# Hirschsprung-associated Enterocolitis — GCMD Library living collection

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

Updated: n/a · 4 episodes · 85 cited statements

## Episodes
### Acute Management
- [Suspected Hirschsprung's-associated enterocolitis (HAEC) Treatment Guideline...](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540) — video · [machine version](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540.md)

### Medical Management
- [Update Course Rewind: Botox in Hirschsprung Disease 2023](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941) — video · 5:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941.md)

### Case-Based Learning
- [Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407) — podcast · 24:11 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407.md)
- [The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461) — podcast · 21:29 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=0) Introduction (Ep 1)
- [0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21) Background and Patient Population (Ep 1)
- [2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120) Eight Key Steps of the Guideline (Ep 1)
- [5:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=300) Post-Admission Management and Summary (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=0) Case Introduction: 7-Year-Old with Post-Pull-Through Obstruction (Ep 2)
- [2:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=140) Differential Diagnosis of Post-Pull-Through Obstruction (Ep 2)
- [6:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=401) Hirschsprung-Associated Enterocolitis: Recognition and Management (Ep 2)
- [11:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=701) Contrast Enema Interpretation and Surgical Planning (Ep 2)
- [22:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1329) Episode Summary and Preview (Ep 2)
- [0:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=5) Case Introduction and Exam Under Anesthesia Overview (Ep 3)
- [1:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=92) Systematic Exam Under Anesthesia Technique (Ep 3)
- [5:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=322) Case Findings and Imaging Interpretation (Ep 3)
- [8:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=480) Repeat Biopsy Interpretation and Pathological Considerations (Ep 3)
- [14:31](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=871) Case Resolution and Surgical Approach (Ep 3)
- [17:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1041) Summary and Key Teaching Points (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=0) Introduction and Case Presentation (Ep 4)
- [1:08](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=68) Botox Technique and Indications (Ep 4)
- [2:00](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=120) Pathophysiology of Post-Operative Enterocolitis (Ep 4)
- [3:36](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=216) Evidence for Botox in HAEC (Ep 4)
- [4:47](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=287) Summary and Conclusion (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Every baby with Hirschsprung disease has a poorly functioning sphincter by nature of the disease" — Caitlin Smith (clinical) [Ep 4 · 1:14](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=74)
- "In order to maintain continence, you want to preserve the dentate line, and you have to leave a tiny bit of aganglionic internal sphincter" — Caitlin Smith (clinical) [Ep 4 · 2:17](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=137)
- "Babies outgrow enterocolitis because their external sphincter is able to overcome their internal sphincter, and that takes time for their body to mature" — Caitlin Smith (opinion) [Ep 4 · 2:23](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=143)
- "The Hirschsprung physiology sets up the colon to act like a pond with poor emptying and motility issues, allowing bacteria to overgrow if the colon is not cleared diligently" — Steven Lee or Doctor Julia Grabowski (clinical) [Ep 4 · 2:37](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=157)
- "There is a significantly higher rate of enterocolitis in Hirschsprung disease after pull-through when you take out the entire colon compared to babies with shorter segment disease" — Caitlin Smith (epidemiological) [Ep 4 · 3:06](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=186)
- "There is a much higher rate of enterocolitis in children with trisomy 21" — Caitlin Smith (epidemiological) [Ep 4 · 3:21](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=201)
- "You can still get enterocolitis even if you're doing rectal irrigations at home; there are times when it's just not enough to empty that colon" — I'm Goddy (clinical) [Ep 4 · 3:25](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=205)
- "There is discussion of whether when you make the diagnosis of total colon Hirschsprung, you should do the colectomy at that time because of the risk of enterocolitis" — Caitlin Smith (opinion) [Ep 4 · 3:35](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=215)
- "There is so much phenotypic variance in Hirschsprung disease that studying the use of Botox in post-pull-through enterocolitis yields imperfect data" — Caitlin Smith (opinion) [Ep 4 · 3:49](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=229)
- "Prophylactic Botox has not been shown to decrease the risk of enterocolitis" — Caitlin Smith (clinical) [Ep 4 · 4:14](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=254)
