The Colorectal Quiz Episode 8: Motility Disorders Part 1

Published: 2021-03-22

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod — host
Amanda Jensen — guest
Jason Frischer — guest
Mark Levitt — guest
Khalib Graham — guest
Anil Darbari — guest

Chapters

0:00Introduction and Episode Setup — Host Rod introduces the episode topic of motility disorders and the collaboration between pediatric surgery and gastroenterology. Amanda Jensen is introduced as co-host for this special episode.
1:31Case Presentation and Guest Introductions — Jason Frischer presents the case of a 10-year-old boy with severe constipation, cramping, poor appetite, and soiling who has failed multiple laxative regimens. Guests Khalib Graham and Anil Darbari are introduced as pediatric gastroenterologists specializing in motility disorders.
2:51Defining Failure of Medical Management — Discussion of what constitutes failure of medical management in pediatric constipation, including inadequate response to appropriate treatment, inability to take medications, persistent symptoms with treatment, failure to grow, and quality of life impacts including reliance on rectal therapy with continued soiling.
4:46Initial Evaluation Approach — Overview of the initial evaluation including detailed history taking, physical examination with attention to abdominal distension and palpable stool, rectal examination, and diagnostic imaging starting with abdominal X-ray and water-soluble contrast enema.
6:10Contrast Enema Interpretation and Limitations — Discussion of contrast enema findings including stool in distal rectum, tortuous redundant sigmoid colon, and colonic dilation. Emphasis that contrast studies are poor predictors of response to medical or surgical management, and that anatomic appearance does not reliably correlate with motility function.
8:59Anorectal Manometry and Its Clinical Value — Detailed explanation of anorectal manometry technique, interpretation of results including measurement of anal sphincter pressures and rectoanal inhibitory reflex (RAIR), and its critical role in distinguishing Hirschsprung disease from functional constipation. The case patient is revealed to have an absent RAIR despite dilated colon on contrast study.
11:19Summary and Conclusion — Recap of the diagnostic approach to motility disorders starting with history and physical, progressing through imaging with contrast enema, and culminating in anorectal manometry to guide surgical versus medical management decisions. Episode concludes with announcement of part two to follow.

Key claims

2:51Failure of medical management is defined as appropriate treatment with no appropriate response, patient cannot take treatment, persistent symptoms or pain with treatment, or failure to grow — Khalib Graham
3:21Failure of retrograde enemas is considered failure of medical management — Khalib Graham
3:35Reliance on rectal therapy or retrograde enemas with continued soiling causing significant effect on functioning is considered failure of medical management — Anil Darbari
3:57General pediatricians typically prescribe osmotic laxatives like MiraLax or lactulose and stimulant laxatives such as Senna or bisacodyl, but there are other medications that pediatricians are not used to prescribing that GI doctors are — Anil Darbari
4:58Some children stool every day but do not completely evacuate — Rod
4:46Initial evaluation includes history of triggers, stooling frequency, timing, and sensation of complete emptying, plus physical exam looking for palpable stool and distension, rectal exam, and diagnostic imaging — Anil Darbari
5:27In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step in management is diagnostic studies including contrast enema — Khalib Graham
5:56Contrast enema is used to assess degree of colonic dilatation and redundancy and to ensure the ratio is normal — Khalib Graham
6:53There are probably many people with redundant colons that stool perfectly normally without imaging documentation — Jason Frischer
6:59It is unclear whether colonic dilation and redundancy precedes constipation or results from outlet obstruction — Rod
7:12Contrast study is not a great predictor of how patients will respond to medical or surgical management — Rod
7:19Crazy looking colons can respond really nicely to treatment, and colons that look totally normal on contrast study may not respond at all to treatment — Rod
7:36Colons used to be resected based on appearance, but patients with motility disorders did not need resection — Mark Levitt
7:54Many dilated colons will respond to treatment — Mark Levitt
8:06Water-soluble contrast is used instead of barium because it helps empty the colon and acts as a cleanout for patients starting new medical therapy — Jason Frischer
8:37Reviewing diagnostic imaging with the family helps them understand anatomy and issues and builds rapport — Rod
9:11The rectoanal inhibitory reflex (RAIR) is when the rectum becomes distended with stool and the internal anal sphincter relaxes — Rod
9:35Anorectal manometry uses a catheter with sensors measuring pressure and a balloon to assess anal sphincter function and its relationship to the rectum — Anil Darbari
10:00High pressures on anorectal manometry may suggest underlying inability to relax causing functional obstruction — Anil Darbari
10:09Patients with Hirschsprung disease have an absent rectoanal inhibitory reflex (RAIR) — Anil Darbari
10:19Anorectal manometry provides information about defecation dynamics by having patients bear down, squeeze, and attempt to defecate while comparing sensation to defecate versus internal anal sphincter response — Anil Darbari
10:36Anorectal manometry is a functional test that provides baseline and functional information — Anil Darbari
10:51In the past, the sphincter and its major role in constipation patients was not well understood — Jason Frischer
12:03Anorectal manometry is critical for determining whether a patient needs surgery or resection, because patients with motility disorders do not need resection — Rod

