# Enterocolitis — GCMD Library living collection

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

Updated: n/a · 24 episodes · 760 cited statements

## Episodes
### Fundamentals
- [Hirschsprung Disease – PediaCast 287](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877) — podcast · 38:55 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877.md)

### Diagnosis & Workup
- [Evaluation & Management Of Hirschsprung's Disease](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626) — video · 44:35 · [machine version](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626.md)
- [Radiology and Image Diagnosis of Hirschsprung Disease](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733) — video · 44:35 · [machine version](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733.md)
- [Hirschsprung Disease: Radiology Aspect](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030) — video · 43:27 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030.md)

### Medical Management
- [Hirschsprung Disease Audience Q&A with Dr. Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440) — podcast · 12:40 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440.md)

### Complications
- [Colorectal - Clinical Practice Updates](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997) — video · 52:31 · [machine version](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997.md)
- [Hirschsprung Disease Part II with Dr. Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310) — podcast · 44:38 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310.md)
- [Update Course Rewind: 2020 Colorectal Part 1](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801) — podcast · 12:25 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801.md)
- [The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616) — podcast · 19:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616.md)
- [Hirschsprung Disease Part 2](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875) — podcast · 44:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875.md)
- [Hirschsprung Disease Part 2](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876) — podcast · 44:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876.md)

### Evidence & Research
- [The use of postoperative calibrations in Hirschsprung disease](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460) — video · 0:59 · [machine version](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460.md)
- [Update Course Rewind 2025: Botox for Hirschsprung’s: Where, When, and Why](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049) — video · 1:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049.md)

### Case-Based Learning
- [Hirschsprung Disease Rapid Fire: Update Course 2015](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985) — video · 12:14 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985.md)
- [Hirschsprung Disease: Update Course 2015](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000) — video · 7:42 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000.md)
- [Hirschsprung Disease: Update Course 2013](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056) — video · 38:06 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056.md)
- [Hirschsprung Disease: Update Course 2013](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061) — video · 38:50 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061.md)
- [Colorectal Quiz Episode 3: Hirschsprung Disease](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649) — podcast · 20:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649.md)

### In-Depth Reviews
- [Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675) — video · 25:37 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675.md)
- [Hirschsprung's Disease](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187) — podcast · 20:48 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187.md)
- [DrBeen Medical Lectures: Dr. Marc Levitt, MD Discusses Hirschsprung Disease](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227) — video · 53:42 · [machine version](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227.md)
- [Hirschsprung](https://library.globalcastmd.com/watch/hirschsprung-13870) — podcast · 22:45 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-13870.md)
- [Hirschsprung's Disease with Dr. Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871) — podcast · 22:45 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871.md)

### Patient & Family Education
- [Hirschsprung-associated enterocolitis in children: An ERNICA animation for parents and families](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808) — video · 3:23 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=0) Postoperative Dilation Protocols in Hirschsprung Disease (Ep 18)
- [0:00](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=0) Introduction and Plain Radiograph Findings in Hirschsprung Disease (Ep 1)
- [5:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=341) Enterocolitis Recognition on Plain Films and Enema Accuracy (Ep 1)
- [11:20](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=680) Contrast Enema Technique - Dr. Ocelami's Approach (Ep 1)
- [21:31](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1291) Contrast Enema Technique - Dr. Kraus's Approach and Long-Segment Disease Challenges (Ep 1)
- [31:40](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1900) Post-Operative Enema Findings and Clinical Debate on Ultra-Short Segment Disease (Ep 1)
- [40:00](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2400) Closing Remarks on Internal Sphincter Achalasia Concept (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=0) Introduction and recap of previous trauma episode (Ep 12)
- [2:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=140) Post-pull-through enterocolitis: presentation and pathophysiology (Ep 12)
- [5:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=320) Anatomic causes of post-pull-through obstruction (Ep 12)
- [8:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=500) Acute enterocolitis management protocol (Ep 12)
- [10:22](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=622) Evaluation of recurrent enterocolitis: contrast study and exam under anesthesia (Ep 12)
- [12:41](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=761) Examination under anesthesia technique and biopsy (Ep 12)
- [18:03](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1083) Surgical management of transition-zone pull-through (Ep 12)
- [20:13](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1213) Surgical management of obstructing Soave cuff (Ep 12)
- [23:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1423) Role of Botox in sphincter achalasia (Ep 12)
- [27:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1630) Management of twisted pull-through (Ep 12)
- [29:41](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1781) Redo of failed Duhamel pouch (Ep 12)
- [32:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1955) Evaluation of the soiling patient (Ep 12)
- [36:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2175) Four clinical scenarios in soiling patients (Ep 12)
- [42:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2559) Surgical options for incontinence and closing remarks (Ep 12)
- [0:01](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=1) Definition and pathophysiology of enterocolitis (Ep 17)
- [0:35](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=35) Epidemiology and triggers (Ep 17)
- [1:33](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=93) Acute management (Ep 17)
- [2:11](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=131) Investigation of underlying causes and long-term management (Ep 17)
- [2:52](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=172) Follow-up and prognosis (Ep 17)
- [0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=0) Hirschsprung Disease: Surgical Approach Selection (Ep 2)
- [6:10](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=370) Hirschsprung Complications and Dissection Technique (Ep 2)
- [12:50](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=770) Anorectal Malformations: Vestibular Fistula Management (Ep 2)
- [19:43](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1183) Rectal Prolapse: Surgical Management (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=0) Introduction and Plain Radiograph Findings (Ep 3)
- [5:41](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=341) Enterocolitis on Plain Radiographs (Ep 3)
- [11:20](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=680) Accuracy of Contrast Enema (Ep 3)
- [15:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=900) Contrast Enema Technique - Dr. Ocelami (Ep 3)
- [21:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1290) Contrast Enema Technique - Dr. Kraus (Ep 3)
- [26:40](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1600) Case Examples and Transition Zone Pitfalls (Ep 3)
- [31:40](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1900) Post-operative Imaging and Surgical Techniques (Ep 3)
- [40:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2400) Ultra-short Segment and Internal Sphincter Achalasia Controversy (Ep 3)
- [0:01](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=1) Introduction and Topic Overview (Ep 19)
- [0:28](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=28) Audience Poll Results (Ep 19)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "The study was prospective and took place from 2021 to 2023" — Lizzie Lee (clinical) [Ep 18 · 0:13](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=13)
- "The study included 33 patients under six months old who underwent endorectal pull-through surgeries" — Lizzie Lee (clinical) [Ep 18 · 0:13](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=13)
- "Patients were assigned to either a new non-dilation protocol group or a traditional dilation group" — Lizzie Lee (clinical) [Ep 18 · 0:24](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=24)
- "The primary outcomes measured were anastomotic complications, enterocolitis, and constipation" — Lizzie Lee (clinical) [Ep 18 · 0:30](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=30)
- "There was no significant difference in anastomotic complications between the two groups" — Lizzie Lee (clinical) [Ep 18 · 0:37](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=37)
- "The non-dilation group had less enterocolitis compared to the traditional dilation group" — Lizzie Lee (clinical) [Ep 18 · 0:37](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=37)
- "The non-dilation group had less constipation compared to the traditional dilation group" — Lizzie Lee (clinical) [Ep 18 · 0:37](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=37)
- "Choosing not to do postoperative anal dilations may be a good alternative with benefits like lower constipation and enterocolitis" — Lizzie Lee (opinion) [Ep 18 · 0:46](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=46)
- "Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art." — Steven Kraus (opinion) [Ep 1 · 1:02](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=62)
- "Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities." — Steven Kraus (clinical) [Ep 1 · 1:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=101)
- "In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction." — Steven Kraus (clinical) [Ep 1 · 3:23](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=203)
- "The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases." — Steven Kraus (clinical) [Ep 1 · 3:57](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=237)
- "Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease." — Steven Kraus (clinical) [Ep 1 · 5:32](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=332)
- "The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph." — Steven Kraus (clinical) [Ep 1 · 5:43](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=343)
- "Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis." — Steven Kraus (clinical) [Ep 1 · 6:58](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=418)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise." — Steven Kraus (clinical) [Ep 1 · 8:14](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=494)
- "The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease." — Steven Kraus (clinical) [Ep 1 · 9:46](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=586)
- "The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies." — Steven Kraus (epidemiological) [Ep 1 · 10:33](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=633)
- "Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate." — Steven Kraus (clinical) [Ep 1 · 11:04](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=664)
- "The false positive transition zone rate on enema is up to 43%." — Steven Kraus (epidemiological) [Ep 1 · 11:20](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=680)
- "Radiologist agreement on transition zone location is fairly high at 90%." — Steven Kraus (epidemiological) [Ep 1 · 11:35](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=695)
- "The concordance rate between radiology and pathology for transition zone location is only about 62% overall." — Steven Kraus (epidemiological) [Ep 1 · 11:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=707)
- "For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%." — Steven Kraus (epidemiological) [Ep 1 · 13:27](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=807)
- "For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%." — Steven Kraus (epidemiological) [Ep 1 · 13:54](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=834)
- "If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization." — Steven Kraus (clinical) [Ep 1 · 14:05](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=845)
- "In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization." — Steven Kraus (opinion) [Ep 1 · 14:29](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=869)
- "The technique for contrast enema involves inserting only a small part of the rectal tube (2-3 cm) into the rectum." — Rodrigo Ocelami (clinical) [Ep 1 · 16:34](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=994)
- "Never use a Foley catheter inside the rectum for contrast enema in suspected Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 1 · 16:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1002)
- "In the neonatal period, use water-soluble contrast diluted 50% with saline." — Rodrigo Ocelami (clinical) [Ep 1 · 17:04](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1024)
- "Inject contrast very slowly and gently with a syringe under continuous fluoroscopy to avoid distending the aganglionic segment." — Rodrigo Ocelami (clinical) [Ep 1 · 17:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1036)
- "After the neonatal period, fill only up to the transverse colon; if the studied segment appears normal in distension, caliber, and mucosa, and the splenic flexure shows no suggestion of total colonic disease, stop at the transverse colon." — Rodrigo Ocelami (clinical) [Ep 1 · 17:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1061)
- "Obtain images in left lateral, right lateral, and AP positions, and remove the tube to visualize the rectum without obstruction." — Rodrigo Ocelami (clinical) [Ep 1 · 18:10](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1090)
- "The primary finding to look for is the transition zone; once found, the diagnosis is made and contrast administration can stop." — Rodrigo Ocelami (clinical) [Ep 1 · 18:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1127)
- "Inversion of the rectosigmoid index is a helpful sign in diagnosing Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 1 · 19:03](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1143)
- "The aganglionic segment will appear spastic, which is why contrast should not be given in large amounts or too fast, or the spasticity will be missed." — Rodrigo Ocelami (clinical) [Ep 1 · 19:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1158)
- "Always counsel families about good hydration after the study and show them the contrast material so they know what to expect when the child evacuates it." — Rodrigo Ocelami (clinical) [Ep 1 · 20:08](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1208)
- "The main technical points are: never use a Foley in the rectum, inject contrast very slowly and gently under continuous fluoroscopy, and look for the diagnostic signs." — Rodrigo Ocelami (clinical) [Ep 1 · 20:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1247)
- "Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains." — Steven Kraus (clinical) [Ep 1 · 21:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1302)
- "Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly." — Steven Kraus (clinical) [Ep 1 · 22:31](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1351)
- "Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe." — Steven Kraus (clinical) [Ep 1 · 23:01](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1381)
- "If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus." — Steven Kraus (clinical) [Ep 1 · 23:30](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1410)
- "Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants." — Steven Kraus (clinical) [Ep 1 · 23:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1427)
- "A true lateral image with femurs superimposed is essential to visualize the presacral space properly." — Steven Kraus (clinical) [Ep 1 · 24:03](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1443)
- "In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum." — Steven Kraus (clinical) [Ep 1 · 24:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1458)
- "If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis." — Steven Kraus (clinical) [Ep 1 · 24:40](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1480)
- "Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology." — Steven Kraus (clinical) [Ep 1 · 25:04](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1504)
- "In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small." — Steven Kraus (clinical) [Ep 1 · 25:30](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1530)
- "In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung." — Steven Kraus (clinical) [Ep 1 · 25:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1542)
- "Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy." — Steven Kraus (clinical) [Ep 1 · 26:03](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1563)
- "In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced." — Steven Kraus (clinical) [Ep 1 · 26:15](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1575)
- "Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt." — Steven Kraus (clinical) [Ep 1 · 28:06](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1686)
- "The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure." — Steven Kraus (clinical) [Ep 1 · 29:30](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1770)
- "A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum." — Steven Kraus (clinical) [Ep 1 · 29:51](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1791)
- "When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests." — Steven Kraus (clinical) [Ep 1 · 30:51](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1851)
- "If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain." — Steven Kraus (opinion) [Ep 1 · 31:07](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1867)
- "Dr. Ponsky performs suction rectal biopsy in almost any patient who required a contrast enema to rule out distal obstruction, regardless of whether the enema suggests meconium plug, small left colon, or other diagnosis." — Todd Ponsky (opinion) [Ep 1 · 31:46](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1906)
- "Dr. Pena would perform rectal biopsy in a case of apparent small left colon because he cannot distinguish it from Hirschsprung disease." — Alberto Peña (opinion) [Ep 1 · 32:44](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1964)
- "In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view." — Steven Kraus (clinical) [Ep 1 · 34:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2058)
- "A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space." — Steven Kraus (clinical) [Ep 1 · 34:55](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2095)
- "The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end." — Steven Kraus (clinical) [Ep 1 · 35:51](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2151)
- "In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction." — Steven Kraus (clinical) [Ep 1 · 36:13](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2173)
- "Dr. Pena questions whether patients who develop the characteristic dilated Duhamel pouch actually had true Hirschsprung disease, since by definition aganglionic bowel should not distend even after 10-15 years." — Alberto Peña (opinion) [Ep 1 · 36:54](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2214)
- "Dr. Pena recommends that when resecting a Duhamel pouch, the specimen should be oriented and the pathologist alerted to determine whether ganglion cells are present in the rectal portion, to test the hypothesis that these were misdiagnosed cases." — Alberto Peña (opinion) [Ep 1 · 37:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2261)
- "Dr. Collins reports that the Duhamel pouches she has examined pathologically have contained both ganglionic and aganglionic parts." — Todd Ponsky (clinical) [Ep 1 · 38:05](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2285)
- "Dr. Pena states that if he sees a patient with megacolon and constipation on enema, he will not perform a rectal biopsy because it is a waste of time from his point of view." — Alberto Peña (opinion) [Ep 1 · 40:28](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2428)
- "Dr. Pena argues that taking a biopsy in a patient with idiopathic constipation risks getting an aganglionic result that does not mean anything, because the patient does not have Hirschsprung disease." — Alberto Peña (opinion) [Ep 1 · 40:39](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2439)
- "There is a normal physiologic aganglionic segment in the distal rectum, but its length at different ages (preterm, term, 6 months) has never been accurately determined in humans." — Alberto Peña (clinical) [Ep 1 · 41:32](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2492)
- "Someone could take a biopsy in the normal physiologic aganglionic area and get a result of no ganglion cells, which does not indicate Hirschsprung disease." — Alberto Peña (clinical) [Ep 1 · 42:05](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2525)
- "The internal sphincter has been defined as a thickening of the circular layer of normal smooth muscle bowel, but Dr. Pena states he has never personally observed this thickening when opening normal rectums at different ages." — Alberto Peña (opinion) [Ep 1 · 42:14](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2534)
- "If the internal sphincter thickening exists, nobody has determined its exact boundaries at different ages." — Alberto Peña (clinical) [Ep 1 · 42:45](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2565)
