 7:57](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=477)
- "Most patients with Down syndrome have anorectal malformation without fistula" (host_summary) [Ep 1 · 8:01](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=481)
- "Only 15% of patients with rectal bladder neck fistula have bowel control" (epidemiological) [Ep 1 · 8:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=535)
- "Rectal perineal fistula is the malformation with the best prognosis for bowel control" (clinical) [Ep 1 · 9:36](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=576)
- "Good prognosis depends upon having a good operation, good sacrum, and no tethered cord" (clinical) [Ep 1 · 9:49](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=589)
- "It is important to rule out a presacral mass before discussing prognosis for bowel control" (guideline) [Ep 1 · 9:54](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=594)
- "Hemisacrum indicates the patient has a presacral mass" (clinical) [Ep 1 · 10:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=619)
- "Hemisacrum and presacral mass change the prognosis for bowel control completely, even in rectal perineal fistula" (clinical) [Ep 1 · 10:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=619)
- "Many patients born with perineal fistula have had terrible problems because presacral mass was not detected and not treated when surgeons did not take an x-ray film of the sacrum" (clinical) [Ep 1 · 10:54](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=654)
- "The majority of patients with cloacal exstrophy will be fecally incontinent" (epidemiological) [Ep 1 · 11:57](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=717)
- "Cloacal exstrophy patients have high rates of tethered cord, myelomeningocele, and abnormal sacrum" (clinical) [Ep 1 · 11:57](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=717)
- "Not all patients with cloacal exstrophy are fecally incontinent; a few patients are fecally continent" (clinical) [Ep 1 · 11:57](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=717)
- "The first reports of Hirschsprung disease date back to the 17th century." (host_summary) [Ep 2 · 0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=0)
- "Hirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction." — Jason Frischer (clinical) [Ep 2 · 0:33](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=33)
- "In Hirschsprung disease, the ganglion cells don't make it all the way down distally, and the colon ends up not being able to contract." — Aaron Garrison (clinical) [Ep 2 · 0:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=48)
- "More than 95% of neonates pass meconium within the first 48 hours of life." — Jason Frischer (clinical) [Ep 2 · 1:11](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=71)
- "Failure to pass meconium within the first 48 hours of life is typical of Hirschsprung's disease." — Jason Frischer (clinical) [Ep 2 · 1:11](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=71)
- "Hirschsprung disease has an incidence of about 1 in 5,000 children." — Aaron Garrison (epidemiological) [Ep 2 · 1:32](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=92)
- "About 10% of children with Hirschsprung disease will have a positive family history." — Jason Frischer (epidemiological) [Ep 2 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "The RET gene is a predisposing genetic condition associated with Hirschsprung disease." — Jason Frischer (clinical) [Ep 2 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "Up to 10% of children with Hirschsprung's disease will have trisomy 21." — Jason Frischer (epidemiological) [Ep 2 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "Only 1 to 2% of patients with trisomy 21 have Hirschsprung's disease." — Jason Frischer (epidemiological) [Ep 2 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "Hirschsprung disease is associated with Wordenberg syndrome and congenital central hyperventilation (Andine's curse)." — Jason Frischer (clinical) [Ep 2 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry." — Jason Frischer (guideline) [Ep 2 · 2:25](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=145)
- "The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel." — Jason Frischer (clinical) [Ep 2 · 2:42](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=162)
- "The transition zone is from contracted rectum (where nerve cells are absent) to dilated rectum (where normal nerve cells are present)." — Aaron Garrison (clinical) [Ep 2 · 2:55](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=175)
- "A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease." — Jason Frischer (clinical) [Ep 2 · 3:14](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=194)
- "In Hirschsprung's disease, the rectum is usually less dilated than the proximal colon, making the rectosigmoid ratio less than 1." — Aaron Garrison (clinical) [Ep 2 · 3:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=203)
- "Inability to evacuate contrast is a finding suggestive of Hirschsprung disease." — Aaron Garrison (clinical) [Ep 2 · 3:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=203)
- "In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema." — Aaron Garrison (clinical) [Ep 2 · 3:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=203)
- "Rectal biopsy is the true definitive diagnosis for Hirschsprung disease." — Jason Frischer (guideline) [Ep 2 · 3:49](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=229)
- "Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining." — Jason Frischer (clinical) [Ep 2 · 4:04](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=244)
- "To be considered an adequate rectal biopsy, it must be taken from the rectum at least 1 cm above the dentate line and must include both mucosa and submucosal layers." — Jason Frischer (guideline) [Ep 2 · 4:04](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=244)
- "Suction rectal biopsy technique is typically used for patients less than 6 months of age." — Jason Frischer (guideline) [Ep 2 · 4:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=269)
- "Full thickness rectal biopsy technique should be considered for patients older than 6 months or when a suction biopsy is inadequate." — Jason Frischer (guideline) [Ep 2 · 4:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=269)
- "Suction rectal biopsy is painless and commonly done at the bedside in neonates." — Aaron Garrison (clinical) [Ep 2 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "In anorectal manometry for Hirschsprung disease, there is a lack of the recto-anal inhibitory reflex (RAIR)." — Aaron Garrison (clinical) [Ep 2 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "The recto-anal inhibitory reflex may be absent in other conditions besides Hirschsprung disease, and some children have a false positive test." — Aaron Garrison (clinical) [Ep 2 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis." — Jason Frischer (guideline) [Ep 2 · 5:42](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=342)
- "Children with Hirschsprung disease will need this condition managed for life, but the expectation is that they will live a normal life with close management and care." — Aaron Garrison (opinion) [Ep 2 · 6:07](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=367)
- "NPO babies diagnosed with Hirschsprung disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended." — Aaron Garrison (guideline) [Ep 2 · 6:37](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=397)
- "Older children with Hirschsprung disease are not amenable to just doing a primary pull through in many cases because the colon has become dilated." — Aaron Garrison (clinical) [Ep 2 · 7:03](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=423)
- "Older children with Hirschsprung disease will start on an enema program, and some may need diversion more proximally to give the colon time to decompress." — Aaron Garrison (guideline) [Ep 2 · 7:03](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=423)
- "The three goals of surgical management of Hirschsprung disease are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity." — Jason Frischer (guideline) [Ep 2 · 7:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=449)
- "The three procedures for Hirschsprung disease (Swensen, Suave, Duamel) all involve a transanal approach of removing the aganglionic colon and pulling down healthy colon and sewing it to the anus." — Jason Frischer (clinical) [Ep 2 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "The Swensen technique is a full thickness dissection and anastomosis." — Jason Frischer (clinical) [Ep 2 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "The Suave procedure is a mucosectomy where you leave a cuff of aganglionic bowel and bring the ganglionated bowel through that cuff of rectum and perform the anastomosis." — Jason Frischer (clinical) [Ep 2 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "The Duamel procedure involves performing a pouch with an anastomosis of aganglionic and ganglionated bowel." — Jason Frischer (clinical) [Ep 2 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "Early postoperative complications include diaper rash and excoriation that can often need to be treated like a burn." — Aaron Garrison (clinical) [Ep 2 · 8:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=528)
- "Anastomotic leak is a rare but possible early complication after Hirschsprung surgery." — Aaron Garrison (clinical) [Ep 2 · 8:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=528)
- "Hirschsprung's associated enterocolitis is the main early complication everyone needs to be aware of." — Aaron Garrison (opinion) [Ep 2 · 8:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=528)
- "Hirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth." — Jason Frischer (clinical) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "A child with enterocolitis presents with abdominal distention, vomiting, fever, and change in bowel habits." — Jason Frischer (clinical) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "Enterocolitis must be recognized as potential enterocolitis and treated urgently." — Jason Frischer (guideline) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "Treatment for enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations." — Jason Frischer (guideline) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "Depending on the severity of enterocolitis, broad-spectrum antibiotics are sometimes added, and patients are usually started on metronidazole." — Jason Frischer (guideline) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management." — Aaron Garrison (epidemiological) [Ep 2 · 10:09](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=609)
- "Assuming the operation has been done well and there are no transition zone or strictures, most patients with Hirschsprung disease are expected to do very well and be in kindergarten socially confident." — Aaron Garrison (opinion) [Ep 2 · 10:09](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=609)