Cases discussed

2:2910-year-old boy with severe constipation, daily cramping, poor appetite, and soiling who has failed multiple laxative regimens

Open questions

Does colonic dilation and redundancy precede constipation or result from outlet obstruction (chicken or egg question)?
What is the complete management plan for the case patient with absent RAIR and dilated colon (to be addressed in part 2)?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

When Constipation Resists Treatment: Functional Testing Over Imaging

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Defining Treatment Failure With Precision

Medical management fails in multiple distinct ways. Failure of medical management means appropriate treatment without appropriate response, inability to take prescribed medications (as in children with autism or cognitive impairments), persistent symptoms or pain despite treatment, or failure to grow 2:51. It also includes failure of retrograde enemas 3:21 and reliance on rectal therapy with continued soiling that significantly affects daily functioning 3:35. This definition matters because general pediatricians typically prescribe osmotic laxatives like MiraLax or lactulose and stimulant laxatives such as Senna or bisacodyl, but there are other medications that pediatricians are not accustomed to prescribing that gastroenterologists use 3:57. Recognizing true treatment failure — rather than inadequate dosing or poor adherence — is the threshold for specialist involvement.

Contrast Enema Shows Anatomy, Not Prognosis

The appearance of the colon predicts almost nothing about treatment response. Contrast enema is used to assess degree of colonic dilatation and redundancy and to ensure the rectosigmoid ratio is normal 5:56, but it is not a great predictor of how patients will respond to medical or surgical management 7:12. Severely abnormal-appearing colons can respond really nicely to treatment, and colons that look totally normal on contrast study may not respond at all 7:19. Historically, colons were resected based on appearance, but patients with motility disorders did not need resection 7:36 — many dilated colons will respond to treatment 7:54. The test provides a roadmap and helps families understand the anatomy 8:37, and using water-soluble contrast instead of barium helps empty the colon and acts as a cleanout for patients starting new medical therapy 8:06. But the image alone cannot tell you whether the problem is structural or functional.

Anorectal Manometry Distinguishes Motility From Obstruction

Functional testing reveals what imaging cannot. Anorectal manometry uses a catheter with sensors measuring pressure and a balloon to assess anal sphincter function and its relationship to the rectum 9:35. It provides baseline and functional information 10:36. High pressures may suggest underlying inability to relax causing functional obstruction 10:00. The test measures the rectoanal inhibitory reflex (RAIR) — when the rectum becomes distended with stool, the internal anal sphincter relaxes 9:11. Patients with Hirschsprung disease have an absent RAIR 10:09. The test also provides information about defecation dynamics by having patients bear down, squeeze, and attempt to defecate while comparing sensation to defecate versus internal anal sphincter response 10:19. In the past, the sphincter and its major role in constipation patients was not well understood 10:51. Now, anorectal manometry is critical for determining whether a patient needs surgery or resection, because patients with motility disorders do not need resection 12:03.