- "Internal sphincter achalasia is a manometric concept, not an anatomic concept, similar to the lower esophageal sphincter." — Alberto Peña (opinion) [Ep 1 · 43:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2596)
- "Dr. Pena does not perform or recommend myectomies, myotomies, or botulinum toxin injections for internal sphincter achalasia because the target muscle area is undefined and these procedures paralyze muscle to facilitate stool passage rather than curing a condition of unknown origin." — Alberto Peña (opinion) [Ep 1 · 43:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2596)
- "The vast majority of Hirschsprung patients do extremely well post-pull-through with normal emptying and bowel control." — Marc Levitt (clinical) [Ep 12 · 3:29](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=209)
- "Post-pull-through problem patients divide into two types: obstruction (failure to empty) and soiling." — Marc Levitt (clinical) [Ep 12 · 3:37](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=217)
- "Enterocolitis after a well-done pull-through is common in babies because they have very tight sphincters and can keep them tight for many hours." — Marc Levitt (clinical) [Ep 12 · 4:25](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=265)
- "After about age one, patients should learn to empty and relax their sphincters; enterocolitis after age one needs evaluation." — Marc Levitt (clinical) [Ep 12 · 4:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=299)
- "Evaluation of recurrent enterocolitis involves a contrast study of the colon and an examination under anesthesia." — Marc Levitt (clinical) [Ep 12 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=320)
- "Anatomic causes of post-pull-through obstruction include distal stricture, obstructing Soave cuff, atonic Duhamel pouch, twisted pull-through (up to 360°), and dilated distal segment." — Marc Levitt (clinical) [Ep 12 · 5:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=338)
- "An obstructing Soave cuff is aganglionic outer rectal wall that can cause obstruction if not properly split or if it has fused or scarred." — Marc Levitt (clinical) [Ep 12 · 5:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=350)
- "Pathologic cause of obstruction is pull-through to transition-zone bowel without healthy ganglion cells or with nerve roots larger than 40 microns." — Marc Levitt (clinical) [Ep 12 · 7:14](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=434)
- "Acute enterocolitis treatment: IV hydration, IV metronidazole (most effective antibiotic), and aggressive rectal irrigations 2–3 times daily with 10–20 cc/kg saline via size 20–22 Foley catheter." — Marc Levitt (clinical) [Ep 12 · 8:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=500)
- "If irrigations fail to relieve distention and improve the baby, the tube may not be reaching high enough or the patient may need an ileostomy." — Marc Levitt (clinical) [Ep 12 · 10:04](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=604)
- "Metronidazole (Flagyl) has the same efficacy IV or PO because in both cases it is excreted in the bile." — Marc Levitt (clinical) [Ep 12 · 11:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=681)
- "In a diverted colon with ileostomy, oral or IV Flagyl will not work for colitis because the drug exits via the ileostomy; vancomycin enemas are needed." — Marc Levitt (clinical) [Ep 12 · 11:32](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=692)
- "Literature reports 15–20% of patients have an episode of enterocolitis within the first year after pull-through." — Marc Levitt (epidemiological) [Ep 12 · 12:13](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=733)
- "On contrast study, look for cuff indentation in the presacral space; the pull-through should hug the sacrum, and anterior deviation suggests a space-occupying cuff." — Marc Levitt (clinical) [Ep 12 · 13:09](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=789)
- "An obstructing Soave cuff can be felt on digital rectal exam under anesthesia as a rubbery thick rubber-band structure in the sacral hollow, outside the pull-through." — Marc Levitt (clinical) [Ep 12 · 16:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=994)
- "Gastroenterologists used to intraluminal scope visualization may miss an obstructing cuff because it is outside the pull-through lumen." — Marc Levitt (clinical) [Ep 12 · 17:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1022)
- "Full-thickness biopsy should be taken 1 cm above the dentate line and sent for permanent section to assess ganglion cell quality and nerve size; frozen section is not reliable for this critical redo diagnosis." — Marc Levitt (clinical) [Ep 12 · 17:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1050)
- "Transition-zone bowel (ganglion cells present but hypertrophic nerves >40 microns) that is not functioning well requires redo pull-through." — Marc Levitt (clinical) [Ep 12 · 18:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1097)
- "Redo pull-through for transition zone: transanal dissection preserving anal canal and dentate line, plus laparotomy or laparoscopy to mobilize to healthy ganglionated bowel, often requiring removal of retained sigmoid curve." — Marc Levitt (clinical) [Ep 12 · 18:27](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1107)
- "For redo transanal dissection, hug the bowel to find the Swenson plane outside the original pull-through and outside the retained aganglionic cuff, which is an areolar space that has never been operated on." — Marc Levitt (clinical) [Ep 12 · 19:25](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1165)
- "To remove an obstructing Soave cuff: dissect pull-through from cuff, then dissect cuff from Swenson plane, and excise the cuff posteriorly and laterally to break the ring—complete circumferential removal is unnecessary." — Marc Levitt (clinical) [Ep 12 · 20:31](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1231)
- "Avoid aggressive anterior cuff dissection near the urethra and vagina; breaking the ring posterolaterally solves the obstruction." — Marc Levitt (clinical) [Ep 12 · 21:24](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1284)
- "Myectomies that have been traditionally successful may have inadvertently cut the Soave cuff rather than the internal sphincter." — Marc Levitt (opinion) [Ep 12 · 21:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1311)
- "Myectomy technique varies widely among surgeons; it is not standardized and can injure skeletal muscle, causing incontinence." — Marc Levitt (opinion) [Ep 12 · 22:09](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1329)
- "Post-pull-through sphincter problems are relatively rare compared to anatomic causes like cuff, stricture, or transition-zone bowel." — Marc Levitt (opinion) [Ep 12 · 24:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1474)
- "If all anatomic and pathologic causes are ruled out and the child still behaves obstructed, the sphincter must be the cause; this can be confirmed with anorectal manometry showing failure to relax." — Marc Levitt (clinical) [Ep 12 · 24:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1491)
- "Sphincter achalasia (tight sphincter with failure to relax) is relatively rare after age one; most children learn sphincter coordination over time." — Marc Levitt (clinical) [Ep 12 · 25:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1519)
- "Botox injection acts as a temporary myectomy and is preferred over permanent myectomy because it wears off as the child learns sphincter relaxation; a series of Botox injections is safer than permanent myectomy, which can cause incontinence." — Marc Levitt (clinical) [Ep 12 · 25:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1535)
- "Coordinate Botox with laxatives: inject Botox, then at 4–8 weeks (as Botox wears off) start aggressive laxatives so the child learns appropriate bowel movement pattern with reduced sphincter tone." — Marc Levitt (clinical) [Ep 12 · 26:07](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1567)
- "Botox may temporarily improve cuff obstruction if it migrates to the cuff level, but the patient will recur because the cuff must be surgically removed for long-term fix." — Marc Levitt (clinical) [Ep 12 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1605)
- "Anorectal manometry can measure the length of high-tone zone: 1 cm of high tone is sphincter achalasia; 3–4 cm is sphincter plus obstructing cuff." — Marc Levitt (clinical) [Ep 12 · 27:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1637)
- "Twisted pull-through: dissect in Swenson plane around pull-through to peritoneal reflection, then laparotomy (preferred over laparoscopy due to adhesions) to mobilize left colon, preserve sigmoid arcade, deliver bowel into abdomen, untwist, and re-pull-through." — Marc Levitt (clinical) [Ep 12 · 28:01](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1681)
- "Redo of failed Duhamel pouch is the hardest Hirschsprung redo due to pelvic fibrosis from the stapled anastomosis." — Marc Levitt (opinion) [Ep 12 · 30:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1818)
- "Duhamel redo technique: transanal dissection to separate pull-through from original rectum, then open abdominal approach with St. Mark's retractor for deep pelvic dissection, remove entire pouch, and convert to Swenson pull-through." — Marc Levitt (clinical) [Ep 12 · 31:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1860)
- "All Hirschsprung patients should be able to empty spontaneously and be clean; the concept that they will eventually get better as teenagers is wrong." — Marc Levitt (opinion) [Ep 12 · 33:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1995)
- "Hirschsprung patients are born with a normal anal canal and normal sphincters; if anything, their sphincters are too good (too tight)." — Marc Levitt (clinical) [Ep 12 · 33:48](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2028)
- "No Hirschsprung patient is born with a missing anal canal or weak sphincter; soiling due to these defects is iatrogenic from surgery." — Marc Levitt (clinical) [Ep 12 · 34:03](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2043)
- "Iatrogenic incontinence occurs when the surgeon starts transanal dissection too low and invades the dentate line, or overstretches the sphincter during dissection." — Marc Levitt (clinical) [Ep 12 · 34:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2068)
- "Laparoscopy-assisted pull-through avoids deep transanal work and reduces risk of sphincter overstretching compared to aggressive transanal dissection." — Marc Levitt (opinion) [Ep 12 · 35:04](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2104)
- "Soiling patient evaluation: determine original operation type (Soave, Duhamel, Swenson), assess sphincter patency (visual, digital, manometry), and assess dentate-line integrity during EUA." — Marc Levitt (clinical) [Ep 12 · 35:36](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2136)
- "Perform digital rectal exam as the patient goes to sleep (before full muscle relaxation) to assess sphincter squeeze; many soiling patients cannot squeeze." — Marc Levitt (clinical) [Ep 12 · 36:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2179)
- "Contrast study in soiling patients: narrow non-dilated pull-through suggests hypermotility; dilated pull-through suggests hypomotility." — Marc Levitt (clinical) [Ep 12 · 37:06](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2226)
- "Four soiling scenarios: (1) Good sphincter/anal canal + narrow colon = hypermotile, treat with loperamide, constipating diet, fiber; (2) Good sphincter/anal canal + dilated colon = hypomotile, treat with laxatives (bridge enemas until medical regimen works); (3) Lost sphincter/anal canal + narrow colon = hypermotile without continence capacity, treat with small-volume enema plus hypermotility agents; (4) Lost sphincter/anal canal + dilated colon = no continence capacity, treat with larger-volume enema." — Marc Levitt (clinical) [Ep 12 · 37:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2263)
- "Hirschsprung soiling differs from anorectal malformation incontinence: Hirschsprung patients were born with good anatomy, so incontinence must be iatrogenic from surgery." — Marc Levitt (clinical) [Ep 12 · 39:12](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2352)
- "Patients with intact sphincter and anal canal have capacity for bowel control and should achieve normal continence with appropriate medical management (laxatives or constipating agents)." — Marc Levitt (clinical) [Ep 12 · 40:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2435)
- "Capacity for bowel control is determined by intact sphincters and anal canal; if these are destroyed, the patient may not have the ability for voluntary bowel control." — Marc Levitt (clinical) [Ep 12 · 41:13](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2473)
- "Patients without capacity for bowel control (destroyed sphincter/anal canal) may need Malone appendicostomy or cecostomy for antegrade enema administration." — Marc Levitt (clinical) [Ep 12 · 42:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2550)
- "With methodical evaluation (contrast enema and examination under anesthesia), there is no problematic Hirschsprung patient that cannot be figured out and improved." — Marc Levitt (opinion) [Ep 12 · 43:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2580)
- "Enterocolitis is an inflammation of the intestine that occurs when the body does not get rid of poop quick enough" (clinical) [Ep 17 · 0:11](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=11)
- "A blockage forms in the large intestine, which causes it to swell" (clinical) [Ep 17 · 0:19](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=19)
- "Bacteria grows and enters the blood vessels" (clinical) [Ep 17 · 0:23](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=23)
- "In rare cases, a bowel perforation can occur, which is when a hole develops on the wall of the large intestine due to pressure" (clinical) [Ep 17 · 0:27](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=27)
- "Signs and symptoms of enterocolitis may include smelly explosive poop, which may sometimes contain blood, a swollen and painful belly, nausea and or vomiting, and fever" (clinical) [Ep 17 · 0:35](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=35)
- "An individual may also show signs of dehydration, such as a lack of activity and reduced urination" (clinical) [Ep 17 · 0:50](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=50)
- "Up to 40-50% of children with Hirschsprung's disease experience enterocolitis, either before or after surgical correction" (epidemiological) [Ep 17 · 0:58](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=58)
- "Enterocolitis is more common after surgical correction" (epidemiological) [Ep 17 · 1:08](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=68)
- "For a small number of children, enterocolitis can be persistent and occur repeatedly throughout their life" (clinical) [Ep 17 · 1:12](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=72)
- "Enterocolitis can be triggered by various different factors, such as a virus, bacterial infection, or intestinal dysbiosis" (clinical) [Ep 17 · 1:20](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=80)
- "To treat symptoms of enterocolitis in children, it is very important to remove the blockage of poop in the large intestine" (clinical) [Ep 17 · 1:33](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=93)
- "Irrigation is done using a special tube called a rectal cannula" (clinical) [Ep 17 · 1:42](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=102)
- "If enterocolitis becomes a repeated problem, your child's clinical team may teach you how to carry out irrigation at home" (guideline) [Ep 17 · 1:48](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=108)
- "Symptoms of dehydration can be treated with a drinkable rehydration solution or where necessary, fluid can be given to your child through a vein" (clinical) [Ep 17 · 1:56](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=116)
- "Blood infections must be prevented using antibiotic medication" (guideline) [Ep 17 · 2:06](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=126)
- "When symptoms have improved, it is important for your child's clinical team to investigate possible triggers and underlying causes of the enterocolitis" (guideline) [Ep 17 · 2:11](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=131)
- "Enterocolitis may be caused by obstruction due to bowel dysfunction or by the anatomy of the remaining bowel after the pull-through operation" (clinical) [Ep 17 · 2:21](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=141)
- "Children with Hirshsprung's disease often experience difficulties getting rid of poop because of tight sphincter muscles in the anus" (clinical) [Ep 17 · 2:30](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=150)
- "There can be behavioral and psychological causes of enterocolitis" (clinical) [Ep 17 · 2:39](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=159)
- "Possible treatment includes support with bowel management, internal Botox injections, and in some cases, surgery" (clinical) [Ep 17 · 2:43](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=163)
- "Structured regular follow-up care by a team of different clinical specialists is essential for children with Hirschsprung's disease, ideally by a multidisciplinary team or MDT" (guideline) [Ep 17 · 2:52](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=172)
- "Identifying any complications or difficulties early is very important" (guideline) [Ep 17 · 3:04](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=184)
- "Even if your child has symptoms of enterocolitis after corrective surgery for Hirschprung's disease, these can improve as they grow older" (clinical) [Ep 17 · 3:10](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=190)
- "For Hirschsprung disease with high transition zone, laparoscopic biopsy and mobilization followed by transanal technique is the preferred approach to avoid being surprised by total colonic aganglionosis during a primary transanal procedure." (opinion) [Ep 2 · 2:05](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=125)
- "An average pediatric surgeon doing primary transanal Hirschsprung pull-through will encounter a higher-than-expected transition zone or total colonic aganglionosis approximately 1 in 10 to 1 in 15 times during their career." (epidemiological) [Ep 2 · 2:19](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=139)
- "A pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions." — Jason Frischer (opinion) [Ep 2 · 4:22](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=262)
- "For standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study." — Jason Frischer (clinical) [Ep 2 · 5:46](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=346)
- "Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation)." — Jason Frischer (clinical) [Ep 2 · 6:12](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=372)
- "Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy." — Jason Frischer (clinical) [Ep 2 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=445)
- "For Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns)." — Jason Frischer (clinical) [Ep 2 · 9:04](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=544)
- "Going only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation." — Jason Frischer (clinical) [Ep 2 · 9:04](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=544)
- "Injury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line." — Jason Frischer (opinion) [Ep 2 · 9:43](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=583)
- "The top of the anal columns serves as a consistent anatomic landmark for Hirschsprung dissection level; measuring from anoderm to top of columns in newborns yields a reproducible distance." (clinical) [Ep 2 · 10:36](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=636)
- "In ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region." — Jason Frischer (clinical) [Ep 2 · 10:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=639)
- "The dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line." — Jason Frischer (clinical) [Ep 2 · 11:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=699)
- "Deliberately leaving a zone of aganglionosis above the dentate line is preferable to risking fecal incontinence; the resulting ultra-short segment can be overcome with laxatives, but incontinence cannot be overcome." — Belinda (opinion) [Ep 2 · 12:23](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=743)
- "For newborn females with vestibular fistula and normal sacrum/renal ultrasound, initial management with dilations is appropriate; many surgeons start with this approach." — Mark (clinical) [Ep 2 · 14:03](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=843)
- "Anorectal malformations that appear widely displaced from normal anal position in the newborn period may show less displacement after a few weeks to months of growth, making initial observation reasonable." — Mark (clinical) [Ep 2 · 14:31](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=871)
- "Primary anoplasty repair in the newborn period is technically challenging; the dissection between vagina and rectum is thinner and it is harder to identify the center of the sphincter in a 2 kg baby compared to an 8-9 kg baby." — Belinda (clinical) [Ep 2 · 15:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=939)
- "Prolonged dilations for vestibular fistula cause scarring and inflammation; dilations should be limited to maximum Hegar size 7-8 with stool softeners, as dilating to 11-12 makes subsequent repair difficult." — Belinda (clinical) [Ep 2 · 16:27](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=987)
- "The traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates." — Jason Frischer (clinical) [Ep 2 · 17:17](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1037)
- "Conservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding." — Jason Frischer (clinical) [Ep 2 · 17:27](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1047)
- "When vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through." — Jason Frischer (clinical) [Ep 2 · 18:54](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1134)
- "Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance." — Jason Frischer (clinical) [Ep 2 · 20:09](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1209)
- "Testing for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed." — Jason Frischer (clinical) [Ep 2 · 20:49](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1249)
- "Initial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management." — Jason Frischer (clinical) [Ep 2 · 21:19](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1279)
- "Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure)." — Jason Frischer (host_summary) [Ep 2 · 23:02](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1382)
- "Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone." — Jason Frischer (host_summary) [Ep 2 · 23:36](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1416)
- "Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice." — Jason Frischer (host_summary) [Ep 2 · 23:56](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1436)
- "Ventral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory." — Jason Frischer (clinical) [Ep 2 · 24:10](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1450)
