Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.
Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.
Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.
Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.
Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.
years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 10 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 10 · 1:02
opinionFluoroscopy 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.↗
▶Ep 10 · 1:02
opinionFluoroscopy 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.↗
▶Ep 10 · 1:41
clinicalSigns of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 10 · 1:41
clinicalSigns of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 10 · 3:23
clinicalIn 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.↗
▶Ep 10 · 3:23
clinicalIn 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.↗
▶Ep 10 · 3:57
clinicalThe 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.↗
▶Ep 10 · 3:57
clinicalThe 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.↗
▶Ep 10 · 5:32
clinicalSeeing air in the rectum on plain radiograph does not rule out Hirschsprung disease.↗
▶Ep 10 · 5:32
clinicalSeeing air in the rectum on plain radiograph does not rule out Hirschsprung disease.↗
▶Ep 10 · 5:43
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 10 · 5:43
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 10 · 6:58
clinicalAir-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis.↗
▶Ep 10 · 6:58
clinicalAir-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis.↗
▶Ep 10 · 8:14
clinicalEnterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise.↗
▶Ep 10 · 8:14
clinicalEnterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise.↗
▶Ep 10 · 8:14
quoteenterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 10 · 8:14
quoteenterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 10 · 9:46
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 10 · 9:46
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 10 · 10:33
epidemiologicalThe false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies.↗
▶Ep 10 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 10 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 10 · 10:33
epidemiologicalThe false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies.↗
▶Ep 10 · 11:04
clinicalTotal colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate.↗
▶Ep 10 · 11:04
clinicalTotal colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate.↗
▶Ep 10 · 11:20
epidemiologicalThe false positive transition zone rate on enema is up to 43%.↗
▶Ep 10 · 11:20
epidemiologicalThe false positive transition zone rate on enema is up to 43%.↗
▶Ep 10 · 11:35
epidemiologicalRadiologist agreement on transition zone location is fairly high at 90%.↗
▶Ep 10 · 11:35
epidemiologicalRadiologist agreement on transition zone location is fairly high at 90%.↗
▶Ep 10 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location is only about 62% overall.↗
▶Ep 10 · 11:47
quotethe concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss.↗
▶Ep 10 · 11:47
quotethe concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss.↗
▶Ep 10 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location is only about 62% overall.↗
▶Ep 10 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%.↗
▶Ep 10 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%.↗
▶Ep 10 · 13:54
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%.↗
▶Ep 10 · 13:54
quoteif you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%.↗
▶Ep 10 · 13:54
quoteif you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%.↗
▶Ep 10 · 13:54
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%.↗
▶Ep 10 · 14:05
clinicalIf an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization.↗
▶Ep 10 · 14:05
clinicalIf an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization.↗
▶Ep 10 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 10 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 10 · 14:29
opinionIn patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization.↗
▶Ep 10 · 14:29
opinionIn patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization.↗
▶Ep 10 · 21:42
clinicalDr. 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.↗
▶Ep 10 · 21:42
clinicalDr. 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.↗
▶Ep 10 · 22:31
clinicalDr. 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.↗
▶Ep 10 · 22:31
clinicalDr. 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.↗
▶Ep 10 · 23:01
clinicalEarly 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.↗
▶Ep 10 · 23:01
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part↗
▶Ep 10 · 23:01
clinicalEarly 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.↗
▶Ep 10 · 23:01
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part↗
▶Ep 10 · 23:30
clinicalIf 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.↗
▶Ep 10 · 23:30
clinicalIf 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.↗
▶Ep 10 · 23:47
clinicalDr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants.↗
▶Ep 10 · 23:47
clinicalDr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants.↗
▶Ep 10 · 24:03
clinicalA true lateral image with femurs superimposed is essential to visualize the presacral space properly.↗
▶Ep 10 · 24:03
clinicalA true lateral image with femurs superimposed is essential to visualize the presacral space properly.↗
▶Ep 10 · 24:18
clinicalIn a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum.↗