The Collaboration That Changes Outcomes

The conversation between gastroenterology and surgery determines who avoids unnecessary resection. Some children stool every day but do not completely evacuate 4:58, and initial evaluation includes history of triggers, stooling frequency, timing, and sensation of complete emptying, plus physical exam looking for palpable stool and distension, rectal exam, and diagnostic imaging 4:46. In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step in management is diagnostic studies including contrast enema 5:27. But the contrast study alone cannot answer the surgical question. The discussants emphasized that functional testing — not anatomic imaging — determines whether a dilated, redundant colon needs resection or will respond to optimized medical management. The shift from resecting based on appearance to treating based on physiology represents the core teaching of this discussion.

Takeaways from this story

Contrast enema appearance does not predict treatment response—severely dilated colons may respond well while normal-appearing colons may not.
Anorectal manometry is critical for distinguishing motility disorders from obstruction and preventing unnecessary resection.
Failure of medical management includes inability to take medications, persistent symptoms despite treatment, and quality-of-life impacts.
Absent rectoanal inhibitory reflex on manometry is characteristic of Hirschsprung disease.

Absent Rectoanal Reflex in a Dilated Colon: When Anatomy Misleads

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

A 10-year-old boy presented with severe constipation, daily cramping, poor appetite, and soiling 2:51. He had been through multiple laxative regimens without success 2:51. The contrast enema showed stool in the distal rectum, a tortuous redundant sigmoid colon, and colonic dilation. Anorectal manometry revealed an absent rectoanal inhibitory reflex (RAIR).

The Decision Point

The imaging looked terrible — dilated, redundant, packed with stool. The reflex testing suggested Hirschsprung disease, which would typically mean resection. But the discussants had learned not to trust appearance alone.

The contrast study does not predict response to treatment 7:12. Colons that look catastrophic on imaging can respond well to medical management, while normal-appearing colons may not respond at all 7:19. In the past, colons were resected based on how they looked, but many of those patients had motility disorders and did not need resection 7:36. Many dilated colons will respond to treatment 7:54.

The absent RAIR complicated the picture. Patients with Hirschsprung disease have an absent RAIR 10:09, which would argue for surgical intervention. But anorectal manometry provides more than a binary yes-or-no on the reflex — it gives baseline and functional information about defecation dynamics 10:36. The test allows clinicians to observe what happens when patients bear down, squeeze, and attempt to defecate, comparing the sensation to defecate against the internal anal sphincter response 10:19. High pressures may suggest underlying inability to relax, causing functional obstruction 10:00.

One of the discussants noted that the sphincter's role in constipation patients was not well understood in the past 10:51. Mark Levitt stated, "I don't know how I survive without this test" [q1]. Anorectal manometry is now considered critical for determining whether a patient needs surgery or resection, because patients with motility disorders do not need resection 12:03.

The central question: Does this child have Hirschsprung disease requiring resection, or a motility disorder that will respond to medical management?

The Reasoning Framework

The discussants emphasized that failure of medical management must be clearly defined before considering surgery 2:51. Failure means appropriate treatment with no appropriate response, inability to take treatment, persistent symptoms or pain despite treatment, or failure to grow 2:51. Failure of retrograde enemas is also considered failure of medical management 3:21. Reliance on rectal therapy or retrograde enemas with continued soiling that significantly affects functioning qualifies as well 3:35.

But "appropriate treatment" at the general pediatrician level typically means osmotic laxatives like MiraLax or lactulose and stimulant laxatives such as Senna or bisacodyl 3:57. There are other medications that pediatricians are not accustomed to prescribing that gastroenterologists use 3:57. Some children stool every day but do not completely evacuate 4:58, which standard regimens may not address.

The workup for patients with long-standing constipation where appropriate treatments have been tried and failed begins with diagnostic studies including contrast enema 5:27. The contrast enema assesses degree of colonic dilatation and redundancy and ensures the ratio is normal 5:56. Water-soluble contrast is used instead of barium because it helps empty the colon and acts as a cleanout for patients starting new medical therapy 8:06.