- "Ventral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age." — Jason Frischer (clinical) [Ep 2 · 24:55](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1495)
- "Mesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs." — Jason Frischer (clinical) [Ep 2 · 24:10](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1450)
- "Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection." — Jason Frischer (clinical) [Ep 2 · 22:45](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1365)
- "In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art." — Steven Kraus (opinion) [Ep 3 · 1:02](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=62)
- "Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities." — Steven Kraus (clinical) [Ep 3 · 2:26](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=146)
- "In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction." — Steven Kraus (clinical) [Ep 3 · 3:23](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=203)
- "Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel." — Steven Kraus (clinical) [Ep 3 · 3:35](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=215)
- "The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases." — Steven Kraus (epidemiological) [Ep 3 · 4:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=240)
- "Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis." — Steven Kraus (clinical) [Ep 3 · 5:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=304)
- "Seeing air in the rectum does not rule out Hirschsprung disease." — Steven Kraus (clinical) [Ep 3 · 5:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=332)
- "The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph." — Steven Kraus (clinical) [Ep 3 · 6:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=378)
- "Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon." — Steven Kraus (clinical) [Ep 3 · 6:58](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=418)
- "Enterocolitis in a newborn is Hirschsprung disease until proven otherwise." — Steven Kraus (clinical) [Ep 3 · 8:14](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=494)
- "Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case." — Steven Kraus (clinical) [Ep 3 · 8:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=512)
- "The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease." — Steven Kraus (clinical) [Ep 3 · 10:22](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=622)
- "The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies." — Steven Kraus (host_summary) [Ep 3 · 10:33](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=633)
- "The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%." — Steven Kraus (opinion) [Ep 3 · 10:43](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=643)
- "Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema." — Steven Kraus (clinical) [Ep 3 · 11:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=664)
- "Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed." — Steven Kraus (clinical) [Ep 3 · 11:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=670)
- "The false positive transition zone rate is up to 43%." — Steven Kraus (host_summary) [Ep 3 · 11:20](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=680)
- "A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%." — Steven Kraus (host_summary) [Ep 3 · 11:35](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=695)
- "The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss." — Steven Kraus (host_summary) [Ep 3 · 11:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=707)
- "For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%." — Steven Kraus (host_summary) [Ep 3 · 13:27](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=807)
- "For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%." — Steven Kraus (host_summary) [Ep 3 · 13:43](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=823)
- "If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location." — Steven Kraus (clinical) [Ep 3 · 14:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=845)
- "In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation." — Steven Kraus (clinical) [Ep 3 · 14:39](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=879)
- "Dr. Ocelami's technique: insert rectal tube only 2-3 centimeters into the rectum, never use a Foley catheter inside the rectum, hold the buttocks tight or ask older child to hold contrast." — Rodrigo Ocelami (clinical) [Ep 3 · 16:34](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=994)
- "In the neonatal period use water soluble contrast diluted 50% contrast and 50% saline, infuse very gently and very slowly with a syringe (not gravity) under fluoroscopy to avoid distending the aganglionic segment." — Rodrigo Ocelami (clinical) [Ep 3 · 17:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1024)
- "After the neonatal period, fill only up to the transverse colon; if the studied segment is normal in distension, caliber, and mucosa, and the splenic flexure shows no suggestion of total colonic disease, stop at the transverse colon." — Rodrigo Ocelami (clinical) [Ep 3 · 17:41](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1061)
- "Obtain two images in left lateral decubitus, two in right lateral decubitus, and two in AP position; remove the tube to get a good look at the rectum without the tube." — Rodrigo Ocelami (clinical) [Ep 3 · 18:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1090)
- "The main goal is to find the transition zone; as soon as you find it, stop the contrast because the diagnosis is made." — Rodrigo Ocelami (clinical) [Ep 3 · 18:50](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1130)
- "The inversion of the rectal sigmoid index is very helpful and valued as a sign." — Rodrigo Ocelami (clinical) [Ep 3 · 19:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1145)
- "The affected or aganglionic segment will be spastic; if you give contrast with too much volume or too fast you will miss the spasticity of the affected segment." — Rodrigo Ocelami (clinical) [Ep 3 · 19:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1158)
- "Irregularity of the bowel and enterocolitis are good signs to look for on enema." — Rodrigo Ocelami (clinical) [Ep 3 · 19:37](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1177)
- "Always talk to the family after the study; ask for good hydration after using barium or water soluble contrast to help the child evacuate and avoid dehydration." — Rodrigo Ocelami (clinical) [Ep 3 · 20:02](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1202)
- "Always show the family the contrast used so when white stuff comes out they know what is going on." — Rodrigo Ocelami (clinical) [Ep 3 · 20:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1216)
- "The main points of technique: never use Foley inside the rectum, inject contrast very slowly and gently using fluoroscopy all the time, look for the signs, and talk to the family before and after the study." — Rodrigo Ocelami (clinical) [Ep 3 · 20:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1247)
- "Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon." — Steven Kraus (clinical) [Ep 3 · 21:42](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1302)
- "If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this." — Steven Kraus (clinical) [Ep 3 · 22:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1325)
- "Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly." — Steven Kraus (clinical) [Ep 3 · 22:31](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1351)
- "Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe." — Steven Kraus (clinical) [Ep 3 · 23:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1390)
- "If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present." — Steven Kraus (clinical) [Ep 3 · 23:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1410)
- "Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants." — Steven Kraus (clinical) [Ep 3 · 23:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1427)
- "On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view." — Steven Kraus (clinical) [Ep 3 · 24:03](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1443)
- "On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone." — Steven Kraus (clinical) [Ep 3 · 24:11](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1451)
- "In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum." — Steven Kraus (clinical) [Ep 3 · 24:22](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1462)
- "If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time." — Steven Kraus (clinical) [Ep 3 · 24:40](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1480)
- "Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon." — Steven Kraus (clinical) [Ep 3 · 24:51](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1491)
- "Rectosigmoid transition cases are usually concordant pathologically and radiologically." — Steven Kraus (clinical) [Ep 3 · 25:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1504)
- "In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease." — Steven Kraus (clinical) [Ep 3 · 25:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1530)
- "The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung." — Steven Kraus (clinical) [Ep 3 · 25:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1547)
- "Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy." — Steven Kraus (clinical) [Ep 3 · 26:03](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1563)
- "If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy." — Steven Kraus (clinical) [Ep 3 · 26:15](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1575)
- "If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition." — Steven Kraus (clinical) [Ep 3 · 27:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1650)
- "Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt." — Steven Kraus (clinical) [Ep 3 · 28:06](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1686)
- "A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition." — Steven Kraus (clinical) [Ep 3 · 29:51](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1791)
- "If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach." — Steven Kraus (clinical) [Ep 3 · 30:59](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1859)
- "Dr. Ponsky always performs suction rectal biopsy in almost any patient who needed a contrast enema to rule out distal obstruction, whether meconium plug, small colon, or other cause." — Todd Ponsky (clinical) [Ep 3 · 31:46](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1906)
- "Dr. Ponsky performs rectal biopsy even in meconium ileus cases." — Todd Ponsky (clinical) [Ep 3 · 32:15](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1935)
- "If it is clearly meconium ileus with reflux into terminal ileum and clinical improvement, some surgeons will not do rectal biopsy." — Todd Ponsky (host_summary) [Ep 3 · 32:23](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1943)
- "Dr. Peña would not do biopsy if sure it is meconium ileus, but would do biopsy for a picture of small left colon because he does not know how to distinguish it from Hirschsprung." — Alberto Peña (clinical) [Ep 3 · 32:37](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1957)
- "In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view." — Steven Kraus (clinical) [Ep 3 · 34:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2058)
- "It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space." — Steven Kraus (clinical) [Ep 3 · 34:59](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2099)
- "The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork." — Steven Kraus (clinical) [Ep 3 · 35:56](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2156)
- "In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction." — Steven Kraus (clinical) [Ep 3 · 36:13](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2173)
- "Dr. Peña wonders why Duhamel patients get dilated rectum; by definition Hirschsprung disease is a condition where the aganglionic segment does not get distended even after 10-15 years, yet in these patients the rectum is very stretched and fecally impacted." — Alberto Peña (opinion) [Ep 3 · 36:54](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2214)
- "Dr. Peña suspects that all patients who developed the traditional Duhamel pouch may never have had Hirschsprung disease; he invites surgeons to orient the resected pouch and have pathologists study whether there are ganglion cells in that rectum." — Alberto Peña (opinion) [Ep 3 · 37:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2250)
- "Dr. Collins has seen resected Duhamel pouches that had both ganglionic and aganglionic parts, but does not know what their contrast enemas looked like." — Todd Ponsky (clinical) [Ep 3 · 38:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2285)
- "Dr. Peña states that if he sees a patient with a contrast enema showing redundant stool-filled colon with normal rectum, he will not take a rectal biopsy because it is a waste of time and the patient has no Hirschsprung disease." — Alberto Peña (opinion) [Ep 3 · 40:26](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2426)
- "Dr. Peña states there is no way to differentiate so-called ultra-short segment Hirschsprung from idiopathic constipation." — Alberto Peña (opinion) [Ep 3 · 41:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2460)
- "The rectum has ganglion cells in normal ganglionic bowel, then there is one area with no ganglion cells, but the length of that normal aganglionic segment has never been accurately determined at different ages in humans." — Alberto Peña (clinical) [Ep 3 · 41:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2492)
- "There is no accurate study of the normal aganglionic segment length in a preemie, full-term baby, or 6-month-old baby; this is a challenge for young pediatric surgeons to contribute." — Alberto Peña (opinion) [Ep 3 · 41:42](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2502)
- "Somebody could take a biopsy in the normal aganglionic area and get a result of no ganglion cells, but it does not mean anything clinically." — Alberto Peña (opinion) [Ep 3 · 42:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2525)
- "The internal sphincter has been defined as a thickening of the circular layer of normal smooth muscle bowel, but Dr. Peña has never personally seen that thickening despite opening normal rectums at different ages." — Alberto Peña (opinion) [Ep 3 · 42:14](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2534)
- "If the internal sphincter thickening exists, nobody has determined the exact limit of that thickening at different ages, so it becomes a kind of magic or witchery type of diagnosis." — Alberto Peña (opinion) [Ep 3 · 42:45](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2565)
- "Internal anal sphincter achalasia is a manometric concept, not an anatomic concept, similar to the lower esophageal sphincter and other sphincters that have been defined but never anatomically seen." — Alberto Peña (opinion) [Ep 3 · 43:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2596)
- "Dr. Peña does not perform myectomies or myotomies and does not recommend those procedures because we do not know where to inject or what area of muscle to target." — Alberto Peña (opinion) [Ep 3 · 43:36](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2616)
- "Botox and similar injections paralyze whatever muscle is there and facilitate passing of stool, but they are not curing a condition of unknown origin." — Alberto Peña (opinion) [Ep 3 · 43:48](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2628)
- "50% of polled surgeons would not inject Botox at the same time as pull-through procedure" — Lei Wen (epidemiological) [Ep 19 · 0:33](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=33)
- "The Cincinnati Children's group injects Botox at the same time of surgery" — Lei Wen (opinion) [Ep 19 · 0:42](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=42)
- "A 2022 multi-center study found that 24% of patients undergoing pull-through procedure also received Botox" — Jill Knepprath (epidemiological) [Ep 19 · 0:45](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=45)
- "Cincinnati Children's study from 2020 to 2024 found decreased risk of enterocolitis within 31 days after pull-through procedure: 0% versus 30%" — Lei Wen (clinical) [Ep 19 · 0:55](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=55)
- "Patients that received Botox had a higher chance of diaper rash" — Jill Knepprath (clinical) [Ep 19 · 1:09](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=69)
- "There is no evidence on the number of units of Botox to use" (clinical) [Ep 19 · 1:20](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=80)
- "Better data is needed on Botox dosing" (opinion) [Ep 19 · 1:23](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=83)
- "Ultrasound guidance allows visualization of every layer, needle position, injection amount and location, and diffusion pattern" (clinical) [Ep 19 · 1:25](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=85)
- "Injecting Botox during pull-through procedure for Hirschsprung's disease has been shown to reduce enterocolitis risk" — Jill Knepprath (clinical) [Ep 19 · 1:37](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=97)
- "Dosing and guidance for Botox injection varies widely" — Jill Knepprath (epidemiological) [Ep 19 · 1:41](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=101)
- "Many non-Hirschsprung causes can present identically to Hirschsprung's disease in newborns, including maternal magnesium sulfate administration, hypothyroidism, opiate exposure, and milk protein allergy" — Marc Levitt (clinical) [Ep 20 · 0:55](https://library.globalcastmd.com/watch/hirschsprung-13870?t=55)
- "10% of patients with meconium plug have Hirschsprung's disease" — Marc Levitt (epidemiological) [Ep 20 · 2:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=120)
- "After passing a meconium plug, suction rectal biopsy should still be performed for confirmation, and if positive for Hirschsprung's, the contrast study should be repeated to better visualize the transition zone" — Marc Levitt (guideline) [Ep 20 · 3:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=180)
- "In total colonic Hirschsprung's disease, there is often no obvious transition zone on contrast study" — Marc Levitt (clinical) [Ep 20 · 3:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=210)
- "Suction rectal biopsy is the gold standard for diagnosing Hirschsprung's disease" — Marc Levitt (guideline) [Ep 20 · 4:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=240)
- "Bacterial overgrowth from stasis leads to bacterial translocation because mucosal integrity in Hirschsprung's disease is abnormal" — Marc Levitt (clinical) [Ep 20 · 4:42](https://library.globalcastmd.com/watch/hirschsprung-13870?t=282)
- "Constipated babies without Hirschsprung's disease do not develop enterocolitis because their mucosal integrity and IgA levels are normal" — Marc Levitt (clinical) [Ep 20 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=320)
- "Down syndrome patients have worse enterocolitis in Hirschsprung's disease because they have a weaker immune barrier" — Marc Levitt (clinical) [Ep 20 · 5:38](https://library.globalcastmd.com/watch/hirschsprung-13870?t=338)
- "Proper irrigation technique uses a 20 French silicone Foley catheter with warm saline in 10-20cc aliquots, washing the inside of the colon by injecting and allowing drainage, moving the catheter a few centimeters each time, which may take 30 minutes" — Marc Levitt (guideline) [Ep 20 · 5:44](https://library.globalcastmd.com/watch/hirschsprung-13870?t=344)
- "Irrigations often need to be performed two or three times per day" — Marc Levitt (guideline) [Ep 20 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=420)
- "If irrigations do not reach the transition zone, distension will not improve" — Marc Levitt (clinical) [Ep 20 · 7:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=430)
- "An ileostomy does not require pathology confirmation at 3 AM and the baby will reliably start stooling and feel well" — Marc Levitt (clinical) [Ep 20 · 8:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=500)
- "A loop ileostomy where both sides are equal is inappropriate because stool will jump across and fill the aganglionic segment, causing continued distension and potential enterocolitis" — Marc Levitt (clinical) [Ep 20 · 9:26](https://library.globalcastmd.com/watch/hirschsprung-13870?t=566)
- "Post-pull-through patients present with two distinct problems: obstruction or soiling, and these two groups rarely overlap" — Marc Levitt (clinical) [Ep 20 · 11:51](https://library.globalcastmd.com/watch/hirschsprung-13870?t=711)
- "Obstructed patients typically do well for about six months after pull-through, then develop chronic distension and may have several enterocolitis episodes" — Marc Levitt (clinical) [Ep 20 · 12:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=730)
- "A Soave procedure without an adequately cut cuff, or with a cuff that has rolled up or refused, will cause physiologic obstruction" — Marc Levitt (clinical) [Ep 20 · 12:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=760)
- "A retained cuff presents as a rubbery circumferential ring outside the pull-through on digital exam" — Marc Levitt (clinical) [Ep 20 · 13:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=790)
- "A twisted pull-through (180 or 360 degrees) causes obstruction and can be felt on digital exam when you cannot get into the pelvis and feel like you are hitting a wall" — Marc Levitt (clinical) [Ep 20 · 13:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=810)
- "A cuff may show extra space in the presacral area on lateral contrast study because the pull-through is pushed forward instead of hugging the sacrum" — Marc Levitt (clinical) [Ep 20 · 14:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=840)
- "In Duhamel procedures, a large pouch reaching into the pelvis can cause obstruction as stool flows through ganglionic bowel, enters the pouch, and sits there" — Marc Levitt (clinical) [Ep 20 · 14:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=870)
- "For Duhamel patients, biopsy must be done on the posterior wall because the anterior wall is the original aganglionic rectum" — Marc Levitt (guideline) [Ep 20 · 15:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=940)
- "Every child born with Hirschsprung's disease has 100% possibility of having bowel control because the continence mechanism is normal and sphincters are not weak" — Marc Levitt (clinical) [Ep 20 · 16:13](https://library.globalcastmd.com/watch/hirschsprung-13870?t=973)
- "Overstretching of sphincters or starting transanal dissection too low and removing the dentate line will lead to fecal incontinence" — Marc Levitt (clinical) [Ep 20 · 17:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1050)
- "If the anus appears closed when the patient is awake, that usually means good sphincters" — Marc Levitt (clinical) [Ep 20 · 18:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1120)
- "The vast majority of Hirschsprung's patients are constipated and need stimulant laxatives, not stool softeners" — Marc Levitt (clinical) [Ep 20 · 19:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1160)