- "Botox has been shown to decrease the length of stay in patients who have been admitted for enterocolitis" — Caitlin Smith (clinical) [Ep 4 · 4:14](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=254)
- "Botox has been shown to potentially decrease hospitalizations in patients who present with recurrent episodes of obstruction or enterocolitis" — Caitlin Smith (clinical) [Ep 4 · 4:26](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=266)
- "Maybe not everyone needs Botox at the time of pull-through, but there is a subset of patients who have predisposition to enterocolitis for whom Botox as part of treatment strategy would be beneficial" — Caitlin Smith (opinion) [Ep 4 · 4:34](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=274)
- "Botox is often administered as 100 units in 1 mL of saline" — Caitlin Smith (clinical) [Ep 4 · 1:45](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=105)
- "Botox injection technique typically involves 3-4 injections in the dentate line" — Caitlin Smith (clinical) [Ep 4 · 1:48](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=108)
- "People are doing any amount of Botox in any aliquots in any number of locations (technique varies widely in the literature)" — Caitlin Smith (clinical) [Ep 4 · 1:33](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=93)
- "Papers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis" — Meera Kotagal (guideline) [Ep 1 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "The guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever" — Meera Kotagal (guideline) [Ep 1 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "GI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea" — Meera Kotagal (clinical) [Ep 1 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "Systemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria" — Meera Kotagal (clinical) [Ep 1 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "Patients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending" — Meera Kotagal (guideline) [Ep 1 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "The exam should include a rectal exam" — Meera Kotagal (guideline) [Ep 1 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "If the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it" — Meera Kotagal (guideline) [Ep 1 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "Irrigations should not be delayed for patients to get an x-ray" — Meera Kotagal (guideline) [Ep 1 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "Irrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients" — Meera Kotagal (guideline) [Ep 1 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "Abdominal films should be obtained upon arrival and then repeated again after an irrigation to demonstrate adequate decompression" — Meera Kotagal (guideline) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Abdominal films can be repeated throughout the course of the hospitalization as clinically necessary" — Meera Kotagal (guideline) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Patients should be NPO and started on IV fluids to assist with resuscitation and hydration" — Meera Kotagal (guideline) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Patients without systemic signs who are mostly clinically well can be maintained on either IV or oral flagyl during hospitalization" — Meera Kotagal (guideline) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "All patients who are vomiting should be on IV antibiotics" — Meera Kotagal (guideline) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Patients with systemic signs who are sicker need broad spectrum antibiotics, specifically Zosyn and flagyl at Cincinnati Children's" — Meera Kotagal (guideline) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "All patients should get a CBC and a basic metabolic panel" — Meera Kotagal (guideline) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=240)
- "A venous blood gas should be obtained for sicker patients to help evaluate resuscitation needs" — Meera Kotagal (guideline) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=240)
- "Patients with systemic signs should be evaluated for potential admission to the ICU" — Meera Kotagal (guideline) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=240)
- "After an admission for enterocolitis, patients are continued on metronidazole and irrigations for a few weeks and then slowly tapered" — Meera Kotagal (guideline) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=300)
- "Underlying anatomic issues such as a stricture or a transition zone pull through must be addressed to prevent recurrent enterocolitis" — Meera Kotagal (clinical) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=300)
- "Post-pull-through obstruction can be caused by stricture, twist (any pull-through type), Soave cuff (Soave procedure), Duhamel spur or non-functional distended segment (Duhamel procedure), or non-functional segment (Rehbein procedure)." — Hira Ahmad (clinical) [Ep 2 · 6:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=405)
- "In obstructed Hirschsprung patients, the colon fills with liquid stool with severe bacterial overgrowth, causing fluid loss into the bowel lumen, hypovolemia, and bacterial translocation/bacteremia, all occurring without passage of stool." — Marc Levitt (clinical) [Ep 2 · 10:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=610)
- "Enterocolitis can occur before surgery, after surgery, and even after successful surgery in babies who don't relax their sphincters and hold stool so efficiently they develop enterocolitis." — Marc Levitt (clinical) [Ep 2 · 11:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=666)