Reviewing diagnostic imaging with the family helps them understand anatomy and issues and builds rapport 8:37. One of the discussants noted that there are probably many people with redundant colons who stool perfectly normally without imaging documentation 6:53. It is unclear whether colonic dilation and redundancy precedes constipation or results from outlet obstruction 6:59.

What Happened

The outcome of this case was not discussed in the episode.

What Transfers

The collaboration between gastroenterology and surgery depends on distinguishing anatomic problems from functional ones. Mark Levitt described the evolution: "nowadays, it's sort of funny because sometimes Anil says to me, I think the kid needs surgery, and I say to Anil, no, I think the kid needs more medical treatment, and that's the collaboration you're shooting for" [q3].

The lesson is procedural: Do not resect based on appearance. Do not assume Hirschsprung based on absent RAIR alone. Layer the functional data — manometry dynamics, response to escalated medical therapy, complete evacuation patterns — before deciding the colon itself is the problem. The imaging tells you what the colon looks like. The manometry tells you what it does. The treatment trial tells you what it can do.

Takeaways from this story

Contrast enema appearance does not predict treatment response — severely dilated colons may respond well to medical management.
Anorectal manometry provides functional data beyond RAIR status, revealing sphincter dynamics critical to surgical decision-making.
Failure of medical management requires clear definition: appropriate treatment with no response, inability to take treatment, or persistent symptoms affecting function.
Gastroenterologists use medications beyond the osmotic and stimulant laxatives typically prescribed by general pediatricians.

From Anatomy to Function: How Manometry Reshaped Surgical Decisions in Pediatric Constipation

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The anatomic era

Colons were resected based on appearance 7:36. A contrast study showing severe dilation and redundancy pointed toward surgical intervention — the reasoning was straightforward: an abnormal-looking colon must be an abnormal-functioning colon. The logic held until it didn't. Patients with motility disorders received resections they did not need 7:36, because the imaging suggested otherwise. The sphincter's role in refractory constipation was poorly understood 10:51, and without functional testing, surgeons had only the roadmap, not the engine performance.

What changed

Anorectal manometry entered practice as a functional test 10:36, measuring not what the colon looks like but what it does. The catheter with pressure sensors and an inflatable balloon assesses anal sphincter function and its relationship to the rectum 9:35. High pressures suggest functional obstruction from inability to relax 10:00. The rectoanal inhibitory reflex — the internal sphincter's relaxation when the rectum distends — can be directly measured 9:11. Its absence defines Hirschsprung disease 10:09. Defecation dynamics become visible: patients bear down, squeeze, attempt to defecate, and the test compares their sensation to defecate against what the internal sphincter actually does in response 10:19.

The test's impact on surgical decision-making was immediate. Mark Levitt: "I don't know how I survive without this test" [q1]. The reason is clinical: manometry is now critical for determining whether a patient needs surgery or resection, because patients with motility disorders do not need resection 12:03. A dilated, redundant colon on contrast study no longer drives the surgical plan. Many dilated colons respond to treatment 7:54. Conversely, colons that look totally normal on contrast study may not respond at all to treatment 7:19. The contrast study is not a great predictor of how patients will respond to medical or surgical management 7:12.

The case that opens this discussion illustrates the disconnect: a child with severe constipation, a contrast enema showing marked dilation and redundancy, and an absent rectoanal inhibitory reflex on manometry. One of the discussants' reaction — "that blows my mind, that with that contrast study, we see an absent rare" — captures the paradigm shift. The imaging suggested one diagnosis; the functional test revealed another.

Current practice

The diagnostic sequence now proceeds from history and physical examination 4:46 through imaging 5:27 to manometry when surgical versus medical management hangs in the balance 12:03. Contrast enema remains first-line for assessing colonic dilation and redundancy and ensuring the rectosigmoid ratio is normal 5:56, but its role is descriptive, not predictive. Water-soluble contrast is preferred because it acts as a cleanout for patients starting new medical therapy 8:06 and helps families understand the anatomy 8:37. The images inform but do not decide.