- "Adding water-soluble fiber to laxatives provides bulk to prevent watery stool, which is difficult to control, while maintaining the propulsion effect of the laxative" — Marc Levitt (clinical) [Ep 20 · 19:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1180)
- "A non-dilated colon on X-ray or contrast study in a patient stooling five times per day indicates a fast-moving colon requiring constipating management rather than laxatives" — Marc Levitt (clinical) [Ep 20 · 20:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1220)
- "Nighttime soiling occurs because patients are totally dependent on voluntary external sphincter control, which they lose awareness of during sleep" — Marc Levitt (clinical) [Ep 20 · 20:48](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1248)
- "Most children should be in normal underwear by age three or four" — Marc Levitt (opinion) [Ep 20 · 22:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1330)
- "Malone procedures are typically performed between age three and a half and eight or nine years" — Marc Levitt (clinical) [Ep 20 · 21:50](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1310)
- "Many non-Hirschsprung causes can mimic the disease including premature rupture of membranes, maternal magnesium sulfate, hypothyroidism, opiate exposure, and milk protein allergy" — Marc Levitt (clinical) [Ep 21 · 0:55](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=55)
- "Anorectal malformation, small left colon syndrome, and colonic atresia are surgical conditions that can present similarly to Hirschsprung's disease" — Marc Levitt (clinical) [Ep 21 · 2:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=120)
- "10% of patients with meconium plug have Hirschsprung's disease" — Marc Levitt (epidemiological) [Ep 21 · 2:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=155)
- "Suction rectal biopsy should be performed even after successful passage of meconium plug to rule out Hirschsprung's disease" — Marc Levitt (guideline) [Ep 21 · 3:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=180)
- "Contrast study should be repeated after meconium plug passage because the rectosigmoid will be dilated with the plug present, obscuring the transition zone" — Marc Levitt (clinical) [Ep 21 · 3:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=195)
- "In total colonic Hirschsprung's disease there is often no obvious transition zone on contrast study" — Marc Levitt (clinical) [Ep 21 · 3:40](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=220)
- "Contrast study serves as a surgical GPS map even though suction rectal biopsy is the gold standard for diagnosis" — Marc Levitt (opinion) [Ep 21 · 4:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=240)
- "Bacterial overgrowth from stasis leads to bacterial translocation because mucosal integrity in Hirschsprung's disease is abnormal" — Marc Levitt (clinical) [Ep 21 · 4:41](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=281)
- "Constipated babies without Hirschsprung's disease do not develop enterocolitis because their mucosal integrity and IgA levels are normal" — Marc Levitt (clinical) [Ep 21 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=320)
- "Down syndrome patients have worse enterocolitis because they have a weaker immune barrier" — Marc Levitt (clinical) [Ep 21 · 5:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=335)
- "Proper irrigation protocol uses a 20 French silicone Foley catheter with warm saline in 10-20cc aliquots, washing the colon for up to 30 minutes, two to three times per day" — Marc Levitt (guideline) [Ep 21 · 5:44](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=344)
- "If irrigations do not reach the transition zone, distension will not improve and stoma creation should be considered" — Marc Levitt (clinical) [Ep 21 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=420)
- "Leveling colostomy requires bringing dilated bowel to the surface with or without frozen section confirmation" — Marc Levitt (clinical) [Ep 21 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=445)
- "Ileostomy with colonic biopsies is preferred because it is extremely reliable, does not require pathology at 3 AM, and the baby will thrive while awaiting definitive pathology results" — Marc Levitt (opinion) [Ep 21 · 7:50](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=470)
- "Ileostomy is difficult to manage in many parts of the world where babies can become dehydrated quickly" — Marc Levitt (clinical) [Ep 21 · 8:30](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=510)
- "The ileostomy approach requires three operations versus two, but reduces risk by making each operation more straightforward" — Marc Levitt (opinion) [Ep 21 · 9:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=540)
- "A loop ileostomy where both sides are equal is inappropriate because stool will jump across and fill the aganglionic segment, causing continued distension and potential enterocolitis" — Marc Levitt (clinical) [Ep 21 · 9:26](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=566)
- "Turnbull ileostomy technique involves cutting the bowel completely on one side of the loop and folding it over to create an end-appearing stoma with flat distal limb" — Marc Levitt (clinical) [Ep 21 · 10:10](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=610)
- "Post-pull-through patients present with two distinct problems: obstruction or soiling, and these rarely overlap" — Marc Levitt (clinical) [Ep 21 · 11:26](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=686)
- "Obstructed patients typically do well for six months post-pull-through, then develop chronic distension, recurrent enterocolitis, and sometimes failure to thrive" — Marc Levitt (clinical) [Ep 21 · 11:50](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=710)
- "Anatomic causes of obstruction include inadequately cut Soave cuff, rolled-up or fused cuff, twisted pull-through, duhamel spur, large duhamel pouch, transition zone pull-through, and stricture" — Marc Levitt (clinical) [Ep 21 · 12:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=745)
- "A retained cuff appears as a rubbery circumferential ring outside the pull-through on digital exam and shows increased presacral space on lateral contrast study" — Marc Levitt (clinical) [Ep 21 · 13:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=780)
- "A twisted pull-through prevents the examining finger from entering the pelvis and creates a sensation of hitting a wall when palpating abdominally" — Marc Levitt (clinical) [Ep 21 · 13:40](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=820)
- "In duhamel patients, biopsy must be taken from the posterior wall because the anterior wall is the original aganglionic rectum" — Marc Levitt (guideline) [Ep 21 · 15:20](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=920)
- "Empiric Botox injection is appropriate when physical exam, contrast study, and biopsy reveal no anatomic or pathologic cause of obstruction, suggesting non-relaxing sphincters" — Marc Levitt (guideline) [Ep 21 · 15:45](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=945)
- "Every child born with Hirschsprung's disease has 100% potential for bowel control because the continence mechanism is normal" — Marc Levitt (clinical) [Ep 21 · 16:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=975)
- "Hirschsprung's sphincters are too good rather than weak, unlike anorectal malformation where associated spinal problems, poor sacrum, or poor muscles limit continence potential" — Marc Levitt (clinical) [Ep 21 · 16:50](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1010)
- "Overstretching of sphincters or starting transanal dissection too low and removing the dentate line will cause iatrogenic fecal incontinence" — Marc Levitt (clinical) [Ep 21 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1045)
- "Patients with iatrogenically damaged sphincters or dentate line require mechanical bowel management with enemas (peristeen or Malone) rather than medical management" — Marc Levitt (guideline) [Ep 21 · 17:55](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1075)
- "A closed anus appearance when awake usually indicates good sphincters" — Marc Levitt (clinical) [Ep 21 · 18:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1105)
- "The vast majority of Hirschsprung's patients are constipated and need stimulant laxatives (senna or bisacodyl), not stool softeners" — Marc Levitt (clinical) [Ep 21 · 18:40](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1120)
- "Adding water-soluble fiber to stimulant laxatives provides bulk to prevent watery stool while maintaining propulsion, creating one to two well-formed stools per day" — Marc Levitt (guideline) [Ep 21 · 19:05](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1145)
- "Botox is often required to help patients overcome withholding or non-relaxing internal sphincter during potty training" — Marc Levitt (clinical) [Ep 21 · 19:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1175)
- "Some Hirschsprung's patients have hypermotility and stool too frequently; stopping stimulant laxatives in these patients can achieve continence within two days" — Marc Levitt (clinical) [Ep 21 · 19:55](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1195)
- "X-ray showing no stool accumulation in a child stooling five times daily indicates fast-moving colon; contrast study showing non-dilated colon confirms hypermotility" — Marc Levitt (clinical) [Ep 21 · 20:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1225)
- "Hypermotile patients require constipating diet, water-soluble fiber, and occasionally loperamide to achieve one to two formed stools per day" — Marc Levitt (guideline) [Ep 21 · 20:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1225)
- "Nighttime soiling occurs because patients are totally dependent on voluntary external sphincter control, which is lost during sleep" — Marc Levitt (clinical) [Ep 21 · 21:01](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1261)
- "Behavioral modifications for nighttime soiling include attempting to stool before bed and giving a small enema before bed to keep the rectum empty for eight hours" — Marc Levitt (guideline) [Ep 21 · 21:28](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1288)
- "Malone antegrade continence enema is appropriate when rectal enemas are not tolerated, peristeen is ineffective, or families prefer not to use the rectal route" — Marc Levitt (guideline) [Ep 21 · 21:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1296)
- "Most Malone procedures are performed between ages 3.5 and 8-9 years, around the time of potty training when it becomes clear antegrade flushes are required" — Marc Levitt (clinical) [Ep 21 · 22:10](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1330)
- "The vast majority of patients with Hirschsprung disease do extremely well after pull-through, with normal emptying and bowel control." — Marc Levitt (clinical) [Ep 22 · 3:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=208)
- "Problem patients divide into two types: obstruction patients who do not empty, and soiling patients." — Marc Levitt (clinical) [Ep 22 · 3:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=230)
- "Enterocolitis after a well-done pull-through is not uncommon, particularly in babies who have very tight sphincters and can keep them tight for many hours." — Marc Levitt (clinical) [Ep 22 · 4:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=260)
- "After about age one, patients should learn to empty and relax their sphincters and have a more normal bowel movement pattern." — Marc Levitt (clinical) [Ep 22 · 4:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=290)
- "Evaluation of a child with persistent obstruction and enterocolitis involves a contrast study of the colon and an examination under anesthesia." — Marc Levitt (clinical) [Ep 22 · 5:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=310)
- "Anatomic causes of post-pull-through obstruction include distal stricture, obstructing cuff, Duhamel pouch dysfunction, twisted pull-through, and dilated segment." — Marc Levitt (clinical) [Ep 22 · 5:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=338)
- "The Suave cuff (retained outer rectal wall) can cause obstruction if not properly split or if it has fused or scarred down." — Marc Levitt (clinical) [Ep 22 · 6:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=360)
- "A pull-through done to transition zone bowel (with hypertrophic nerves larger than 40 microns) rather than healthy ganglionated bowel can lead to obstruction." — Marc Levitt (clinical) [Ep 22 · 7:32](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=452)
- "Healthy pull-through segment should have ganglion cells and nerves 40 microns or less in size; anything larger is transition zone bowel that might not function." — Marc Levitt (clinical) [Ep 22 · 7:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=471)
- "Treatment of enterocolitis includes hydration, intravenous metronidazole (most effective antibiotic), and aggressive rectal irrigations two to three times daily." — Marc Levitt (clinical) [Ep 22 · 8:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=499)
- "Rectal irrigations use 10 to 20 cc per insertion through a large Foley catheter (size 20-22), allowing drainage between insertions to wash the colon." — Marc Levitt (clinical) [Ep 22 · 9:37](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=577)
- "Metronidazole has the same efficacy whether given IV or PO because in both cases it is excreted in the bile." — Marc Levitt (clinical) [Ep 22 · 11:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=681)
- "Approximately 15-20% of patients can have an episode of enterocolitis within the first year after pull-through, but after one year they should not be having enterocolitis anymore." — Marc Levitt (epidemiological) [Ep 22 · 12:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=741)
- "On contrast study, the pull-through should hug the sacrum; if diverted forward by a space-occupying mass, this may indicate an obstructing cuff." — Marc Levitt (clinical) [Ep 22 · 12:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=778)
- "The Suave cuff is outside the pull-through and cannot be detected intraluminally with endoscopy; it must be felt on digital rectal exam." — Marc Levitt (clinical) [Ep 22 · 16:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1000)
- "On examination under anesthesia, palpate along the hollow of the sacrum with the fifth digit to feel the cuff as a rubbery, thick rubber-band structure around the pull-through." — Marc Levitt (clinical) [Ep 22 · 17:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1040)
- "Biopsy should be taken above the dentate line by about one centimeter and sent for permanent section (not frozen) to assess ganglion cells and nerve size." — Marc Levitt (clinical) [Ep 22 · 17:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1070)
- "A patient with transition-zone pull-through who is not doing well needs a redo pull-through to healthy ganglionated bowel." — Marc Levitt (clinical) [Ep 22 · 18:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1101)
- "Redo pull-through for transition zone often requires removing the sigmoid curve to reach healthy bowel." — Marc Levitt (clinical) [Ep 22 · 19:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1140)
- "For obstructing cuff, dissect between bowel and cuff, then make a second plane outside the cuff in the Swenson plane and remove the posterior and lateral portions of the cuff to break the ring." — Marc Levitt (clinical) [Ep 22 · 20:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1230)
- "Myectomies that have been traditionally successful may have been cutting the Suave cuff rather than the internal sphincter, though surgeons thought they were cutting sphincter." — Marc Levitt (opinion) [Ep 22 · 21:49](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1309)
- "Myectomies are problematic because they can hurt skeletal muscle and leave the patient incontinent; different surgeons perform them differently with inconsistent technique." — Marc Levitt (opinion) [Ep 22 · 22:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1350)
- "Post-pull-through sphincter problems are relatively rare compared to anatomic causes of obstruction." — Marc Levitt (opinion) [Ep 22 · 23:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1438)
- "If all anatomic possibilities have been ruled out and pathology is okay but the child still behaves as obstructed, the problem must be the sphincter, which can be confirmed with anorectal manometry." — Marc Levitt (clinical) [Ep 22 · 24:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1470)
- "Botox acts as a temporary myectomy and is preferred over permanent myectomy because it wears off as children learn to coordinate stooling with sphincter relaxation." — Marc Levitt (clinical) [Ep 22 · 25:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1510)
- "Botox can be coordinated with laxatives at 4-8 weeks post-injection when tone is partially returning, helping children learn appropriate bowel movement patterns." — Marc Levitt (clinical) [Ep 22 · 26:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1560)
- "Botox will temporarily improve a cuff problem if the injection migrates up to the cuff level, but the patient will not get better long-term and will keep recurring." — Marc Levitt (clinical) [Ep 22 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1605)
- "Anorectal manometry can measure the length of high tone: one centimeter suggests sphincter dysfunction, while three to four centimeters indicates sphincter plus cuff." — Marc Levitt (clinical) [Ep 22 · 27:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1637)
- "Redo of a Duhamel pouch is probably the hardest operation in Hirschsprung disease due to extensive pelvic fibrosis from the stapled connection." — Marc Levitt (opinion) [Ep 22 · 29:49](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1789)
- "All patients with Hirschsprung disease should be able to empty spontaneously and should be clean." — Marc Levitt (opinion) [Ep 22 · 32:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1978)
- "Patients with Hirschsprung disease are born with a normal anal canal and normal sphincters; if anything, their sphincters are too good." — Marc Levitt (clinical) [Ep 22 · 33:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2000)
- "Many soiling Hirschsprung patients have lost anal canal or weak sphincters, and the only possible conclusion is that these are iatrogenic from starting transanal dissection too low or overstretching." — Marc Levitt (opinion) [Ep 22 · 33:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2030)
- "Evaluation of soiling patients includes determining the original surgery type, assessing sphincter patulousness by visual and digital exam and manometry, and assessing dentate line integrity." — Marc Levitt (clinical) [Ep 22 · 34:47](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2087)
- "A contrast study can serve as a poor man's colonic manometry: narrow non-dilated pull-through suggests hypermotility, while dilated pull-through suggests hypomotility." — Marc Levitt (clinical) [Ep 22 · 37:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2220)
- "Soiling patients with good anal canal and sphincter but non-dilated colon are hypermotile and need slowing down with constipating diet, loperamide, and water-soluble fiber." — Marc Levitt (clinical) [Ep 22 · 37:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2260)
- "Soiling patients with good anal canal and sphincter but dilated colon are hypomotile and need laxatives to speed them up." — Marc Levitt (clinical) [Ep 22 · 38:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2295)
- "Soiling patients with lost anal canal or sphincter and non-dilated colon need a small-volume enema program plus treatment for hypermotility." — Marc Levitt (clinical) [Ep 22 · 38:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2320)
- "Soiling patients with lost anal canal or sphincter and dilated colon need a larger-volume enema and do not need hypermotility treatment." — Marc Levitt (clinical) [Ep 22 · 39:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2350)
- "The first question in any soiling patient is whether they have the capacity for bowel control, determined by whether sphincters and anal canal are intact." — Marc Levitt (clinical) [Ep 22 · 41:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2462)
- "Patients with capacity for bowel control can usually be treated with medicines, while those without capacity will need some sort of enema program." — Marc Levitt (clinical) [Ep 22 · 41:31](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2491)
- "Hirschsprung disease affects approximately 1 in 5,000 children" — Mike (epidemiological) [Ep 24 · 7:40](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=460)
- "In Hirschsprung disease, nerve ganglia in the colon wall are absent in the distal portion, preventing the affected segment from relaxing" — Mike (clinical) [Ep 24 · 5:58](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=358)
- "The natural state of the large bowel is the squeezed state, and it normally cycles between squeezed and unsqueezed as stool moves through" — Mike (clinical) [Ep 24 · 6:48](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=408)
- "Down syndrome has a higher incidence of Hirschsprung disease than the general population" — Mike (epidemiological) [Ep 24 · 8:09](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=489)
- "Hirschsprung disease shows genetic clustering with documented cases spanning three generations (grandparent, child, grandchild)" — Mike (epidemiological) [Ep 24 · 8:45](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=525)
- "Nerve ganglia normally migrate from top to bottom during intestinal development, so Hirschsprung disease always affects bowel from the distal end upward with no skip areas" — Mike (clinical) [Ep 24 · 10:32](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=632)
- "Most babies pass meconium in the first 24 hours; failure to do so raises suspicion for Hirschsprung disease" — Mike (clinical) [Ep 24 · 11:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=665)
- "Rare Hirschsprung cases with very limited distal involvement can present beyond the newborn period with chronic constipation rather than acute obstruction" — Mike (clinical) [Ep 24 · 12:12](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=732)
- "Older children with undiagnosed Hirschsprung disease typically show failure to thrive, persistent abdominal distention, and episodes of diarrhea (actually enterocolitis) in addition to constipation" (clinical) [Ep 24 · 13:01](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=781)
- "Maternal magnesium sulfate given to slow contractions during difficult delivery can make newborn bowels very slow for several days" — Mike (clinical) [Ep 24 · 14:21](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=861)
- "Hypothyroidism and maternal narcotic exposure can cause slow bowel function in newborns mimicking Hirschsprung disease" — Mike (clinical) [Ep 24 · 14:21](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=861)
- "Contrast enema in Hirschsprung disease shows a narrow distal colon segment with dilated proximal colon" — Mike (clinical) [Ep 24 · 16:11](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=971)