- "For a patient with prior Hirschsprung diagnosis presenting sick, assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis is different (e.g., Crohn's disease, E. coli enterocolitis)." — Jason Frischer (clinical) [Ep 2 · 12:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=726)
- "Post-pull-through enterocolitis within the first 3 months occurs in about 20% of patients, based on a study from Cincinnati and Columbus." — Marc Levitt (epidemiological) [Ep 2 · 13:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=838)
- "Families should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform rectal irrigations, and they should be discharged with supplies to perform irrigations at home." — Jason Frischer (guideline) [Ep 2 · 14:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=898)
- "In rare circumstances where a patient is too ill and sedation in the ER doesn't work, go to the OR under general anesthesia for irrigation until the patient improves; occasionally an ileostomy is needed to get the child out of trouble and work up the pull-through problem later." — Marc Levitt (clinical) [Ep 2 · 16:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=990)
- "On contrast enema, it is important to look at the presacral space (space between the hollow of the sacrum and the pull-through); a widened presacral space is an abnormal finding." — Marc Levitt (clinical) [Ep 2 · 19:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1154)
- "On contrast enema, if the catheter is inserted too high or the balloon is under too much pressure, distal pathology cannot be easily ascertained." — Rebecca Rentia (clinical) [Ep 2 · 20:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1248)
- "A lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy." — Jason Frischer (clinical) [Ep 2 · 19:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1183)
- "The anatomy of the original pull-through can explain the patient's obstructive symptoms, and it is important to know what pull-through type was performed to determine if there is a fixable problem." — Marc Levitt (clinical) [Ep 2 · 3:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=186)
- "If the original operative note is unavailable, a contrast study can help infer the original surgery type based on imaging findings; expertise in reading post-pull-through contrast studies is essential." — Marc Levitt (clinical) [Ep 2 · 7:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=462)
- "In a very ill child, a contrast study would not be the best initial option; resuscitation and stabilization should come first." — Rebecca Rentia (clinical) [Ep 2 · 8:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=505)
- "When performing initial rectal exam on a distended child with suspected enterocolitis, step to the side because there may be an explosive release of stool and gas." — Jason Frischer (clinical) [Ep 2 · 4:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=291)
- "In Hirschsprung patients with distention, irritability, and fever, enterocolitis should be assumed until proven otherwise." — Marc Levitt (clinical) [Ep 2 · 10:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=639)
- "Irrigation is the best way to break the cycle of enterocolitis because patients are not passing stool due to distal obstruction." — Marc Levitt (clinical) [Ep 2 · 10:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=655)
- "When reading literature on Hirschsprung enterocolitis rates, be aware that definitions vary (admission, need for irrigations, need for antibiotics); the PCPLC consortium is working on validating the Langer score for uniform application." — Marc Levitt (opinion) [Ep 2 · 13:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=811)
- "After pull-through surgery, wait one to two weeks before performing the first irrigation, and the first irrigation should be performed by someone who is confident and knows where the anastomosis is." — Marc Levitt (clinical) [Ep 2 · 14:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=871)
- "In a logical workup, obtain the contrast study before going to the OR for rectal exam under anesthesia, as it may reveal findings that guide the surgical approach." — Jason Frischer (clinical) [Ep 2 · 18:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1099)
- "For exam under anesthesia in Hirschsprung's patients, digital exam should assess for circumferential stricture at the anastomosis" — Hira Ahmad (clinical) [Ep 3 · 1:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=96)
- "Hagar dilator can be used to size the anastomotic opening to ensure adequate caliber" — Hira Ahmad (clinical) [Ep 3 · 1:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=117)
- "Foley catheter passage can determine if there is a twist in the pull-through segment" — Hira Ahmad (clinical) [Ep 3 · 2:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=124)
- "Swabe cuff presents as a 1-2 centimeter circumferential narrowing that is not the anastomosis itself" — Hira Ahmad (clinical) [Ep 3 · 2:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=143)
- "For patients with previous Duhamel procedure, full-thickness rectal biopsy should be performed posteriorly because that segment should be ganglionic" — Hira Ahmad (clinical) [Ep 3 · 2:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=153)
- "In Duhamel procedure, rectal exam should assess for two lumens and a spur between them, as stool can flow into the Duhamel pouch, fill it, and compress the ganglionated pull-through" — Marc Levitt (clinical) [Ep 3 · 3:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=180)