▶Ep 10 · 24:18
clinicalIn a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum.↗
▶Ep 10 · 24:40
clinicalIf 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.↗
▶Ep 10 · 24:40
clinicalIf 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.↗
▶Ep 10 · 24:40
quoteif you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 10 · 24:40
quoteif you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 10 · 25:04
clinicalRectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology.↗
▶Ep 10 · 25:04
clinicalRectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology.↗
▶Ep 10 · 25:30
clinicalIn 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.↗
▶Ep 10 · 25:30
clinicalIn 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.↗
▶Ep 10 · 25:42
clinicalIn 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.↗
▶Ep 10 · 25:42
clinicalIn 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.↗
▶Ep 10 · 26:03
clinicalContrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy.↗
▶Ep 10 · 26:03
clinicalContrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy.↗
▶Ep 10 · 26:15
clinicalIn infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced.↗
▶Ep 10 · 26:15
clinicalIn infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced.↗
▶Ep 10 · 28:06
clinicalSmall left colon syndrome typically has a transition at the splenic flexure that is very abrupt.↗
▶Ep 10 · 28:06
clinicalSmall left colon syndrome typically has a transition at the splenic flexure that is very abrupt.↗
▶Ep 10 · 29:30
clinicalThe rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure.↗
▶Ep 10 · 29:30
clinicalThe rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure.↗
▶Ep 10 · 29:51
clinicalA 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.↗
▶Ep 10 · 29:51
clinicalA 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.↗
▶Ep 10 · 30:51
clinicalWhen 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.↗
▶Ep 10 · 30:51
clinicalWhen 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.↗
▶Ep 10 · 31:07
opinionIf 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.↗
▶Ep 10 · 31:07
opinionIf 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.↗
▶Ep 10 · 34:18
clinicalIn 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.↗
▶Ep 10 · 34:18
clinicalIn 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.↗
▶Ep 10 · 34:55
clinicalA true lateral view of the rectum is very important in post-surgical patients to assess the presacral space.↗
▶Ep 10 · 34:55
clinicalA true lateral view of the rectum is very important in post-surgical patients to assess the presacral space.↗
▶Ep 10 · 35:51
clinicalThe 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.↗
▶Ep 10 · 35:51
clinicalThe 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.↗
▶Ep 10 · 36:13
clinicalIn symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction.↗
▶Ep 10 · 36:13
clinicalIn symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction.↗
Radiology and Image Diagnosis of Hirschsprung Disease
▶Ep 18 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 18 · 1:02
opinionIn 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.↗
▶Ep 18 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 18 · 1:02
opinionIn 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.↗
▶Ep 18 · 2:26
clinicalMultiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 18 · 2:26
clinicalMultiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 18 · 3:23
clinicalIn 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.↗
▶Ep 18 · 3:23
clinicalIn 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.↗
▶Ep 18 · 3:35
clinicalBubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel.↗
▶Ep 18 · 3:35
clinicalBubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel.↗
▶Ep 18 · 4:00
epidemiologicalThe 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.↗
▶Ep 18 · 4:00
epidemiologicalThe 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.↗
▶Ep 18 · 5:04
clinicalBowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis.↗
▶Ep 18 · 5:04
clinicalBowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis.↗
▶Ep 18 · 5:32
clinicalSeeing air in the rectum does not rule out Hirschsprung disease.↗
▶Ep 18 · 5:32
clinicalSeeing air in the rectum does not rule out Hirschsprung disease.↗
▶Ep 18 · 6:18
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 18 · 6:18
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 18 · 6:58
clinicalAir-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon.↗
▶Ep 18 · 6:58
clinicalAir-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon.↗
▶Ep 18 · 8:14
quoteEnterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 18 · 8:14
clinicalEnterocolitis in a newborn is Hirschsprung disease until proven otherwise.↗
▶Ep 18 · 8:14
quoteEnterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 18 · 8:14
clinicalEnterocolitis in a newborn is Hirschsprung disease until proven otherwise.↗
▶Ep 18 · 8:32
clinicalTotal intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case.↗
▶Ep 18 · 8:32
clinicalTotal intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case.↗
▶Ep 18 · 10:22
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 18 · 10:22
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 18 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 18 · 10:33
host_summaryThe false negative rate of transition zone by enema is between 20% and 25% according to multiple studies.↗
▶Ep 18 · 10:33
epidemiologicalThe false negative rate of transition zone by enema is between 20% and 25% according to multiple studies.↗