- "Definitive diagnosis of Hirschsprung disease requires rectal biopsy showing both absent ganglion cells and thickened nerves around where ganglion cells should be" — Mike (clinical) [Ep 24 · 16:11](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=971)
- "Initial management of Hirschsprung disease involves rectal irrigation with a catheter to decompress the bowel and wash out stagnant stool and bacteria" — Mike (clinical) [Ep 24 · 18:14](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1094)
- "Rectal irrigation is distinct from enema: irrigation involves continuous washing with fluid going in and coming back out, while enema is injection followed by waiting" — Mike (clinical) [Ep 24 · 18:14](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1094)
- "Historical management of Hirschsprung disease 15-20 years ago required three operations over six months: colostomy, pull-through procedure, and colostomy closure" — Mike (clinical) [Ep 24 · 20:15](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1215)
- "Modern Hirschsprung surgery can be performed entirely through the anus with no abdominal incisions, sometimes with laparoscopic assistance, in the first week of life" — Mike (clinical) [Ep 24 · 20:15](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1215)
- "In Hirschsprung enterocolitis, diarrhea occurs inside the colon but cannot exit due to distal obstruction, causing severe dehydration without visible diarrhea output" — Mike (clinical) [Ep 24 · 21:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1317)
- "Several babies die annually in the United States from Hirschsprung enterocolitis, and it is a common cause of newborn death in the developing world" — Mike (epidemiological) [Ep 24 · 21:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1317)
- "In enterocolitis, bacteria translocate across the inflamed colonic lining into the bloodstream, and the most distended bowel segment can perforate if the process continues" — Mike (clinical) [Ep 24 · 23:10](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1390)
- "Children with Hirschsprung disease who are not doing well after surgery should be evaluated for anatomic problems, which are almost always definable and fixable" — Mike (opinion) [Ep 24 · 24:02](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1442)
- "Hirschsprung disease is not a condition that improves over time on its own; persistent problems require investigation and intervention" — Mike (opinion) [Ep 24 · 24:02](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1442)
- "Evaluation of suboptimal Hirschsprung outcomes includes contrast study to assess current colonic anatomy, biopsy to confirm adequate bowel was pulled through, and surgical examination of the pull-through segment" — Mike (clinical) [Ep 24 · 24:02](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1442)
- "Even after anatomically perfect Hirschsprung surgery, many children have mild constipation requiring laxatives and minor dietary modifications" — Mike (clinical) [Ep 24 · 27:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1625)
- "Normal babies with constipation or impaction do not develop the severe bacterial overgrowth and systemic illness seen in Hirschsprung enterocolitis, suggesting unique susceptibility of Hirschsprung colonic lining" — Mike (clinical) [Ep 24 · 27:51](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1671)
- "The two major research priorities in Hirschsprung disease are identifying the specific causative gene and understanding the mechanism of enterocolitis susceptibility" — Mike (opinion) [Ep 24 · 27:51](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1671)
- "Dr. Levitt has treated patients from all 50 US states and 88 countries" — Mike (epidemiological) [Ep 24 · 32:50](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1970)
- "The vast majority of patients with Hirschsprung disease do extremely well after pull-through, with no emptying problems and normal bowel control" — Marc Levitt (clinical) [Ep 23 · 3:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=208)
- "Problem patients after pull-through divide into two types: obstruction patients who cannot empty, and soiling patients" — Marc Levitt (clinical) [Ep 23 · 3:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=230)
- "Enterocolitis after a well-done pull-through is not uncommon, particularly in babies, because babies have very tight sphincters capable of staying tight for many hours" — Marc Levitt (clinical) [Ep 23 · 4:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=260)
- "After about age one, patients should learn to empty and relax their sphincters with a more normal bowel movement pattern" — Marc Levitt (clinical) [Ep 23 · 4:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=290)
- "Evaluation of post-pull-through obstruction involves a contrast study of the colon and an examination under anesthesia" — Marc Levitt (clinical) [Ep 23 · 5:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=310)
- "Anatomic causes of post-pull-through obstruction include distal stricture, obstructing cuff, atonic Duhamel pouch, twisted pull-through (up to 360 degrees), and dilated distal segment" — Marc Levitt (clinical) [Ep 23 · 5:36](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=336)
- "Pathologic cause of obstruction: pull-through not done to ganglionated bowel with normal-sized nerves (transition zone)" — Marc Levitt (clinical) [Ep 23 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=420)
- "Healthy pull-through segment requires ganglion cells present and nerve roots no bigger than 40 microns; larger nerves indicate transition zone bowel that might not function" — Marc Levitt (clinical) [Ep 23 · 7:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=471)
- "Treatment for post-pull-through enterocolitis: hydration, intravenous metronidazole (most effective antibiotic), and aggressive irrigations two to three times daily" — Marc Levitt (clinical) [Ep 23 · 8:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=499)
- "Irrigation technique: 10-20 cc per kilo into large Foley (size 20-22), allow to drip out, repeat while moving tube to wash colon interior" — Marc Levitt (clinical) [Ep 23 · 9:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=579)
- "Metronidazole has same efficacy IV or PO because in both cases it is excreted in the bile" — Marc Levitt (clinical) [Ep 23 · 11:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=681)
- "In diverted colon (with ileostomy), metronidazole will not work for colitis because drug exits via ileostomy; vancomycin enemas needed instead" — Marc Levitt (clinical) [Ep 23 · 11:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=690)
- "Approximately 15-20% of patients can have an enterocolitis episode within the first year after pull-through, but after one year they should not be having enterocolitis" — Marc Levitt (epidemiological) [Ep 23 · 12:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=741)
- "On contrast study, pull-through should hug the sacrum; if diverted forward by space-occupying mass, suspect obstructing cuff" — Marc Levitt (clinical) [Ep 23 · 12:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=778)
- "Obstructing cuff may be palpable on digital rectal exam as rubbery thick rubber-band structure around pull-through along sacral hollow, but is outside the lumen and not visible on endoscopy" — Marc Levitt (clinical) [Ep 23 · 15:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=918)
- "For transition zone pull-through causing obstruction, management is redo pull-through to healthy ganglionated bowel, often requiring removal of retained sigmoid curve" — Marc Levitt (clinical) [Ep 23 · 18:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1101)
- "For obstructing cuff, dissect between bowel and cuff, then make second plane outside cuff in Swenson plane; remove posterior-lateral ring (not entire circumference) to break the ring and solve obstruction" — Marc Levitt (clinical) [Ep 23 · 20:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1230)
- "Myectomies that have been traditionally successful may have been cutting the Soave cuff rather than internal sphincter, but technique varies widely between surgeons" — Marc Levitt (opinion) [Ep 23 · 21:49](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1309)
- "Myectomies can hurt skeletal muscle and leave patient incontinent; strongly argue against them" — Marc Levitt (opinion) [Ep 23 · 22:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1360)
- "Post-pull-through sphincter problems are relatively rare compared to anatomic problems; not usually the sphincter causing obstruction" — Marc Levitt (clinical) [Ep 23 · 24:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1445)
- "Many Hirschsprung patients have tight sphincters on anorectal manometry, with powerful internal sphincter that fails to relax" — Marc Levitt (clinical) [Ep 23 · 24:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1445)
- "For obstructed child with no anatomic problem and confirmed sphincter dysfunction on manometry, Botox is indicated" — Marc Levitt (clinical) [Ep 23 · 24:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1480)
- "Botox acts as temporary myectomy; preferred over permanent myectomy because it wears off as child learns sphincter coordination, avoiding permanent incontinence risk" — Marc Levitt (clinical) [Ep 23 · 25:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1520)
- "Botox timing strategy: inject, then at 4-8 weeks start aggressive laxatives as Botox wears off, helping child learn appropriate bowel movement pattern" — Marc Levitt (clinical) [Ep 23 · 26:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1570)
- "Botox can temporarily improve cuff obstruction if injection migrates to cuff level, but patient will recur because cuff must be removed for long-term fix" — Marc Levitt (clinical) [Ep 23 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1605)
- "Anorectal manometry can distinguish sphincter dysfunction (1 cm high-tone zone) from sphincter plus cuff (3-4 cm high-tone zone)" — Marc Levitt (clinical) [Ep 23 · 27:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1637)
- "Redo of Duhamel pouch is probably the hardest operation in Hirschsprung disease due to pelvic fibrosis from stapled connection" — Marc Levitt (opinion) [Ep 23 · 30:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1820)
- "All patients with Hirschsprung disease should be able to empty spontaneously and should be clean" — Marc Levitt (opinion) [Ep 23 · 31:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1900)
- "Patients with Hirschsprung disease are born with normal anal canal and normal sphincters; if anything, sphincters are too good" — Marc Levitt (clinical) [Ep 23 · 32:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1950)
- "No Hirschsprung patient is born with missing anal canal or weak sphincter; when present, these are iatrogenic from surgeon starting transanal dissection too low and invading dentate line" — Marc Levitt (clinical) [Ep 23 · 33:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1980)
- "Sphincter destruction can result from overstretching during aggressive transabdominal or transanal dissection" — Marc Levitt (clinical) [Ep 23 · 34:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2040)
- "Capacity for bowel control in soiling patients determined by sphincter integrity (assessed by visual exam, digital exam, anorectal manometry) and dentate line preservation" — Marc Levitt (clinical) [Ep 23 · 35:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2120)
- "Contrast study serves as 'poor man's colonic manometry': narrow non-dilated pull-through suggests hypermotility; dilated pull-through suggests hypomotility" — Marc Levitt (clinical) [Ep 23 · 37:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2220)
- "Soiling patient with intact anal canal/sphincter and non-dilated colon: hypermotile, needs slowing with constipating diet, loperamide, water-soluble fiber" — Marc Levitt (clinical) [Ep 23 · 37:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2260)
- "Soiling patient with intact anal canal/sphincter and dilated colon: hypomotile, needs laxatives to speed up, has capacity for bowel control" — Marc Levitt (clinical) [Ep 23 · 38:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2295)
- "Soiling patient with destroyed anal canal/sphincter and non-dilated colon: hypermotile without continence capacity, needs small-volume enema plus constipating regimen" — Marc Levitt (clinical) [Ep 23 · 38:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2295)
- "Soiling patient with destroyed anal canal/sphincter and dilated colon: needs larger volume enema, no hypermotility treatment" — Marc Levitt (clinical) [Ep 23 · 38:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2331)
- "Hirschsprung soiling differs from anorectal malformation incontinence because Hirschsprung patients ought to have good anal canal and sphincter; if absent, it relates to surgery" — Marc Levitt (clinical) [Ep 23 · 39:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2360)
- "Patients with capacity for bowel control (intact sphincter/anal canal) may receive bridge enema program for social continence while transitioning to appropriate medical regimen" — Marc Levitt (clinical) [Ep 23 · 40:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2420)
- "Surgical management for soiling patients without capacity for bowel control: Malone appendicostomy or cecostomy" — Marc Levitt (clinical) [Ep 23 · 42:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2555)
- "When performing primary transanal pull-through without biopsy, approximately 1 in 10 to 1 in 15 cases will have a transition zone higher than expected or total colonic aganglionosis" — Holcomb (clinical) [Ep 4 · 1:47](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=107)
- "Laparoscopic approach with three 3-millimeter ports allows mobilization in approximately 45 minutes" — Jason (clinical) [Ep 4 · 4:57](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=297)
- "Standard rectosigmoid Hirschsprung (6-10 centimeters up) can be completed transanally in approximately 2 hours" — Jason (clinical) [Ep 4 · 5:06](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=306)
- "Postoperative Hirschsprung complications are categorized into obstructive symptoms (enterocolitis, failure to thrive, abdominal distention) and soiling issues (true incontinence versus pseudo-incontinence)" — Jason (clinical) [Ep 4 · 5:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=353)
- "Obstructive symptoms after Hirschsprung surgery must be evaluated to distinguish anatomic problems from pathologic problems" — Jason (clinical) [Ep 4 · 6:13](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=373)
- "True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line" — Jason (clinical) [Ep 4 · 6:20](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=380)
- "Workup for postoperative Hirschsprung problems includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists" — Jason (clinical) [Ep 4 · 6:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=413)
- "If no anatomic reason is found for postoperative problems, biopsy should be performed" — Jason (clinical) [Ep 4 · 6:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=413)
- "A normal Hirschsprung anus should appear as a normal appearing anus with a normal anal canal, not patulous" — Jason (clinical) [Ep 4 · 7:24](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=444)
- "Dissection should begin approximately 1 centimeter above the dentate line in Hirschsprung surgery" — Jason (clinical) [Ep 4 · 8:24](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=504)
- "A 1-centimeter distance above the dentate line in a newborn may become 2.5 to 3 centimeters when the child is 7 years old" — Jason (clinical) [Ep 4 · 8:33](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=513)
- "If the anastomosis is performed too high, the patient may develop what some call short segment or ultra short segment Hirschsprung disease" — Jason (clinical) [Ep 4 · 8:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=533)
- "Injury to the dentate line can render patients potentially fecally incontinent, which is a devastating injury" — Jason (clinical) [Ep 4 · 9:11](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=551)
- "The dentate line is defined as the transition from squamous epithelium to columnar epithelium" — Jason (clinical) [Ep 4 · 9:37](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=577)
- "The top of the anal columns is used as a landmark for the dentate line location" — Jason (clinical) [Ep 4 · 9:51](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=591)
- "In J-pouch surgery for ulcerative colitis or FAP, the anastomosis is performed right at the top of the columns or slightly lower if polyps are present" — Jason (clinical) [Ep 4 · 10:07](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=607)
- "The dentate line location in anatomic literature and illustrations is variable, with different sources pointing to different locations within the anal columns" — Jason (clinical) [Ep 4 · 11:07](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=667)
- "Surgeons may intentionally leave a zone of aganglionosis to avoid fecal incontinence, as residual aganglionosis can be managed with laxatives but incontinence cannot be overcome" — Belinda (clinical) [Ep 4 · 11:50](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=710)
- "The surgical approach should hedge on the side of leaving ultra short segment Hirschsprung disease rather than injuring the anal canal" — Jason (opinion) [Ep 4 · 12:04](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=724)
- "Placing three abdominal incisions may be less invasive than torquing in the anal canal during prolonged transanal dissection" (opinion) [Ep 4 · 3:50](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=230)
- "Transanal dissection should not involve stretching sphincters for 4 hours; if dissection is taking that long, laparoscopic approach should be used" — Jason (opinion) [Ep 4 · 4:35](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=275)
- "Leveling colostomy may be the safest approach when pathology support is limited or unavailable, such as on mission trips" — Jason (clinical) [Ep 4 · 3:13](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=193)
- "For a newborn with Hirschsprung disease and a transition zone at the descending colon level, laparoscopic biopsy and mobilization is the preferred approach among polled experts." — Mark (opinion) [Ep 5 · 1:35](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=95)
- "For the average pediatric surgeon performing primary transanal pull-through without biopsy, there is approximately a 1 in 10 to 1 in 15 chance of encountering disease higher than expected or total colonic aganglionosis during their career." (epidemiological) [Ep 5 · 2:09](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=129)
- "Surgeons performing transanal pull-through without prior biopsy should have a predetermined exit strategy for managing unexpectedly proximal disease." (opinion) [Ep 5 · 2:44](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=164)
- "The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through." — Jason Frischer (opinion) [Ep 5 · 3:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=186)
- "Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable." — Jason Frischer (opinion) [Ep 5 · 3:46](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=226)
- "Leveling colostomy represents a three-stage procedure for Hirschsprung disease management." — Jason Frischer (clinical) [Ep 5 · 4:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=243)
- "Pure transanal pull-through may not be less invasive than laparoscopic approach, as prolonged torquing in the anal canal can be more traumatic than three small abdominal incisions." — Todd Ponsky (opinion) [Ep 5 · 4:22](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=262)
- "Transanal dissection attempting to reach high past the pelvic reflection involves significant pulling and stretching of the sphincters." — Belinda (clinical) [Ep 5 · 4:53](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=293)
- "Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching." — Jason Frischer (opinion) [Ep 5 · 5:07](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=307)
- "Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases." — Jason Frischer (clinical) [Ep 5 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=330)
- "Standard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study." — Jason Frischer (clinical) [Ep 5 · 5:46](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=346)
- "Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues." — Jason Frischer (clinical) [Ep 5 · 6:12](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=372)
- "Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence." — Jason Frischer (clinical) [Ep 5 · 6:31](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=391)
- "Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems." — Jason Frischer (clinical) [Ep 5 · 6:45](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=405)
- "True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line." — Jason Frischer (clinical) [Ep 5 · 6:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=412)
- "Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation." — Jason Frischer (clinical) [Ep 5 · 7:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=424)
- "Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease." — Jason Frischer (host_summary) [Ep 5 · 7:08](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=428)
- "Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists." — Jason Frischer (clinical) [Ep 5 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=445)
- "In the 1960s and 1970s fluoroscopy was done by everybody and done very well, but with the advent of MRI, CT, and ultrasound there has been a shift to more current modalities and fluoroscopy is almost a lost art." (opinion) [Ep 6 · 0:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=20)
- "In a newborn on plain radiograph you cannot tell the difference between colon and small bowel; you can only say there are multiple dilated loops suggesting distal bowel obstruction." (clinical) [Ep 6 · 2:38](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=158)
- "The differential diagnosis for neonatal distal bowel obstruction includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia, which together account for about 99% of cases." (clinical) [Ep 6 · 3:12](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=192)
- "Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease." (clinical) [Ep 6 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=287)
- "The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph." (clinical) [Ep 6 · 4:58](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=298)
- "Air-fluid levels visible in the colon on cross-table or decubitus views are a sign of inflammatory process, potentially enterocolitis." (clinical) [Ep 6 · 6:13](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=373)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise." (clinical) [Ep 6 · 7:29](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=449)
- "The false negative rate of contrast enema for Hirschsprung disease is between 20% and 25%." (host_summary) [Ep 6 · 9:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=587)
- "The false positive transition zone rate on contrast enema is up to 43%." (host_summary) [Ep 6 · 10:35](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=635)