- "Treatment for problematic Duhamel spur is to take out the common wall; occasionally the Duhamel pouch itself needs excision" — Marc Levitt (clinical) [Ep 3 · 3:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=205)
- "Before anesthesia induction, it is important to examine the anus for sphincteric contraction vs. patulous appearance" — Marc Levitt (clinical) [Ep 3 · 3:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=216)
- "A patulous anus will not develop enterocolitis" — Marc Levitt (clinical) [Ep 3 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=228)
- "During exam and biopsy, close examination is needed to ensure the dentate line was preserved at the original pull-through" — Marc Levitt (clinical) [Ep 3 · 3:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=237)
- "If the dentate line has been lost at original pull-through or sphincters have been overstretched, the patient will not have enterocolitis but will have fecal incontinence" — Marc Levitt (clinical) [Ep 3 · 4:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=252)
- "Botox is being studied to prevent enterocolitis with the theory of chemo-denervating nerves in the area instead of permanent stretch or anatomic destruction from surgery" — Jason Frischer (clinical) [Ep 3 · 4:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=266)
- "Lone Star retractor should be used to obtain a circumferential view of the anastomotic area during exam under anesthesia" — Rebecca Rentia (clinical) [Ep 3 · 4:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=297)
- "To palpate for Swabe cuff, place finger against the sacrum and pull down to feel rubbery tissue outside the pull-through" — Marc Levitt (clinical) [Ep 3 · 14:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=848)
- "If repeat biopsy after pull-through shows no ganglion cells, it is very likely an aganglionotic or transition zone pull-through, though sampling error must be considered" — Marc Levitt (clinical) [Ep 3 · 8:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=488)
- "Ganglion cells with hypertrophic nerves on repeat biopsy is more controversial; some surgeons offer redo for significantly obstructive patients with this finding" — Marc Levitt (opinion) [Ep 3 · 8:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=513)
- "Hypertrophic nerves in the presence of ganglion cells can occur in functional constipation patients, and may develop in Hirschsprung's patients not emptying well due to sphincter dysfunction" — Marc Levitt (clinical) [Ep 3 · 8:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=532)
- "Until comparing original and repeat pathology, it is unclear whether hypertrophic nerves represent original pathology error or secondary changes that evolved over time" — Marc Levitt (clinical) [Ep 3 · 9:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=586)
- "The Swenson procedure was the first Hirschsprung's operation and is the purest, leaving the least amount of Hirschsprung's tissue behind" — Marc Levitt (clinical) [Ep 3 · 13:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=785)
- "The Swabe and Duhamel procedures were developed because surgeons were doing the Swenson in too wide a plane and injuring the nervi erigentes in the mesorectum" — Marc Levitt (clinical) [Ep 3 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=795)
- "If you stay right on the bowel wall during Swenson dissection, you avoid nerve injury" — Marc Levitt (clinical) [Ep 3 · 13:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=804)
- "In the original laparoscopic Swabe described by Keith Jorgeson, a 5 centimeter cuff was recommended, which is too long" — Marc Levitt (opinion) [Ep 3 · 12:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=760)
- "Many Swabe surgeons are now approaching a Swenson technique or have transitioned to Swenson, using a mini-cuff (approximately 1 centimeter)" — Marc Levitt (clinical) [Ep 3 · 12:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=750)
- "Sometimes the Swabe cuff fuses back together or is not cut all the way, creating an aganglionotic obstructive ring around the pull-through" — Marc Levitt (clinical) [Ep 3 · 13:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=825)
- "For redo pull-through in aganglionotic cases, the approach is total body prep, then transanal dissection in prone position first, going as far as possible; if healthy bowel cannot reach, be prepared for laparoscopy or laparotomy" — Marc Levitt (clinical) [Ep 3 · 15:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=954)
- "Redo pull-throughs are easier to perform in prone position" — Marc Levitt (opinion) [Ep 3 · 16:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=967)
- "Initial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early" — Jason Frischer (guideline) [Ep 3 · 17:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1043)
- "Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response" — Jason Frischer (guideline) [Ep 3 · 17:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1048)
- "Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia" — Jason Frischer (guideline) [Ep 3 · 17:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1061)
- "Gastroenterologists and surgeons must know the anatomy of the original pull-through procedure (Swabe, Swenson, or Duhamel) when evaluating obstructed patients" — Marc Levitt (guideline) [Ep 3 · 18:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1112)

## Changelog
- Sep 7: 4 items added automatically

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