▶Ep 18 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 18 · 10:43
opinionThe false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%.↗
▶Ep 18 · 10:43
opinionThe false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%.↗
▶Ep 18 · 11:04
clinicalTotal colonic Hirschsprung disease is a very difficult diagnosis to make on enema.↗
▶Ep 18 · 11:04
clinicalTotal colonic Hirschsprung disease is a very difficult diagnosis to make on enema.↗
▶Ep 18 · 11:10
clinicalShort segment disease is also difficult to diagnose, partly due to technique and how the enema is performed.↗
▶Ep 18 · 11:10
clinicalShort segment disease is also difficult to diagnose, partly due to technique and how the enema is performed.↗
▶Ep 18 · 11:20
host_summaryThe false positive transition zone rate is up to 43%.↗
▶Ep 18 · 11:20
epidemiologicalThe false positive transition zone rate is up to 43%.↗
▶Ep 18 · 11:35
host_summaryA study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%.↗
▶Ep 18 · 11:35
epidemiologicalA study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%.↗
▶Ep 18 · 11:47
host_summaryThe concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss.↗
▶Ep 18 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss.↗
▶Ep 18 · 13:27
host_summaryFor short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%.↗
▶Ep 18 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%.↗
▶Ep 18 · 13:43
host_summaryFor long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%.↗
▶Ep 18 · 13:43
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%.↗
▶Ep 18 · 14:05
clinicalIf 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.↗
▶Ep 18 · 14:05
clinicalIf 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.↗
▶Ep 18 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 18 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 18 · 14:39
clinicalIn 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.↗
▶Ep 18 · 14:39
clinicalIn 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.↗
▶Ep 18 · 21:42
clinicalDr. 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.↗
▶Ep 18 · 21:42
clinicalDr. 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.↗
▶Ep 18 · 22:05
clinicalIf contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this.↗
▶Ep 18 · 22:05
clinicalIf contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this.↗
▶Ep 18 · 22:31
clinicalDr. 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.↗
▶Ep 18 · 22:31
clinicalDr. 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.↗
▶Ep 18 · 23:10
clinicalEarly 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.↗
▶Ep 18 · 23:10
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.↗
▶Ep 18 · 23:10
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.↗
▶Ep 18 · 23:10
clinicalEarly 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.↗
▶Ep 18 · 23:30
clinicalIf 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.↗
▶Ep 18 · 23:30
clinicalIf 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.↗
▶Ep 18 · 23:47
clinicalDr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants.↗
▶Ep 18 · 23:47
clinicalDr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants.↗
▶Ep 18 · 24:03
clinicalOn 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.↗
▶Ep 18 · 24:03
clinicalOn 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.↗
▶Ep 18 · 24:11
clinicalOn 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.↗
▶Ep 18 · 24:11
clinicalOn 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.↗
▶Ep 18 · 24:22
clinicalIn a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum.↗
▶Ep 18 · 24:22
clinicalIn a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum.↗
▶Ep 18 · 24:40
clinicalIf you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time.↗
▶Ep 18 · 24:40
quoteIf you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 18 · 24:40
clinicalIf you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time.↗
▶Ep 18 · 24:40
quoteIf you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 18 · 24:51
clinicalUse 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.↗
▶Ep 18 · 24:51
clinicalUse 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.↗
▶Ep 18 · 25:04
clinicalRectosigmoid transition cases are usually concordant pathologically and radiologically.↗
▶Ep 18 · 25:04
clinicalRectosigmoid transition cases are usually concordant pathologically and radiologically.↗
▶Ep 18 · 25:30
clinicalIn 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.↗
▶Ep 18 · 25:30
clinicalIn 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.↗
▶Ep 18 · 25:47
clinicalThe 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.↗
▶Ep 18 · 25:47
clinicalThe 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.↗
▶Ep 18 · 26:03
clinicalContrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy.↗
▶Ep 18 · 26:03
quoteI would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy.↗
▶Ep 18 · 26:03
clinicalContrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy.↗
▶Ep 18 · 26:03
quoteI would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy.↗
▶Ep 18 · 26:15
clinicalIf you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy.↗
▶Ep 18 · 26:15
clinicalIf you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy.↗
▶Ep 18 · 27:30
clinicalIf 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.↗
▶Ep 18 · 27:30
clinicalIf 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.↗
▶Ep 18 · 28:06
clinicalSmall left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt.↗