- "Radiologist agreement on transition zone location is fairly high at 90%." (host_summary) [Ep 6 · 10:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=647)
- "The concordance rate between radiologic and pathologic transition zone location is only about 62% overall." (host_summary) [Ep 6 · 11:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=662)
- "For short segment (rectosigmoid) Hirschsprung disease, the concordance between radiologic and pathologic transition zones is about 75%." (host_summary) [Ep 6 · 12:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=763)
- "For long segment Hirschsprung disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zones is only about 25%." (host_summary) [Ep 6 · 13:09](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=789)
- "Repeat enemas in patients with long segment disease are futile and will not provide better localization of the transition zone." (clinical) [Ep 6 · 13:44](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=824)
- "In patients with longer segment disease, surgeons should plan the operation assuming the transition may be high rather than relying on the enema findings." (clinical) [Ep 6 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=834)
- "Never use a Foley catheter inside the rectum for contrast enema in suspected Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 6 · 15:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=957)
- "Insert the rectal tube only 2 to 3 centimeters into the rectum for contrast enema." — Rodrigo Ocelami (clinical) [Ep 6 · 15:49](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=949)
- "In the neonatal period, use water-soluble contrast diluted 50% with saline for contrast enema." — Rodrigo Ocelami (clinical) [Ep 6 · 16:19](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=979)
- "Inject contrast very slowly and gently via syringe (not gravity) to avoid distending the aganglionic segment and missing the diagnosis." — Rodrigo Ocelami (clinical) [Ep 6 · 16:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=991)
- "After the neonatal period, fill only up to the transverse colon; if the studied segment appears normal in distension, caliber, and mucosa, and the splenic flexure shows no suggestion of total colonic involvement, stop at the transverse colon." — Rodrigo Ocelami (clinical) [Ep 6 · 16:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1016)
- "Obtain two images in left lateral decubitus, two in right lateral decubitus, and two in AP position during contrast enema." — Rodrigo Ocelami (clinical) [Ep 6 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1045)
- "The inversion of the rectosigmoid index (rectum smaller than sigmoid) is very helpful in diagnosing Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 6 · 18:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1098)
- "The affected (aganglionic) segment will be spastic, which is why contrast should not be given in large amounts or too fast, as this will cause you to miss the spasticity." — Rodrigo Ocelami (clinical) [Ep 6 · 18:33](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1113)
- "Always counsel families about good hydration after contrast enema to help the child evacuate the contrast and avoid dehydration." — Rodrigo Ocelami (clinical) [Ep 6 · 19:17](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1157)
- "Show the family the contrast material before and after the study so they know what to expect when white material comes out." — Rodrigo Ocelami (clinical) [Ep 6 · 19:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1171)
- "The water-soluble iodinated contrast used for enemas has an osmolality of about 400, similar to colon-cleansing agents, and is hyperosmotic." (clinical) [Ep 6 · 20:59](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1259)
- "The hyperosmotic contrast not only helps make the diagnosis but also attempts to clean the colon." (clinical) [Ep 6 · 21:11](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1271)
- "If contrast stays in the colon, neonates can become dehydrated, so the neonatal ICU must be informed." (clinical) [Ep 6 · 21:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1280)
- "Use gravity infusion from a bag with large IV tubing at a moderate pace (not slow) to rapidly show both distal and proximal segments and visualize the transition zone quickly." (clinical) [Ep 6 · 21:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1305)
- "Early maximal distention is best for seeing the transition zone; waiting too long can cause distention of the distal aganglionic segment because it is soft tissue, not a rigid pipe." (clinical) [Ep 6 · 22:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1338)
- "If the colon looks small in a neonate, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present." (clinical) [Ep 6 · 22:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1365)
- "In a full-term infant, use a 12 to 14 French Foley catheter; in a premature infant, use a smaller size." (clinical) [Ep 6 · 23:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1382)
- "A true lateral image with femurs superimposed is essential to visualize the presacral space properly." (clinical) [Ep 6 · 23:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1398)
- "On frontal view, ensure the tube is visible but also visualize distal to it to avoid missing a very distal transition zone." (clinical) [Ep 6 · 23:26](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1406)
- "In a normal neonate, the proximal colon toward the splenic flexure is always a little smaller than the rectum." (clinical) [Ep 6 · 23:37](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1417)
- "If a Foley catheter balloon is inflated in the rectum to prevent leakage, it will miss very short segment Hirschsprung disease every single time." (clinical) [Ep 6 · 23:55](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1435)
- "Contrast enema in premature infants does not follow the rules; the colon can look immature and small, making it difficult to distinguish from Hirschsprung disease." (clinical) [Ep 6 · 25:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1502)
- "Contrast enema can be performed in premature infants as young as 35 to 36 weeks gestational age with reasonable diagnostic accuracy." (clinical) [Ep 6 · 25:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1518)
- "Below 35-36 weeks gestational age, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of contrast enema decreases." (clinical) [Ep 6 · 25:30](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1530)
- "The rectosigmoid transition in Hirschsprung disease is typically at the S2 level; if distal to S1-S2 it is considered distal rectal, if more proximal it is typical rectosigmoid." (clinical) [Ep 6 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1605)
- "Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt." (clinical) [Ep 6 · 27:21](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1641)
- "The rectosigmoid index (rectum larger than sigmoid) is a good principle, but do not stop there—examine all the way up to the splenic flexure." (clinical) [Ep 6 · 28:48](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1728)
- "A case initially diagnosed radiologically as small left colon syndrome with transition at splenic flexure proved to be total colonic aganglionosis with transition in the terminal ileum." (clinical) [Ep 6 · 29:06](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1746)
- "If you have a proximal transition zone on enema, you cannot accurately determine where the pathologic transition actually is." (clinical) [Ep 6 · 30:14](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1814)
- "A proximal transition zone should prompt consideration of a more invasive surgical approach (laparoscopic or open) rather than transanal, because the true transition location is uncertain." (clinical) [Ep 6 · 30:22](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1822)
- "Rectal biopsy should be performed in almost any patient who needed a contrast enema to rule out distal obstruction, including cases of meconium plug or small left colon." — Todd Ponsky (clinical) [Ep 6 · 31:01](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1861)
- "In clearly documented meconium ileus where reflux into terminal ileum is achieved and the patient clinically improves, rectal biopsy may not be necessary." — Todd Ponsky (clinical) [Ep 6 · 31:35](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1895)
- "After Soave pull-through, contrast enema shows a wide presacral space due to the retained muscular cuff from partial-thickness dissection." (clinical) [Ep 6 · 33:27](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2007)
- "The widened presacral space after Soave is best seen on lateral view because the cuff extends circumferentially." (clinical) [Ep 6 · 34:05](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2045)
- "A true lateral view of the rectum is very important in post-surgical patients to assess for complications." (clinical) [Ep 6 · 34:14](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2054)
- "The Duhamel procedure creates a chimera of aganglionic segment distally with ganglionic segment proximally, not placed end-to-end or side-to-side but as a patchwork." (clinical) [Ep 6 · 35:06](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2106)
- "In symptomatic patients after Duhamel, an anterior pouch containing stool enlarges and impresses on the ganglionic bowel, causing obstruction." (clinical) [Ep 6 · 35:28](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2128)
- "In untreated Hirschsprung disease, even in patients 10, 12, 14, or 15 years old, a dilated rectum is never seen; by definition the aganglionic segment does not distend." (clinical) [Ep 6 · 36:09](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2169)
- "Patients who develop the characteristic Duhamel pouch with fecal impaction in the rectum may never have had true Hirschsprung disease, as the aganglionic rectum should not distend." (opinion) [Ep 6 · 36:33](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2193)
- "When resecting a Duhamel pouch, the specimen should be oriented and the pathologist alerted to determine whether ganglion cells are present in the rectum." (clinical) [Ep 6 · 36:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2216)
- "Resected Duhamel pouches have been observed to contain both ganglionic and aganglionic parts." (clinical) [Ep 6 · 37:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2240)
- "A contrast enema showing dilated, redundant colon filled with stool but normal rectum and presacral space represents idiopathic constipation, not Hirschsprung disease." (clinical) [Ep 6 · 37:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2263)
- "In a patient with a contrast enema showing dilated colon and normal rectum, rectal biopsy is a waste of time because the patient does not have Hirschsprung disease." (opinion) [Ep 6 · 39:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2383)
- "If a biopsy is taken in functional constipation, there is risk of obtaining an aganglionic result from the normal physiologic aganglionic zone, which does not mean the patient has Hirschsprung disease." (clinical) [Ep 6 · 39:54](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2394)
- "There is no way to differentiate so-called ultra-short segment Hirschsprung disease from idiopathic constipation." (opinion) [Ep 6 · 40:15](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2415)
- "The rectum has a normal area with ganglion cells, then a zone with no ganglion cells (normal physiologic aganglionosis), but the length of this aganglionic zone has never been accurately determined at different ages." (clinical) [Ep 6 · 40:28](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2428)
- "There is no accurate study defining the length of normal physiologic aganglionosis in preterm infants, full-term babies, 6-month-olds, or older children—this is a challenge for young pediatric surgeons." (opinion) [Ep 6 · 40:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2457)
- "A biopsy taken in the zone of normal physiologic aganglionosis will show no ganglion cells but does not indicate Hirschsprung disease." (clinical) [Ep 6 · 41:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2480)
- "The internal sphincter has been defined as a thickening of the circular layer of normal smooth muscle bowel, but this thickening has never been personally observed in opened normal rectums at different ages." (opinion) [Ep 6 · 41:29](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2489)
- "If the internal sphincter thickening exists, nobody has determined the exact limit of that thickening at different ages." (opinion) [Ep 6 · 41:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2516)
- "Achalasia of the internal sphincter is a manometric concept, not an anatomic concept." (opinion) [Ep 6 · 42:07](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2527)
- "Myectomies, myotomies, and botulinum toxin injections for internal sphincter achalasia are not recommended because no one knows what area of muscle they are actually treating." (opinion) [Ep 6 · 42:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2551)
- "Botulinum toxin injection paralyzes whatever muscle is present and facilitates stool passage, but it is not curing a condition of unknown origin." (opinion) [Ep 6 · 42:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2577)
- "Dr. Langer has published articles in a Seminars in Pediatric Surgery issue on Hirschsprung disease less than a year ago" (host_summary) [Ep 7 · 0:13](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=13)
- "In newborn bowel obstruction with distended abdomen and distal air, start with contrast enema rather than upper GI" — Todd Ponsky (opinion) [Ep 7 · 1:45](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=105)
- "Bilious emesis typically prompts upper GI, but newborn distal obstruction is an exception where contrast enema is more informative" — Todd Ponsky (clinical) [Ep 7 · 2:11](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=131)
- "A significant portion of fellows at a Washington DC course said they would get upper GI first in newborn with bilious emesis before contrast enema" — Todd Ponsky (host_summary) [Ep 7 · 2:40](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=160)
- "False positive contrast enemas showing transition zones in newborns without Hirschsprung disease have been documented in published literature" — Langer (clinical) [Ep 7 · 4:58](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=298)
- "Tissue diagnosis is absolutely required before operating for Hirschsprung disease" — Todd Ponsky (guideline) [Ep 7 · 4:51](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=291)
- "In rare cases of severe enterocolitis, a patient may require emergency diversion before tissue diagnosis is available, particularly if presenting on Friday with pathology results not available until Wednesday" (clinical) [Ep 7 · 5:16](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=316)
- "8% of cases in Mana Proctor's paper showed short-appearing transition zones on imaging that were actually long-segment disease pathologically" — Langer (host_summary) [Ep 7 · 8:02](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=482)
- "Female patients with Hirschsprung disease may have higher rates of long-segment disease than males" — Jason (clinical) [Ep 7 · 8:18](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=498)
- "The incidence of long-segment Hirschsprung disease in girls is fifty-fifty" (epidemiological) [Ep 7 · 8:49](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=529)
- "Most cecal perforations from Hirschsprung disease are not total colonic disease but shorter segment disease where the cecum becomes distended and perforates" — Langer (clinical) [Ep 7 · 20:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1252)
- "In long-segment Hirschsprung disease, wait 6 to 12 months before pull-through to allow stoma output to thicken and prevent severe perianal excoriation" — Langer (clinical) [Ep 7 · 22:40](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1360)
- "When transition zone is in ascending colon (just cecum remaining), results of pulling cecum down are poor due to stasis and enterocolitis; better to do ileal Duhamel" — Langer (opinion) [Ep 7 · 23:34](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1414)
- "If transition zone is at hepatic flexure rather than ascending colon, preserve the colon and bring it down" — Langer (opinion) [Ep 7 · 24:23](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1463)
- "There are two definitions of ultra-short segment Hirschsprung disease: (1) absence of recto-anal inhibitory reflex with normal ganglion cells (internal sphincter achalasia, not true Hirschsprung), and (2) very short segment of aganglionosis" — Langer (clinical) [Ep 7 · 15:08](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=908)
- "Dr. Pena and Dr. Levitt do not believe in ultra-short segment Hirschsprung disease and do not perform myectomies" — Jason (host_summary) [Ep 7 · 13:28](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=808)
- "Myectomy is an extremely difficult technical operation with poor success rates in the speaker's experience" (opinion) [Ep 7 · 12:58](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=778)
- "For older children (age 5-6 and up), manometry showing normal recto-anal inhibitory reflex rules out Hirschsprung disease without need for biopsy" — Langer (clinical) [Ep 7 · 14:19](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=859)
- "Absence of recto-anal inhibitory reflex on manometry requires biopsy because there can be false absence of the reflex" — Langer (clinical) [Ep 7 · 14:37](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=877)
- "The anal canal in an adult is 3 to 4 centimeters long, compared to 1 centimeter in an infant, which affects biopsy interpretation" (clinical) [Ep 7 · 17:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1024)
- "Hypertrophic nerves should not be present in normal anal canal, even though there is normal dropout of ganglion cells" (clinical) [Ep 7 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1045)
- "In older children (age 2-3 and up), suction rectal biopsy should not be performed; instead do open rectal biopsy under general anesthesia" — Todd Ponsky (opinion) [Ep 7 · 28:51](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1731)
- "In 3-year-old with severely dilated colon from chronic Hirschsprung disease, the dilated segment is unlikely to collapse and should be resected" — Todd Ponsky (opinion) [Ep 7 · 30:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1806)
- "Dilated colon in 3-year-old with Hirschsprung disease can shrink down with diverting stoma and irrigations over 6-8 months" — Langer (clinical) [Ep 7 · 32:23](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1943)
- "The older the child, the less likely severely dilated colon will shrink down with diversion" — Langer (clinical) [Ep 7 · 32:42](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1962)
- "Attempting to resect severely dilated colon transanally causes enormous stretch on the sphincter and impairs postoperative continence" — Jason (clinical) [Ep 7 · 31:50](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1910)
- "A patient at a well-known Ohio institution had multiple normal colonoscopic biopsies but subsequent rectal biopsy showed aganglionosis and hypertrophic nerves" — Jason (clinical) [Ep 7 · 33:22](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2002)
- "The incidence of enterocolitis is significantly higher (approximately double) in children with trisomy 21 compared to genetically normal children with Hirschsprung disease" (epidemiological) [Ep 7 · 36:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2165)
- "Chronic oral metronidazole is used liberally for recurrent enterocolitis and some children need it for three months or longer" — Langer (clinical) [Ep 7 · 37:18](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2238)
- "Botox injection decreased the number of hospitalizations for enterocolitis in published study, though it does not always work" — Langer (clinical) [Ep 7 · 37:48](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2268)
- "In newborn bowel obstruction with distal air, contrast enema should precede upper GI unless clinical presentation strongly suggests malrotation" — Todd Ponsky (opinion) [Ep 8 · 1:59](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=119)
- "Tissue diagnosis is mandatory before surgery for Hirschsprung disease; contrast enema alone is insufficient" — Todd Ponsky (host_summary) [Ep 8 · 5:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=306)
- "False positive contrast enemas showing transition zones can occur in newborns without Hirschsprung disease" — Jacob Langer (clinical) [Ep 8 · 5:13](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=313)
- "In critically ill patients with enterocolitis, surgery may be necessary before pathology results are available (typically takes until Wednesday if specimen obtained Friday)" — Todd Ponsky (host_summary) [Ep 8 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=330)
- "In Mana Proctor's series, 8% of cases with apparent short transition zone on imaging had pathologically higher transition zones (long transition zone concept)" — Jacob Langer (epidemiological) [Ep 8 · 8:16](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=496)
- "Female patients may have higher risk of long-segment disease, with 50-50 incidence of long-segment in girls" — Jason Frischer (epidemiological) [Ep 8 · 8:56](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=536)
- "Prone positioning for pull-through is easier on surgeon's back and neck compared to lithotomy" — Todd Ponsky (opinion) [Ep 8 · 9:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=597)
- "Two definitions exist for ultra-short segment Hirschsprung: (1) absence of recto-anal inhibitory reflex with normal ganglion cells on biopsy (internal sphincter achalasia, not true Hirschsprung), and (2) very short segment of aganglionosis" — Jacob Langer (clinical) [Ep 8 · 15:23](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=923)
- "Manometry showing normal recto-anal inhibitory reflex rules out Hirschsprung disease in older children without need for biopsy" — Jacob Langer (clinical) [Ep 8 · 14:33](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=873)
- "Absence of recto-anal inhibitory reflex on manometry requires biopsy confirmation due to false positives" — Jacob Langer (clinical) [Ep 8 · 14:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=892)
- "For ultra-short segment with confirmed aganglionosis, pull-through is preferred over myectomy" — Jacob Langer (opinion) [Ep 8 · 16:36](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=996)
- "Most 16-year-olds with newly diagnosed Hirschsprung require diversion due to massive bowel dilation" — Jacob Langer (clinical) [Ep 8 · 16:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1017)
- "Laparoscopic Duhamel is preferred for older patients because thickened rectum makes transanal dissection difficult and causes excessive sphincter stretch" — Jacob Langer (opinion) [Ep 8 · 17:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1025)