Failure of medical management has specific definitions: appropriate treatment with no appropriate response, inability to take medications, persistent symptoms or pain with treatment, failure to grow 2:51, failure of retrograde enemas 3:21, or reliance on rectal therapy with continued soiling causing significant functional impairment 3:35. Before manometry, these patients might have been surgical candidates based on imaging alone. Now the functional test determines the path.

The collaboration between gastroenterology and surgery has inverted in some cases. "Nowadays, it's sort of funny because sometimes Anil says to me, I think the kid needs surgery, and I say to Anil, no, I think the kid needs more medical treatment, and that's the collaboration you're shooting for" [q3]. The gastroenterologist, armed with functional data, may advocate for surgery when the surgeon sees a salvageable colon. The surgeon, understanding motility, may advocate for continued medical management when the gastroenterologist sees treatment failure. The test made both positions defensible.

What remains unsettled

The chicken-or-egg question persists: does colonic dilation and redundancy precede constipation or result from outlet obstruction 6:59? The answer matters for understanding natural history but apparently not for treatment decisions, which now rest on function rather than form. Whether many people have redundant colons and stool perfectly normally without imaging documentation 6:53 suggests that anatomic variation may be clinically silent until other factors intervene.

The threshold for manometry in the diagnostic algorithm is not standardized. The discussants describe it as the next step when surgical versus medical management must be determined 12:03, but the criteria for reaching that decision point — beyond failure of medical management — are not specified. How long to persist with medical therapy, which medication escalations to attempt before testing, and whether manometry should be performed earlier in patients with specific imaging findings remain questions of judgment rather than protocol.

Takeaways from this story

Contrast enema appearance does not predict treatment response — severely dilated colons may respond to medical therapy
Anorectal manometry distinguishes Hirschsprung from functional constipation via rectoanal inhibitory reflex measurement
Manometry now determines surgical candidacy in refractory constipation — motility disorders do not require resection
High sphincter pressures on manometry suggest functional obstruction from inability to relax rather than anatomic disease

Topic overview

A multidisciplinary discussion between pediatric colorectal surgeons and gastroenterologists on the evaluation and management of severe constipation and motility disorders in children. The case centers on a 10-year-old boy with refractory constipation, soiling, and poor appetite who has failed multiple laxative regimens. The discussants emphasize the importance of defining failure of medical management, the role of diagnostic imaging including contrast enema, and the critical value of anorectal manometry in distinguishing functional constipation from motility disorders that may mimic surgical conditions like Hirschsprung disease. The episode concludes before completing the case workup, with part two promised for the following week.

Key takeaways

Anorectal manometry is critical to distinguish motility disorders from Hirschsprung disease before considering surgery. (10:09)
Colonic appearance on contrast enema poorly predicts treatment response; dilated colons may respond well to medical therapy. (7:12)
Failure of medical management includes inability to tolerate treatment, persistent symptoms despite therapy, or growth failure. (2:51)
Water-soluble contrast is preferred over barium as it provides therapeutic cleanout while enabling diagnostic assessment. (8:06)

Keywords

constipation soiling Hirschsprung disease motility disorders functional constipation autism anorectal manometry contrast enema water-soluble contrast enema abdominal X-ray rectal exam retrograde enemas colonic resection PSARP MiraLax

Hashtags

#PediatricSurgery #MotilityDisorders #ColorectalCare #PedsGI

Transcript

Click "Show Transcript" to view the full text (12960 characters)