▶Ep 18 · 28:06
clinicalSmall left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt.↗
▶Ep 18 · 29:51
clinicalA 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.↗
▶Ep 18 · 29:51
clinicalA 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.↗
▶Ep 18 · 30:59
quoteI just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is.↗
▶Ep 18 · 30:59
clinicalIf 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.↗
▶Ep 18 · 30:59
clinicalIf 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.↗
▶Ep 18 · 30:59
quoteI just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is.↗
▶Ep 18 · 34:18
clinicalIn 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.↗
▶Ep 18 · 34:18
clinicalIn 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.↗
▶Ep 18 · 34:59
clinicalIt is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space.↗
▶Ep 18 · 34:59
clinicalIt is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space.↗
▶Ep 18 · 35:56
clinicalThe 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.↗
▶Ep 18 · 35:56
clinicalThe 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.↗
▶Ep 18 · 36:13
clinicalIn 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.↗
▶Ep 18 · 36:13
clinicalIn 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.↗
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 1 · 1:02
opinionFluoroscopy 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.↗
▶Ep 1 · 1:41
clinicalSigns of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 1 · 3:23
clinicalIn 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.↗
▶Ep 1 · 3:57
clinicalThe 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.↗
▶Ep 1 · 5:32
clinicalSeeing air in the rectum on plain radiograph does not rule out Hirschsprung disease.↗
▶Ep 1 · 5:43
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 1 · 6:58
clinicalAir-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis.↗
▶Ep 1 · 8:14
clinicalEnterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise.↗
▶Ep 1 · 8:14
quoteenterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 1 · 9:46
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 1 · 10:33
epidemiologicalThe false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies.↗
▶Ep 1 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 1 · 11:04
clinicalTotal colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate.↗
▶Ep 1 · 11:20
epidemiologicalThe false positive transition zone rate on enema is up to 43%.↗
▶Ep 1 · 11:35
epidemiologicalRadiologist agreement on transition zone location is fairly high at 90%.↗
▶Ep 1 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location is only about 62% overall.↗
▶Ep 1 · 11:47
quotethe concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss.↗
▶Ep 1 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%.↗
▶Ep 1 · 13:54
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%.↗
▶Ep 1 · 13:54
quoteif you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%.↗
▶Ep 1 · 14:05
clinicalIf an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization.↗
▶Ep 1 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 1 · 14:29
opinionIn patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization.↗
▶Ep 1 · 21:42
clinicalDr. 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.↗
▶Ep 1 · 22:31
clinicalDr. 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.↗
▶Ep 1 · 23:01
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part↗
▶Ep 1 · 23:01
clinicalEarly 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.↗
▶Ep 1 · 23:30
clinicalIf 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.↗
▶Ep 1 · 23:47
clinicalDr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants.↗
▶Ep 1 · 24:03
clinicalA true lateral image with femurs superimposed is essential to visualize the presacral space properly.↗
▶Ep 1 · 24:18
clinicalIn a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum.↗
▶Ep 1 · 24:40
quoteif you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 1 · 24:40
clinicalIf 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.↗
▶Ep 1 · 25:04
clinicalRectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology.↗
▶Ep 1 · 25:30
clinicalIn 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.↗
▶Ep 1 · 25:42
clinicalIn 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.↗
▶Ep 1 · 26:03
clinicalContrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy.↗
▶Ep 1 · 26:15
clinicalIn infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced.↗
▶Ep 1 · 28:06
clinicalSmall left colon syndrome typically has a transition at the splenic flexure that is very abrupt.↗
▶Ep 1 · 29:30
clinicalThe rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure.↗
▶Ep 1 · 29:51
clinicalA 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.↗
▶Ep 1 · 30:51
clinicalWhen 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.↗
▶Ep 1 · 31:07
opinionIf 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.↗
▶Ep 1 · 34:18
clinicalIn 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.↗
▶Ep 1 · 34:55
clinicalA true lateral view of the rectum is very important in post-surgical patients to assess the presacral space.↗
▶Ep 1 · 35:51
clinicalThe 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.↗
▶Ep 1 · 36:13
clinicalIn symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction.↗
Radiology and Image Diagnosis of Hirschsprung Disease
▶Ep 3 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 3 · 1:02
opinionIn 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.↗
▶Ep 3 · 2:26
clinicalMultiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 3 · 3:23
clinicalIn 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.↗
▶Ep 3 · 3:35
clinicalBubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel.↗
▶Ep 3 · 4:00
epidemiologicalThe 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.↗
▶Ep 3 · 5:04
clinicalBowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis.↗
▶Ep 3 · 5:32
clinicalSeeing air in the rectum does not rule out Hirschsprung disease.↗
▶Ep 3 · 6:18
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 3 · 6:58
clinicalAir-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon.↗
▶Ep 3 · 8:14
clinicalEnterocolitis in a newborn is Hirschsprung disease until proven otherwise.↗
▶Ep 3 · 8:14
quoteEnterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 3 · 8:32
clinicalTotal intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case.↗
▶Ep 3 · 10:22
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 3 · 10:33
host_summaryThe false negative rate of transition zone by enema is between 20% and 25% according to multiple studies.↗
▶Ep 3 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 3 · 10:43
opinionThe false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%.↗
▶Ep 3 · 11:04
clinicalTotal colonic Hirschsprung disease is a very difficult diagnosis to make on enema.↗
▶Ep 3 · 11:10
clinicalShort segment disease is also difficult to diagnose, partly due to technique and how the enema is performed.↗
▶Ep 3 · 11:20
host_summaryThe false positive transition zone rate is up to 43%.↗
▶Ep 3 · 11:35
host_summaryA study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%.↗
▶Ep 3 · 11:47
host_summaryThe concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss.↗
▶Ep 3 · 13:27
host_summaryFor short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%.↗
▶Ep 3 · 13:43
host_summaryFor long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%.↗
▶Ep 3 · 14:05
clinicalIf 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.↗
▶Ep 3 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 3 · 14:39
clinicalIn 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.↗
▶Ep 3 · 21:42
clinicalDr. 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.↗
▶Ep 3 · 22:05
clinicalIf contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this.↗
▶Ep 3 · 22:31
clinicalDr. 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.↗
▶Ep 3 · 23:10
clinicalEarly 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.↗
▶Ep 3 · 23:10
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.↗
▶Ep 3 · 23:30
clinicalIf 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.↗
▶Ep 3 · 23:47
clinicalDr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants.↗
▶Ep 3 · 24:03
clinicalOn 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.↗
▶Ep 3 · 24:11
clinicalOn 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.↗
▶Ep 3 · 24:22
clinicalIn a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum.↗
▶Ep 3 · 24:40
quoteIf you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 3 · 24:40
clinicalIf you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time.↗
▶Ep 3 · 24:51
clinicalUse 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.↗
▶Ep 3 · 25:04
clinicalRectosigmoid transition cases are usually concordant pathologically and radiologically.↗
▶Ep 3 · 25:30
clinicalIn 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.↗
▶Ep 3 · 25:47
clinicalThe 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.↗
▶Ep 3 · 26:03
quoteI would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy.↗
▶Ep 3 · 26:03
clinicalContrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy.↗
▶Ep 3 · 26:15
clinicalIf you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy.↗
▶Ep 3 · 27:30
clinicalIf 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.↗
▶Ep 3 · 28:06
clinicalSmall left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt.↗
▶Ep 3 · 29:51
clinicalA 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.↗
▶Ep 3 · 30:59
clinicalIf 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.↗
▶Ep 3 · 30:59
quoteI just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is.↗
▶Ep 3 · 34:18
clinicalIn 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.↗
▶Ep 3 · 34:59
clinicalIt is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space.↗
▶Ep 3 · 35:56
clinicalThe 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.↗
▶Ep 3 · 36:13
clinicalIn 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.↗
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 2 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 2 · 1:02
opinionFluoroscopy 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.↗
▶Ep 2 · 1:02
opinionFluoroscopy 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.↗
▶Ep 2 · 1:41
clinicalSigns of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 2 · 1:41
clinicalSigns of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 2 · 3:23
clinicalIn 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.↗
▶Ep 2 · 3:23
clinicalIn 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.↗
▶Ep 2 · 3:57
clinicalThe 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.↗
▶Ep 2 · 3:57
clinicalThe 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.↗
▶Ep 2 · 5:32
clinicalSeeing air in the rectum on plain radiograph does not rule out Hirschsprung disease.↗
▶Ep 2 · 5:32
clinicalSeeing air in the rectum on plain radiograph does not rule out Hirschsprung disease.↗
▶Ep 2 · 5:43
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 2 · 5:43