- "Adult anal canal is 3-4 centimeters long (possibly 5 cm), compared to 1 cm in infants; biopsies at 3 cm in adults may be from anal canal where ganglion cells are normally absent" — Garrison (clinical) [Ep 8 · 17:21](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1041)
- "Hypertrophic nerves should not be present in normal anal canal, even though ganglion cells are absent there" — Todd Ponsky (host_summary) [Ep 8 · 17:40](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1060)
- "Transitional epithelium (not normal rectal mucosa) should be seen on biopsy if specimen is truly from anal canal" — Jacob Langer (clinical) [Ep 8 · 17:53](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1073)
- "Most cecal perforations in Hirschsprung disease occur with shorter-segment disease (not total colonic), as cecum distends most and perforates like in rectal cancer" — Jacob Langer (clinical) [Ep 8 · 21:10](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1270)
- "For cecal perforation, close perforation and create loop ileostomy without frozen section of ileum, as total colonic disease is unlikely" — Jacob Langer (opinion) [Ep 8 · 21:10](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1270)
- "In long-segment disease, delay pull-through 6-12 months until stoma output thickens to prevent severe perianal excoriation" — Jacob Langer (clinical) [Ep 8 · 22:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1372)
- "Pull-throughs using only cecum (very short colonic segment) have poor outcomes with stasis and enterocolitis; ileal Duhamel may be preferable" — Jacob Langer (opinion) [Ep 8 · 23:50](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1430)
- "If transition zone is at hepatic flexure (not just cecum), preserve the colon and perform Duhamel" — Jacob Langer (opinion) [Ep 8 · 24:37](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1477)
- "When bringing right colon down, flip it over rather than rotating; preserve marginal artery and let anatomy determine orientation" — Jacob Langer (clinical) [Ep 8 · 25:47](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1547)
- "Manometry is not reliably performed until age 5-6 years" — Jacob Langer (clinical) [Ep 8 · 29:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1744)
- "In children over age 2-3 years, perform open rectal biopsy under general anesthesia rather than office suction biopsy due to patient cooperation issues" — Todd Ponsky (host_summary) [Ep 8 · 29:11](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1751)
- "For 3-year-old with massive dilation, divert and attempt bowel decompression; resect dilated segment if it does not collapse after 6-8 months" — Jacob Langer (opinion) [Ep 8 · 30:17](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1817)
- "Older children are less likely to have bowel shrinkage after diversion, but 3-year-olds may still respond" — Jacob Langer (clinical) [Ep 8 · 32:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1977)
- "Transanal resection of massively dilated colon in older children causes enormous sphincter stretch and impairs postoperative continence; laparoscopic dissection to pelvic floor is preferred" — Jason Frischer (clinical) [Ep 8 · 32:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1925)
- "Colonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable" — Jason Frischer (clinical) [Ep 8 · 33:42](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2022)
- "Manometry is reliable for diagnosing Hirschsprung in older children when biopsies may be unreliable" — Todd Ponsky (host_summary) [Ep 8 · 34:11](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2051)
- "For enterocolitis 6 months post-pull-through with fever, distention, and diarrhea but no peritonitis, treat with IV fluids, broad-spectrum antibiotics, and rectal irrigations" — Todd Ponsky (host_summary) [Ep 8 · 35:15](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2115)
- "Incidence of enterocolitis in children with trisomy 21 is double that of genetically normal children with Hirschsprung disease" — Todd Ponsky (host_summary) [Ep 8 · 36:20](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2180)
- "For recurrent enterocolitis, first rule out distal obstruction and residual aganglionosis with exam under anesthesia and biopsies" — Jacob Langer (guideline) [Ep 8 · 37:00](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2220)
- "Chronic oral metronidazole is used liberally for recurrent enterocolitis; some patients require it for months, and symptoms recur when discontinued" — Jacob Langer (clinical) [Ep 8 · 37:32](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2252)
- "Botox injection decreases number of hospitalizations for enterocolitis, though it does not work in all patients" — Jacob Langer (clinical) [Ep 8 · 38:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2283)
- "Post-pull-through Hirschsprung's patients may develop stricture or outlet obstruction as the anastomotic area heals and narrows, typically presenting weeks after initial good stooling." — Megan (clinical) [Ep 9 · 2:07](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=127)
- "There is no standardized post-operative regimen for Hirschsprung's patients; treatment is individualized based on patient response." — Eunice (clinical) [Ep 9 · 3:54](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=234)
- "For Hirschsprung's enterocolitis, typical management includes NPO status, IV Flagyl, and rectal irrigations (10 cc/kg normal saline every 8 hours for first 24-48 hours)." — Megan (clinical) [Ep 9 · 7:17](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=437)
- "Patients with more severe enterocolitis (signs of sepsis) receive broad-spectrum antibiotics including gram-negative coverage in addition to Flagyl." — Eunice (clinical) [Ep 9 · 8:00](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=480)
- "Teaching parents to perform home rectal irrigations improves quality of life by allowing them to manage early constipation episodes without emergency room visits." — Eunice (clinical) [Ep 9 · 12:19](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=739)
- "The published guideline for obstructed post-Hirschsprung's patients recommends: exam to rule out mechanical obstruction, rectal biopsy if obstruction persists, Botox for outlet obstruction, then motility studies if symptoms continue." — Megan (host_summary) [Ep 9 · 16:23](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=983)
- "High-amplitude propagating contractions (HAPC) with pressures upwards of 400 mmHg can cause pseudoincontinence in post-Hirschsprung's patients, which no patient can voluntarily control." — Megan (clinical) [Ep 9 · 21:05](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1265)
- "Hirschsprung's patients with hypermotility-related incontinence are more difficult to manage than anorectal malformation patients because they have an intact sphincter creating outlet obstruction even with antegrade continence enemas." — Megan (clinical) [Ep 9 · 17:56](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1076)
- "Most pediatric rectal prolapse occurs during potty training age (around 3-4 years old) due to weak pelvic floor and low rectal position in children." — Eunice (clinical) [Ep 9 · 25:14](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1514)
- "Cystic fibrosis should be considered in the differential diagnosis of pediatric rectal prolapse." — Eunice (clinical) [Ep 9 · 25:45](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1545)
- "Conservative management of rectal prolapse includes treating constipation, proper toilet positioning (sitting upright with feet supported, not falling through the seat), and limiting time on the toilet." — Eunice (clinical) [Ep 9 · 26:08](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1568)
- "A systematic review of 900 patients with rectal prolapse showed 300 underwent sclerotherapy (8 studies, 3 agents) and 600 underwent operative management (22 studies, 17 different procedures), indicating lack of consensus on best surgical approach." — Eunice (host_summary) [Ep 9 · 31:11](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1871)
- "Sclerotherapy for rectal prolapse has high initial success rate, and cumulative success rate exceeds 80% after up to three attempts; after three failed attempts, operative intervention is reasonable." — Eunice (host_summary) [Ep 9 · 33:17](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1997)
- "95% alcohol is the most commonly used sclerosing agent for rectal prolapse because it has high success rates and is readily available in hospitals (used by interventional radiology)." — Eunice (clinical) [Ep 9 · 33:49](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2029)
- "Sclerotherapy for rectal prolapse has minimal risk of long-term complications; complications are mostly acute and negligible." — Eunice (host_summary) [Ep 9 · 34:10](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2050)
- "Among operative options for rectal prolapse, laparoscopic rectopexy has the highest success rate with lowest risk of complications." — Eunice (host_summary) [Ep 9 · 35:10](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2110)
- "Approximately half of children over 3 years old with rectal prolapse have concurrent psychiatric diagnoses such as obsessive-compulsive disorder, anxiety, or depression." — Eunice (host_summary) [Ep 9 · 37:18](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2238)
- "Pelvic floor rehabilitation combined with psychiatric support and sclerotherapy provides more durable outcomes in rectal prolapse patients with psychiatric comorbidities by strengthening pelvic floor musculature and providing behavior modification." — Eunice (clinical) [Ep 9 · 37:54](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2274)
- "Gastrographin challenge for adhesive small bowel obstruction is standard of care in adult surgery and limited pediatric data parallels adult data in safety and efficacy." — Beth (host_summary) [Ep 9 · 47:27](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2847)
- "The gastrographin protocol requires attending surgeon examination and X-ray review before initiation to ensure no signs of peritonitis or strangulation." — Beth (clinical) [Ep 9 · 45:55](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2755)
- "In the gastrographin protocol, if contrast reaches the cecum by 8-10 hours, the obstruction is resolved and NG tube can be removed; if not in cecum by 24 hours, patient should proceed to operating room." — Beth (clinical) [Ep 9 · 49:13](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2953)
- "Hirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction." — Aaron Garrison (clinical) [Ep 10 · 0:07](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=7)
- "More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease." — Jason Frischer (clinical) [Ep 10 · 0:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=35)
- "Some infants with Hirschsprung's disease do pass meconium." — Jason Frischer (clinical) [Ep 10 · 0:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=35)
- "Hirschsprung disease has an incidence of about 1 in 5,000 children." — Aaron Garrison (epidemiological) [Ep 10 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "About 10% of children with Hirschsprung disease will have a positive family history." — Aaron Garrison (epidemiological) [Ep 10 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "There are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease." — Aaron Garrison (clinical) [Ep 10 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Up to 10% of children with Hirschsprung's disease will have trisomy 21." — Aaron Garrison (epidemiological) [Ep 10 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Only 1 to 2% of patients with trisomy 21 have Hirschsprung disease." — Aaron Garrison (epidemiological) [Ep 10 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Hirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes." — Aaron Garrison (clinical) [Ep 10 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "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 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema." — Jason Frischer (epidemiological) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Rectal biopsy is the true definitive diagnosis for Hirschsprung disease." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "To be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Suction biopsy technique is typically used for patients less than six months of age." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate." — Jason Frischer (clinical) [Ep 10 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR)." — Jason Frischer (clinical) [Ep 10 · 4:23](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=263)
- "The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test." — Jason Frischer (clinical) [Ep 10 · 4:23](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=263)
- "Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis." — Jason Frischer (guideline) [Ep 10 · 4:23](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=263)
- "Enterocolitis is the life-threatening part of Hirschsprung's disease." — Aaron Garrison (clinical) [Ep 10 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "NICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended." — Aaron Garrison (clinical) [Ep 10 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "Older children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases." — Aaron Garrison (clinical) [Ep 10 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity." — Jason Frischer (clinical) [Ep 10 · 6:42](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=402)
- "The contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always." — Aaron Garrison (clinical) [Ep 10 · 6:59](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=419)
- "The goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line." — Aaron Garrison (clinical) [Ep 10 · 6:59](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=419)
- "In the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible." — Jason Frischer (clinical) [Ep 10 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys." — Jason Frischer (clinical) [Ep 10 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel." — Jason Frischer (clinical) [Ep 10 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum." — Jason Frischer (clinical) [Ep 10 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina." — Jason Frischer (opinion) [Ep 10 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction." — Jason Frischer (clinical) [Ep 10 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel." — Aaron Garrison (clinical) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "The Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures." — Aaron Garrison (opinion) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "Children who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch." — Aaron Garrison (clinical) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "In the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision." — Aaron Garrison (clinical) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "All three surgical techniques (Swenson, Suave, and Duhamel) are equally effective." — Aaron Garrison (opinion) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "Early complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn." — Aaron Garrison (clinical) [Ep 10 · 11:49](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=709)
- "Anastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion." — Aaron Garrison (clinical) [Ep 10 · 11:49](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=709)
- "Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth." — Jason Frischer (clinical) [Ep 10 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "A child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all." — Jason Frischer (clinical) [Ep 10 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations." — Jason Frischer (clinical) [Ep 10 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation." — Jason Frischer (clinical) [Ep 10 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management." — Aaron Garrison (epidemiological) [Ep 10 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=834)
- "Most patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten." — Aaron Garrison (clinical) [Ep 10 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=834)
- "For patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure." — Jason Frischer (clinical) [Ep 10 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "Anatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment." — Jason Frischer (clinical) [Ep 10 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "For patients with anatomic problems after pull-through, you typically have to revise the pull through." — Jason Frischer (clinical) [Ep 10 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies." — Jason Frischer (clinical) [Ep 10 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "Botox paralyzes skeletal muscle but clearly has some impact on smooth muscle" — Marc Levitt (clinical) [Ep 11 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=117)
- "Babies have very tight anal sphincter with or without Hirschsprung's disease, and if they hold stool in successfully, normal babies get constipated while Hirschsprung babies get enterocolitis" — Marc Levitt (clinical) [Ep 11 · 2:06](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=126)
- "After a perfectly done operation that preserves 1 centimeter of anal canal without hurting sphincters, high tone will occur in a baby that doesn't know how to relax" — Marc Levitt (clinical) [Ep 11 · 2:26](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=146)
- "Botox is valuable for babies coming back with enterocolitis episodes after ensuring no anatomic or pathologic problem with the pull-through" — Marc Levitt (clinical) [Ep 11 · 3:15](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=195)
- "In the early period up to one year of age, bad behavior by the patient can occur even with a perfectly done pull-through" — Marc Levitt (clinical) [Ep 11 · 3:27](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=207)
- "After one year of age, there may be an anatomic or pathologic problem, and Botox is not very valuable because the underlying problem must be identified" — Marc Levitt (clinical) [Ep 11 · 3:36](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=216)
- "A retained cuff that is too big, not split completely, or rolled up is particularly offensive to the ability of the pull-through to empty" — Marc Levitt (clinical) [Ep 11 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=287)
- "Patients with retained cuff will get better temporarily with Botox but will continue to fail every 2 or 3 months" — Marc Levitt (clinical) [Ep 11 · 5:09](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=309)
- "Nerves greater than 40 microns indicate a transition zone pull-through" — Marc Levitt (clinical) [Ep 11 · 5:35](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=335)
- "Many pathologists are not measuring nerve caliber, and pediatric surgeons should demand that their pathologists do this to avoid doing a pull-through in the transition zone" — Marc Levitt (opinion) [Ep 11 · 5:43](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=343)
- "When anatomic and pathologic issues are completely ruled out (no twist, stricture, cuff, etc.), Botox may be done once or maybe twice and then the patient is done" — Marc Levitt (clinical) [Ep 11 · 5:58](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=358)
- "If a patient over 1 year of age keeps misbehaving, there is likely an anatomic or pathologic problem" — Marc Levitt (clinical) [Ep 11 · 6:14](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=374)
- "Dr. Levitt has never met a patient with Hirschsprung disease that is anatomically perfect (no stricture, cuff, duhamel pouch causing trouble, twist) with normal ganglion cells and nerves less than 40 microns who does not spontaneously empty, except rare patients under one year who have not learned to relax their anal canal" — Marc Levitt (opinion) [Ep 11 · 6:24](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=384)
- "If symptoms persist in an older child, there is an anatomic or pathologic problem that has not yet been identified" — Marc Levitt (clinical) [Ep 11 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=420)
- "Dr. Levitt's Botox technique: 100 units in 10 cc saline, injecting 2.5 cc submucosal into each quadrant with a very small gauge needle" — Marc Levitt (clinical) [Ep 11 · 7:07](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=427)
- "Dr. Levitt will never do internal sphincterotomy because it is permanent Botox and could cause permanent incontinence" — Marc Levitt (opinion) [Ep 11 · 7:30](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=450)
- "Most practitioners use between 60 and 100 units of Botox for Hirschsprung patients" — Scott Ingham (clinical) [Ep 11 · 8:08](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=488)
- "Some practitioners use much less volume (1 mL total with 0.25 mL per quadrant) compared to Dr. Levitt's 10 mL technique" — Scott Ingham (clinical) [Ep 11 · 8:44](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=524)
- "A dilated pull-through segment may be secondary to noncompliance with dilations or bowel regimen, or the surgeon may not have taken out enough bowel at the original surgery" — Marc Levitt (clinical) [Ep 11 · 9:35](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=575)
- "Patients with dilated segment and no other anatomic abnormality who continue to misbehave may be offered redo surgery to remove the dilated segment, though this is exceedingly rare" — Marc Levitt (clinical) [Ep 11 · 10:01](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=601)
- "Almost always there is something causing the dilation, either a cuff or a transition zone segment of bowel" — Marc Levitt (clinical) [Ep 11 · 10:13](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=613)
- "The workup for patients with dilated segments includes contrast study, examination under anesthesia, and rectal biopsy" — Marc Levitt (clinical) [Ep 11 · 10:34](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=634)
- "For redo pull-through, Dr. Levitt performs transanal approach saving the anal canal, delivers bowel into abdomen, then decides whether tapering is needed" — Marc Levitt (clinical) [Ep 11 · 11:11](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=671)
- "A tapered segment will be fairly dysmotile for many months" — Marc Levitt (clinical) [Ep 11 · 11:24](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=684)
- "Dr. Levitt always diverts patients with an ileostomy if tapering or redo is required" — Marc Levitt (clinical) [Ep 11 · 11:31](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=691)
- "Most likely the dilated segment can be removed and healthy segment brought down without tapering" — Marc Levitt (clinical) [Ep 11 · 11:37](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=697)
- "It is critical to ensure removal of any distal obstruction during redo surgery; Dr. Levitt has seen patients redone with Soave cuff left alone, requiring redo of the redo to remove the cuff before improvement" — Marc Levitt (clinical) [Ep 11 · 11:46](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=706)