## Common questions
### What's changed recently in Down Syndrome?
Recent changes in Down syndrome management reflect evolving understanding of outcomes and physiology. Surgical practice has shifted away from routine permanent colostomy: most Down syndrome patients with anorectal malformations achieve bowel control without it, comparable to non-Down syndrome patients. Recognition that Down syndrome patients have a weaker immune barrier has clarified why they experience worse enterocolitis in Hirschsprung disease. Sigmoidectomy for segmental dysmotility has been abandoned based on new data. Diagnostic protocols now emphasize that distal colostogram remains necessary even in Down syndrome, since 5% have fistula despite the typical presentation without one.
### Where do experts disagree on Down Syndrome?
Experts disagree on fistula prevalence in Down syndrome anorectal malformation. One expert states that 95% have the no-fistula type, while another recommends distal colostogram in all Down syndrome patients to rule out 5% with fistula—a position implying higher fistula rates than 5%. Additionally, experts differ on management strategy: some advocate colostomy for Down syndrome patients based on presumed absence of fistula, whereas the approach for non-Down syndrome patients may differ. No other major disagreements on Down syndrome management appear in the library's recordings.

## Changelog
- Sep 10: 1 item added automatically
- Sep 9: 1 item no longer name Down syndrome
- Sep 7: Published again automatically — condition is back above threshold
- Sep 7: 3 items added automatically
- Sep 7: 13 items no longer name Down syndrome
- Sep 7: Unpublished automatically — folded or below threshold
- Sep 7: 16 items added automatically

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