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 2 · 6:58
clinicalAir-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis.↗
▶Ep 2 · 6:58
clinicalAir-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis.↗
▶Ep 2 · 8:14
clinicalEnterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise.↗
▶Ep 2 · 8:14
quoteenterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 2 · 8:14
quoteenterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 2 · 8:14
clinicalEnterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise.↗
▶Ep 2 · 9:46
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 2 · 9:46
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 2 · 10:33
epidemiologicalThe false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies.↗
▶Ep 2 · 10:33
epidemiologicalThe false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies.↗
▶Ep 2 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 2 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 2 · 11:04
clinicalTotal colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate.↗
▶Ep 2 · 11:04
clinicalTotal colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate.↗
▶Ep 2 · 11:20
epidemiologicalThe false positive transition zone rate on enema is up to 43%.↗
▶Ep 2 · 11:20
epidemiologicalThe false positive transition zone rate on enema is up to 43%.↗
▶Ep 2 · 11:35
epidemiologicalRadiologist agreement on transition zone location is fairly high at 90%.↗
▶Ep 2 · 11:35
epidemiologicalRadiologist agreement on transition zone location is fairly high at 90%.↗
▶Ep 2 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location is only about 62% overall.↗
▶Ep 2 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location is only about 62% overall.↗
▶Ep 2 · 11:47
quotethe concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss.↗
▶Ep 2 · 11:47
quotethe concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss.↗
▶Ep 2 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%.↗
▶Ep 2 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%.↗
▶Ep 2 · 13:54
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%.↗
▶Ep 2 · 13:54
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%.↗
▶Ep 2 · 13:54
quoteif you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%.↗
▶Ep 2 · 13:54
quoteif you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%.↗
▶Ep 2 · 14:05
clinicalIf an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization.↗
▶Ep 2 · 14:05
clinicalIf an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization.↗
▶Ep 2 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 2 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 2 · 14:29
opinionIn patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization.↗
▶Ep 2 · 14:29
opinionIn patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization.↗
▶Ep 2 · 21:42
clinicalDr. 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.↗
▶Ep 2 · 21:42
clinicalDr. 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.↗
▶Ep 2 · 22:31
clinicalDr. 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.↗
▶Ep 2 · 22:31
clinicalDr. 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.↗
▶Ep 2 · 23:01
clinicalEarly 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.↗
▶Ep 2 · 23:01
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part↗
▶Ep 2 · 23:01
clinicalEarly 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.↗
▶Ep 2 · 23:01
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part↗
▶Ep 2 · 23:30
clinicalIf 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.↗
▶Ep 2 · 23:30
clinicalIf 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.↗
▶Ep 2 · 23:47
clinicalDr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants.↗
▶Ep 2 · 23:47
clinicalDr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants.↗
▶Ep 2 · 24:03
clinicalA true lateral image with femurs superimposed is essential to visualize the presacral space properly.↗
▶Ep 2 · 24:03
clinicalA true lateral image with femurs superimposed is essential to visualize the presacral space properly.↗
▶Ep 2 · 24:18
clinicalIn a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum.↗
▶Ep 2 · 24:18
clinicalIn a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum.↗
▶Ep 2 · 24:40
quoteif you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 2 · 24:40
clinicalIf 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.↗
▶Ep 2 · 24:40
quoteif you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 2 · 24:40
clinicalIf 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.↗
▶Ep 2 · 25:04
clinicalRectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology.↗
▶Ep 2 · 25:04
clinicalRectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology.↗
▶Ep 2 · 25:30
clinicalIn 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.↗
▶Ep 2 · 25:30
clinicalIn 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.↗
▶Ep 2 · 25:42
clinicalIn 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.↗
▶Ep 2 · 25:42
clinicalIn 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.↗
▶Ep 2 · 26:03
clinicalContrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy.↗
▶Ep 2 · 26:03
clinicalContrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy.↗
▶Ep 2 · 26:15
clinicalIn infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced.↗
▶Ep 2 · 26:15
clinicalIn infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced.↗
▶Ep 2 · 28:06
clinicalSmall left colon syndrome typically has a transition at the splenic flexure that is very abrupt.↗
▶Ep 2 · 28:06