- "Maternal magnesium sulfate used to slow delivery can cause neonatal abdominal distention that mimics Hirschsprung disease" — Levitt (clinical) [Ep 13 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Maternal opiates can cause neonatal abdominal distention mimicking Hirschsprung disease" — Levitt (clinical) [Ep 13 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Hypothyroidism can present with neonatal abdominal distention similar to Hirschsprung disease" — Levitt (clinical) [Ep 13 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Small left colon syndrome associated with maternal diabetes can mimic Hirschsprung disease" — Levitt (clinical) [Ep 13 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Contrast enema should not be performed in the presence of enterocolitis due to risk of perforation" — Levitt (clinical) [Ep 13 · 6:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=404)
- "Rectal irrigations before contrast enema do not change the result of the contrast study" — Levitt (opinion) [Ep 13 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "The contrast study serves as a roadmap for surgery rather than a definitive diagnostic tool for Hirschsprung disease" — Levitt (clinical) [Ep 13 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "In Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio" — Frischer (clinical) [Ep 13 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=592)
- "Hyperperistalsis and tortuosity in the rectum on contrast enema is a classic finding in Hirschsprung disease, reflecting hypercontractility of the aganglionic segment" — Levitt (clinical) [Ep 13 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=630)
- "The exact location of the transition zone cannot be precisely determined on contrast study" — Levitt (clinical) [Ep 13 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=630)
- "Suction rectal biopsy is appropriate for neonates and does not require open biopsy in the operating room" — Levitt (clinical) [Ep 13 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=766)
- "Three good biopsy specimens should be obtained for pathologic evaluation" — Frischer (clinical) [Ep 13 · 13:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=783)
- "Quick diff staining highlights ganglion cells better than standard H&E staining" — Frischer (clinical) [Ep 13 · 13:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=783)
- "The diagnostic criteria for Hirschsprung disease at the Washington institution is absence of ganglion cells in 100 pathologic levels" — Levitt (clinical) [Ep 13 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "If a single ganglion cell is found on biopsy, the diagnosis is not Hirschsprung disease regardless of ganglion cell density" — Levitt (clinical) [Ep 13 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Nerve trunk hypertrophy is defined as nerve trunks greater than 40 microns in diameter" — Levitt (clinical) [Ep 13 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Pathologists should measure nerve trunks in rectal biopsies to confirm hypertrophy" — Levitt (clinical) [Ep 13 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "A pathology report showing no ganglion cells without comment on nerve hypertrophy is not satisfactory for surgical decision-making" — Levitt (clinical) [Ep 13 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Patients have been incorrectly operated on for Hirschsprung disease based on pathology reports showing no ganglion cells but lacking nerve hypertrophy documentation" — Levitt (clinical) [Ep 13 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Everyone is physiologically aganglionic in the zone of the anal canal" — Levitt (clinical) [Ep 13 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "Hypertrophic nerves are not found in the anal canal zone, so absence of ganglion cells there without nerve hypertrophy does not indicate Hirschsprung disease" — Levitt (clinical) [Ep 13 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "Presence of squamous epithelium in a rectal biopsy confirms the biopsy was taken too low (in the anal canal)" — Levitt (clinical) [Ep 13 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "The optimal location for rectal biopsy is 0.5 to 1 cm above the crypts to ensure columnar epithelium" — Levitt (clinical) [Ep 13 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "The crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line" — Frischer (clinical) [Ep 13 · 16:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=1005)
- "Infants presenting with Hirschsprung-like symptoms who have ganglion cells but numerous eosinophils on biopsy may have allergic colitis" — Levitt (clinical) [Ep 13 · 16:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=1015)
- "After Hirschsprung pull-through, Dr. Durham brings patients back about 2 weeks after surgery to calibrate the anus and assess for cicatrix or narrowing at the anastomosis." — Megan Durham (clinical) [Ep 14 · 1:58](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=118)
- "Problems after Hirschsprung pull-through commonly occur later rather than very early on in the young child." — Megan Durham (clinical) [Ep 14 · 2:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=133)
- "Dr. Huang does not perform routine post-operative therapies initially after Hirschsprung pull-through because the anastomosis is healing and insertion of finger or dilator risks disrupting the anastomosis." — Eunice Huang (clinical) [Ep 14 · 2:23](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=143)
- "There is probably not a standard post-operative method for Hirschsprung patients because each patient is different, with some doing beautifully after identical surgery while others require frequent follow-up." — Eunice Huang (opinion) [Ep 14 · 2:46](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=166)
- "For a first episode of enterocolitis in a patient who has been doing well, Dr. Huang would be more likely to not intervene much beyond treating the enterocolitis and ensuring appropriate recovery." — Eunice Huang (clinical) [Ep 14 · 4:14](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=254)
- "For chronic or recurrent enterocolitis after Hirschsprung pull-through, concerns include anatomic problems, physiologic dysmotility of the ganglionic segment, or technical issues such as a twist." — Eunice Huang (clinical) [Ep 14 · 4:39](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=279)
- "At Children's Healthcare of Atlanta, acute Hirschsprung-associated enterocolitis management does not include fixed NPO time or immediate TPN initiation." — Megan Durham (clinical) [Ep 14 · 5:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=313)
- "Children's Healthcare of Atlanta protocol for enterocolitis includes rectal irrigations with about 10 cc/kg normal saline every 8 hours for at least the first 24 to 48 hours." — Megan Durham (clinical) [Ep 14 · 5:19](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=319)
- "IV Flagyl is typically started for Hirschsprung-associated enterocolitis at Children's Healthcare of Atlanta." — Megan Durham (clinical) [Ep 14 · 5:29](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=329)
- "Hirschsprung enterocolitis patients present across a spectrum from mild (slight white count elevation and concerning X-ray distention) to severe (gross distention with obvious shock), requiring different treatment approaches." — Rod Gerardo (host_summary) [Ep 14 · 5:32](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=332)
- "Dr. Durham would discharge a child after enterocolitis on Flagyl, laxatives, and rectal irrigations for some period of time, particularly for children who tend to dilate their colon." — Megan Durham (clinical) [Ep 14 · 6:18](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=378)
- "Teaching parents how to perform washouts at home and providing them the tools allows them freedom to do initial washout when their child is getting sick, improving quality of life at home." — Eunice Huang (clinical) [Ep 14 · 6:48](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=408)
- "Children's Healthcare of Atlanta has developed a standardized teaching regimen for rectal irrigations across different campuses and a regular education process for floor nurses." — Megan Durham (clinical) [Ep 14 · 7:05](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=425)
- "Nursing staff commonly have different levels of education regarding rectal irrigations and enemas because this is not an everyday common occurrence." — Megan Durham (clinical) [Ep 14 · 7:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=433)
- "A standardized order form with links to policy has been implemented to make rectal irrigation procedures clearer for nurses." — Megan Durham (clinical) [Ep 14 · 7:37](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=457)
- "Dr. Langer published a guideline with the APSA Hirschsprung Disease Research Interest Group for diagnosis and management of obstructive symptoms after Hirschsprung pull-through." — Megan Durham (guideline) [Ep 14 · 8:10](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=490)
- "The APSA algorithm for post-pull-through obstruction includes decision points starting with rectal exam and contrast enema, potentially moving to rectal biopsy, botulinum toxin injection, and ultimately motility workup that determines need for further colonic resection versus bowel management, stoma, or ACE." — Rod Gerardo (host_summary) [Ep 14 · 8:33](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=513)
- "Obstructed Hirschsprung patients are easier to identify because not passing stool is an easy sign for parents to see, whereas hypermodal patients with fecal incontinence present a more difficult diagnostic challenge." — Megan Durham (clinical) [Ep 14 · 9:37](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=577)
- "In Case 2, exam under anesthesia revealed intact sphincters and intact dentate line." — Megan Durham (clinical) [Ep 14 · 10:52](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=652)
- "The patient in Case 2 had high-amplitude propagating contractions (HAPCs) on manometry with pressures upwards of 400 mmHg all the way down to the anus." — Megan Durham (clinical) [Ep 14 · 10:56](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=656)
- "Nobody can control the type of pressure (400 mmHg HAPCs) coming down to the anus." — Megan Durham (opinion) [Ep 14 · 11:11](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=671)
- "The patient in Case 2 was diagnosed with pseudo-incontinence with hypermotility." — Rod Gerardo (host_summary) [Ep 14 · 11:14](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=674)
- "Adjusting fiber intake, daily Imodium, and adding cholestyramine successfully managed the hypermotility patient, allowing return to school with other kids within about a year." — Rod Gerardo (host_summary) [Ep 14 · 11:21](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=681)
- "There are two types of problematic post-pull-through Hirschsprung's patients: obstructed patients (not emptying, distention, enterocolitis, failure to thrive) and soiling patients (pooping constantly, never distended, minimal constipation)." — Marc Levitt (clinical) [Ep 15 · 1:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=101)
- "If the pull-through is done correctly with no anatomic problems and preservation of the sphincter mechanism, most Hirschsprung's patients do extremely well, though some need medical treatment to manage constipation." — Marc Levitt (clinical) [Ep 15 · 4:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=249)
- "There is no reason why any Hirschsprung patient should be obstructed or soiling if properly managed; if they are, investigation is needed to identify and fix the problem." — Marc Levitt (clinical) [Ep 15 · 4:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=280)
- "Pathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed." — Jason Frischer (clinical) [Ep 15 · 5:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=307)
- "A pull-through can decompensate if the patient does not have adequate medical management or sphincter management, potentially leading to nerve hypertrophy." — Marc Levitt (clinical) [Ep 15 · 5:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=347)
- "The most important question for any soiling patient is: what is the patient's potential for bowel control? This question is often neglected." — Marc Levitt (clinical) [Ep 15 · 6:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=407)
- "All Hirschsprung's patients have the best possible potential for bowel control because they were born with normal sphincters (sometimes too strong and non-relaxing, but not lax) and intact dentate line with preserved anal canal sensation." — Marc Levitt (clinical) [Ep 15 · 7:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=429)
- "When a Hirschsprung's patient has an intact dentate line and intact sphincters, they have full potential for voluntary bowel movements and bowel control." — Marc Levitt (clinical) [Ep 15 · 7:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=458)
- "If the dentate line is lost (because dissection was started too low) or sphincters were overstretched and don't contract well, the patient may have lost their potential for bowel control." — Marc Levitt (clinical) [Ep 15 · 7:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=472)
- "3D anorectal manometry can objectively assess whether sphincters are intact, whether the patient has a good squeeze, and whether that squeeze is concentric." — Marc Levitt (clinical) [Ep 15 · 9:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=555)
- "Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function." — Jason Frischer (clinical) [Ep 15 · 9:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=598)
- "Sphincters become overstretched from transanal approach with deep dissection, wrong plane, or retractors placed in the anus; overstretched sphincters will not return to normal." — Marc Levitt (clinical) [Ep 15 · 10:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=648)
- "Patients with poor potential for bowel control (like anorectal malformation with poor spine/sacrum or spina bifida) need to be in a dedicated bowel management program with enemas or antegrade options." — Hira Ahmad (clinical) [Ep 15 · 12:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=740)
- "Patients with lost potential for bowel control (injured sphincters or lost dentate line) need a mechanical emptying program." — Marc Levitt (clinical) [Ep 15 · 12:39](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=759)
- "A mechanical program can get borderline patients clean and psychologically motivated to be clean, making them more likely to successfully potty train." — Marc Levitt (clinical) [Ep 15 · 12:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=773)
- "Mark Levitt's current routine is to perform 3D anorectal manometry in all soiling Hirschsprung's patients to assess squeeze quality and dentate line presence, then decide whether to attempt potty training with laxatives or start mechanical cleaning." — Marc Levitt (clinical) [Ep 15 · 13:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=791)
- "A new sphincter tightening technique has been developed and published in JPS with great results in multiple patients with disrupted or patulous sphincters." — Marc Levitt (clinical) [Ep 15 · 14:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=842)
- "Rectal prolapse after Hirschsprung's pull-through is iatrogenic and should never occur if sphincters are preserved; it results from overstretched sphincters becoming patulous to the point of laxity." — Marc Levitt (clinical) [Ep 15 · 15:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=902)
- "During normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis." — Jason Frischer (clinical) [Ep 15 · 16:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=967)
- "For patients with patulous sphincters, Mark Levitt would offer sphincter reconstruction and perform a Malone at the same time, as the Malone can serve as a bridge to continence by allowing patients to practice holding and releasing flushes on command." — Marc Levitt (clinical) [Ep 15 · 17:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=1033)
- "Hirschsprung disease occurs in about 1 in 5000 live births." — Marc Levitt (epidemiological) [Ep 16 · 3:30](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=210)
- "In Hirschsprung disease, ganglion cells have not migrated to the distal colon, and without ganglion cells the colon cannot relax and therefore stays squeezed." — Marc Levitt (clinical) [Ep 16 · 4:53](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=293)
- "90% of Hirschsprung patients are diagnosed in the first couple of months of life, the vast majority in the first week or so of life." — Marc Levitt (epidemiological) [Ep 16 · 4:42](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=282)
- "Because the lining of the bowel is not normal in Hirschsprung disease, bacteria that stay in the colon can migrate out and get into the bloodstream, creating a life-threatening condition called enterocolitis." — Marc Levitt (clinical) [Ep 16 · 6:05](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=365)
- "If Hirschsprung disease is recognized, it is pretty straightforward to intervene; you do not necessarily need surgery to prevent enterocolitis, you just need good nursing care and proper irrigation to get the stool to flow." — Marc Levitt (clinical) [Ep 16 · 7:06](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=426)
- "About 5% of Hirschsprung patients present after 1 year of life; the vast majority present as babies." — Marc Levitt (epidemiological) [Ep 16 · 8:10](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=490)
- "Down syndrome is associated with Hirschsprung disease." — Marc Levitt (clinical) [Ep 16 · 9:14](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=554)
- "10% of patients with meconium plug actually have Hirschsprung disease as the underlying cause; 90% just pass the plug and get better." — Marc Levitt (epidemiological) [Ep 16 · 10:46](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=646)
- "Milk protein allergy can mimic Hirschsprung disease; if you biopsy looking for Hirschsprung, you will find ganglion cells but lots of eosinophils." — Marc Levitt (clinical) [Ep 16 · 11:22](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=682)
- "To confirm Hirschsprung disease, you need both the absence of ganglion cells and confirmation that the nerves associated with those ganglion cells are thickened (hypertrophic)." — Marc Levitt (clinical) [Ep 16 · 13:40](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=820)
- "Nerve trunks greater than 40 microns are abnormal in rectal biopsy specimens." — Marc Levitt (clinical) [Ep 16 · 14:31](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=871)
- "You cannot diagnose Hirschsprung with a frozen section, but you can rule it out if ganglion cells are present. To prove it is Hirschsprung disease, you need several days and need to evaluate 100 slices of the sample." — Marc Levitt (clinical) [Ep 16 · 16:37](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=997)
- "In about 15% of Hirschsprung cases, the aganglionic segment extends higher than the splenic flexure." — Marc Levitt (epidemiological) [Ep 16 · 20:41](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1241)
- "Contrast enema is accurate in identifying the transition zone about 90% of the time, so when doing surgery, you need to confirm under the microscope where the healthy bowel begins." — Marc Levitt (clinical) [Ep 16 · 22:09](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1329)
- "The dilated colon in Hirschsprung disease will shrink down to more normal size as soon as it is given the opportunity to successfully empty out the anus once the blockade has been removed." — Marc Levitt (clinical) [Ep 16 · 22:43](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1363)
- "You really only need about 10% of your colon to function completely normally and have one bowel movement per day." — Marc Levitt (clinical) [Ep 16 · 29:06](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1746)
- "Most Hirschsprung patients only lose about 15 to 20% of their colon because that is where the abnormal segment is, so they can have a completely normal stooling life with one bowel movement per day." — Marc Levitt (clinical) [Ep 16 · 29:14](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1754)
- "Patients who have to lose their entire colon and have small bowel brought to the anus tend to have more frequent stools, somewhere between 2 and 6 per day, but can all maintain bowel control provided the surgeon successfully preserves the anal canal and sphincters." — Marc Levitt (clinical) [Ep 16 · 29:29](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1769)
- "Sometimes the irrigation tube does not reach high enough and does not get into the normal bowel, and therefore you cannot successfully decompress the bowel; such patients would benefit from a diversion with a stoma." — Marc Levitt (clinical) [Ep 16 · 30:46](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1846)
- "In Hirschsprung disease, the internal sphincter does not relax normally. When you have fullness in your rectum, your internal sphincter is supposed to relax, but in Hirschsprung disease it tightens at the wrong time and can hold stool in at an inappropriate time." — Marc Levitt (clinical) [Ep 16 · 42:39](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2559)
- "Even after successful Hirschsprung surgery, you are in danger of getting enterocolitis if you do not have good flow, and the sphincters can slow down the flow enough that you can develop enterocolitis even after surgery." — Marc Levitt (clinical) [Ep 16 · 41:43](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2503)
- "If you give Botox to temporarily knock out the sphincters (the Botox wears off over the next 3 months), the baby can learn to push on their abdomen and overcome the non-relaxing sphincters." — Marc Levitt (clinical) [Ep 16 · 41:59](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2519)
- "The vast majority of Hirschsprung patients recover very uneventfully, stool normally, and when they get to age 3 or 4 they successfully potty train." — Marc Levitt (clinical) [Ep 16 · 43:59](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2639)
- "Hirschsprung disease is a source of significant morbidity and mortality in the developing world if it is unrecognized." — Marc Levitt (epidemiological) [Ep 16 · 44:52](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2692)
- "If a family has a baby with Hirschsprung disease, the risk of another baby having Hirschsprung disease in their family is about 1 in 200, significantly higher than the general population risk of 1 in 5000." — Marc Levitt (epidemiological) [Ep 16 · 38:40](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2320)
- "Hirschsprung-associated enterocolitis is treated with irrigations, metronidazole antibiotic (for anaerobic bacteria), and intravenous hydration." — Marc Levitt (clinical) [Ep 16 · 39:29](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2369)

## Changelog
- Sep 9: 1 item added automatically
- Sep 8: 2 items no longer name enterocolitis
- Sep 7: 25 items added automatically

---
Educational content from recorded physician discussions — not medical advice. Cite the canonical URL or the ?t= deep link. Policy: https://library.globalcastmd.com/ai