clinicalSmall left colon syndrome typically has a transition at the splenic flexure that is very abrupt.↗
▶Ep 2 · 29:30
clinicalThe rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure.↗
▶Ep 2 · 29:30
clinicalThe rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure.↗
▶Ep 2 · 29:51
clinicalA 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.↗
▶Ep 2 · 29:51
clinicalA 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.↗
▶Ep 2 · 30:51
clinicalWhen 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.↗
▶Ep 2 · 30:51
clinicalWhen 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.↗
▶Ep 2 · 31:07
opinionIf 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.↗
▶Ep 2 · 31:07
opinionIf 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.↗
▶Ep 2 · 34:18
clinicalIn 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.↗
▶Ep 2 · 34:18
clinicalIn 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.↗
▶Ep 2 · 34:55
clinicalA true lateral view of the rectum is very important in post-surgical patients to assess the presacral space.↗
▶Ep 2 · 34:55
clinicalA true lateral view of the rectum is very important in post-surgical patients to assess the presacral space.↗
▶Ep 2 · 35:51
clinicalThe 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.↗
▶Ep 2 · 35:51
clinicalThe 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.↗
▶Ep 2 · 36:13
clinicalIn symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction.↗
▶Ep 2 · 36:13
clinicalIn symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction.↗
Radiology and Image Diagnosis of Hirschsprung Disease
▶Ep 6 · 1:02
opinionIn 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.↗
▶Ep 6 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 6 · 1:02
quoteyears ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art.↗
▶Ep 6 · 1:02
opinionIn 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.↗
▶Ep 6 · 2:26
clinicalMultiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 6 · 2:26
clinicalMultiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities.↗
▶Ep 6 · 3:23
clinicalIn 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.↗
▶Ep 6 · 3:23
clinicalIn 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.↗
▶Ep 6 · 3:35
clinicalBubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel.↗
▶Ep 6 · 3:35
clinicalBubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel.↗
▶Ep 6 · 4:00
epidemiologicalThe 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.↗
▶Ep 6 · 4:00
epidemiologicalThe 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.↗
▶Ep 6 · 5:04
clinicalBowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis.↗
▶Ep 6 · 5:04
clinicalBowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis.↗
▶Ep 6 · 5:32
clinicalSeeing air in the rectum does not rule out Hirschsprung disease.↗
▶Ep 6 · 5:32
clinicalSeeing air in the rectum does not rule out Hirschsprung disease.↗
▶Ep 6 · 6:18
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 6 · 6:18
clinicalThe radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph.↗
▶Ep 6 · 6:58
clinicalAir-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon.↗
▶Ep 6 · 6:58
clinicalAir-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon.↗
▶Ep 6 · 8:14
clinicalEnterocolitis in a newborn is Hirschsprung disease until proven otherwise.↗
▶Ep 6 · 8:14
quoteEnterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 6 · 8:14
quoteEnterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise.↗
▶Ep 6 · 8:14
clinicalEnterocolitis in a newborn is Hirschsprung disease until proven otherwise.↗
▶Ep 6 · 8:32
clinicalTotal intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case.↗
▶Ep 6 · 8:32
clinicalTotal intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case.↗
▶Ep 6 · 10:22
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 6 · 10:22
clinicalThe contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease.↗
▶Ep 6 · 10:33
host_summaryThe false negative rate of transition zone by enema is between 20% and 25% according to multiple studies.↗
▶Ep 6 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 6 · 10:33
epidemiologicalThe false negative rate of transition zone by enema is between 20% and 25% according to multiple studies.↗
▶Ep 6 · 10:33
quoteThe false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.↗
▶Ep 6 · 10:43
opinionThe false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%.↗
▶Ep 6 · 10:43
opinionThe false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%.↗
▶Ep 6 · 11:04
clinicalTotal colonic Hirschsprung disease is a very difficult diagnosis to make on enema.↗
▶Ep 6 · 11:04
clinicalTotal colonic Hirschsprung disease is a very difficult diagnosis to make on enema.↗
▶Ep 6 · 11:10
clinicalShort segment disease is also difficult to diagnose, partly due to technique and how the enema is performed.↗
▶Ep 6 · 11:10
clinicalShort segment disease is also difficult to diagnose, partly due to technique and how the enema is performed.↗
▶Ep 6 · 11:20
host_summaryThe false positive transition zone rate is up to 43%.↗
▶Ep 6 · 11:20
epidemiologicalThe false positive transition zone rate is up to 43%.↗
▶Ep 6 · 11:35
epidemiologicalA study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%.↗
▶Ep 6 · 11:35
host_summaryA study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%.↗
▶Ep 6 · 11:47
host_summaryThe concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss.↗
▶Ep 6 · 11:47
epidemiologicalThe concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss.↗
▶Ep 6 · 13:27
epidemiologicalFor short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%.↗
▶Ep 6 · 13:27
host_summaryFor short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%.↗
▶Ep 6 · 13:43
host_summaryFor long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%.↗
▶Ep 6 · 13:43
epidemiologicalFor long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%.↗
▶Ep 6 · 14:05
clinicalIf 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.↗
▶Ep 6 · 14:05
clinicalIf 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.↗
▶Ep 6 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 6 · 14:16
quoteif you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.↗
▶Ep 6 · 14:39
clinicalIn 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.↗
▶Ep 6 · 14:39
clinicalIn 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.↗
▶Ep 6 · 21:42
clinicalDr. 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.↗
▶Ep 6 · 21:42
clinicalDr. 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.↗
▶Ep 6 · 22:05
clinicalIf contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this.↗
▶Ep 6 · 22:05
clinicalIf contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this.↗
▶Ep 6 · 22:31
clinicalDr. 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.↗
▶Ep 6 · 22:31
clinicalDr. 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.↗
▶Ep 6 · 23:10
clinicalEarly 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.↗
▶Ep 6 · 23:10
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.↗
▶Ep 6 · 23:10
quoteEarly maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.↗
▶Ep 6 · 23:10
clinicalEarly 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.↗
▶Ep 6 · 23:30
clinicalIf 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.↗
▶Ep 6 · 23:30
clinicalIf 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.↗
▶Ep 6 · 23:47
clinicalDr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants.↗
▶Ep 6 · 23:47
clinicalDr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants.↗
▶Ep 6 · 24:03
clinicalOn 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.↗
▶Ep 6 · 24:03
clinicalOn 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.↗
▶Ep 6 · 24:11
clinicalOn 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.↗
▶Ep 6 · 24:11
clinicalOn 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.↗
▶Ep 6 · 24:22
clinicalIn a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum.↗
▶Ep 6 · 24:22
clinicalIn a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum.↗
▶Ep 6 · 24:40
quoteIf you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 6 · 24:40
clinicalIf you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time.↗
▶Ep 6 · 24:40
quoteIf you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.↗
▶Ep 6 · 24:40
clinicalIf you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time.↗
▶Ep 6 · 24:51
clinicalUse 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.↗
▶Ep 6 · 24:51
clinicalUse 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.↗
▶Ep 6 · 25:04
clinicalRectosigmoid transition cases are usually concordant pathologically and radiologically.↗
▶Ep 6 · 25:04
clinicalRectosigmoid transition cases are usually concordant pathologically and radiologically.↗
▶Ep 6 · 25:30
clinicalIn 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.↗
▶Ep 6 · 25:30
clinicalIn 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.↗
▶Ep 6 · 25:47
clinicalThe 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.↗
▶Ep 6 · 25:47
clinicalThe 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.↗
▶Ep 6 · 26:03
quoteI would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy.↗
▶Ep 6 · 26:03
clinicalContrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy.↗
▶Ep 6 · 26:03
quoteI would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy.↗
▶Ep 6 · 26:03
clinicalContrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy.↗
▶Ep 6 · 26:15
clinicalIf you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy.↗
▶Ep 6 · 26:15
clinicalIf you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy.↗
▶Ep 6 · 27:30
clinicalIf 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.↗
▶Ep 6 · 27:30
clinicalIf 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.↗
▶Ep 6 · 28:06
clinicalSmall left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt.↗
▶Ep 6 · 28:06
clinicalSmall left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt.↗
▶Ep 6 · 29:51
clinicalA 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.↗
▶Ep 6 · 29:51
clinicalA 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.↗
▶Ep 6 · 30:59
clinicalIf 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.↗
▶Ep 6 · 30:59
quoteI just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is.↗
▶Ep 6 · 30:59
clinicalIf 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.↗
▶Ep 6 · 30:59
quoteI just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is.↗
▶Ep 6 · 34:18
clinicalIn 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.↗
▶Ep 6 · 34:18
clinicalIn 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.↗
▶Ep 6 · 34:59
clinicalIt is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space.↗
▶Ep 6 · 34:59
clinicalIt is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space.↗
▶Ep 6 · 35:56
clinicalThe 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.↗
▶Ep 6 · 35:56
clinicalThe 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.↗
▶Ep 6 · 36:13
clinicalIn 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.↗
▶Ep 6 · 36:13
clinicalIn 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.↗