Hey there listeners, this is Rod from Cincinnati Children's. If you haven't already, download the Stay Current pediatric surgery app. The reason being is because if you're listening to this colorectal quiz, In the app, I'm gonna put X-ray images, coostograms, articles, whatever Doctor Fisher and Doctor Levitt are talking about, you can read along or look along with them in the app. So download it now, it's in the Apple App Store, it's in the Google Play Store, but until then, Enjoy the episode. If you've been listening to the colorectal quiz every week, then you know that the field of colorectal surgery can become multidisciplinary very quickly. That's why today we teamed up with our Peds GI colleagues to talk about motility disorder. A disease process that necessitates really good cooperation between GI and surgery to make sure that our patients are getting the best care. And today's also a special episode because I brought a friend along. Hi, I'm Amanda Jensen. I'm a pediatric surgery, colorectal subspecialty fellow at Cincinnati Children's Hospital. Amanda and I are going to walk you through this high yield discussion. On the diagnosis and management of motility disorder. So without further ado, this is the colorectal quiz. Welcome back, everyone. We're excited for you to join us again as we continue on our colorectal quizzes. That's Jason Frischer. He's a pediatric colorectal surgeon at Cincinnati Children's Hospital. Today, we are really excited to have some guests with us today. And from Cincinnati Children's Hospital, we have Doctor Khalib Graham. Doctor Khalib Graham is a pediatric gastroenterologist who specializes in Motility disorders. Oh yeah, so great you're here. Thank you for joining us and my good buddy, that's Doctor Mark Levitt at Children's National Hospital and partner in crime, Anil Darbari. Doctor Anil Darbari is also a gastroenterologist who specializes in motility disorders, and I've learned a ton, and now it's, nowadays, it's sort of funny because sometimes Anil says to me, I think the kid needs surgery, and I say to Anil, no, I think the kid needs more medical treatment, and that's the collaboration you're shooting for. The case that we have is that of a 10 year old boy with severe constipation. He presents with daily cramping, poor appetite, and soiling. He's been on multiple laxative regimens according to the family, and these have been tried with no success. What does it mean to failed medical management? Why do you need a gastroenterologist? Can a pediatrician take care of a patient like this? That's an excellent question, Mark, because defining failure of medical management is multifolded. The patient has appropriate treatment but no appropriate response. That is. Pretty clear cut, considered a failure. The patient cannot take treatment. So for example, kids with autism, other cognitive problems who really cannot take the medications that are prescribed, or the patient has persistent symptoms or pain with treatment, we would consider that as a failure of medical management or has failure to grow. We sometimes use retrograde enemas for these managements, and if that also So it doesn't work, I would consider that as a failure of medical management as well. In regards to quality of life, what is considered a failure of medical management? If a patient is very much reliant on rectal therapy or the retrograde enemas or having, continue having soiling and it's causing a, a, a significant effect on their, on their functioning as a young child, um, then that we also would Consider that a failure of medical management potentially. And that's assuming that they're on adequate doses for their bowel management. The other factor that comes into play is that most of the time we think about, uh, constipation medication at the general pediatrician level, you're thinking about your osmotic laxatives like MiraLax or lactulose, and then, and then you may think about your stimulant laxatives such as Senna or bisocodol. But there are probably other medications that the pediatrician is probably not used to prescribing and the GI doc is. So, here's a quick summary. So what you're saying in regards to quality of life is that the patient is relying on rectal enemas, however, still having soiling, or it is affecting their daily life and their function. Nice. OK, so next question. What do you include in your initial evaluation? So, always, anytime you see a patient and they're, they're, they're first coming to see me, you wanna get a really good history. That means trying to understand, you know, triggers, how often they're stooling, when they stool, do they feel like they're completely empty? Because some kids stool every day, but they don't completely evacuate. And then, of course, you always have to do a good physical exam. Looking at their abdomens, see if there's palpable stool. Are they? Significantly distended. A rectal exam many times is a very important part of the process. And then you wanna move on to diagnostic imaging, and abdominal X-ray, um, even potentially, uh, water-soluble contrast enemas. How do you like to, what, what's your first line of therapy, Anil, in a patient like this? How do you, how do you start treating them? If the appropriate treatments have been tried and uh they have failed. The first step in managing would be the diagnostic studies because there's a good, clear history. So in a patient with long standing constipation, where the appropriate treatments have been tried, often that's not true in routine functional constipation cases where the history is not very clear or the adherence to medical management is not very clear. So you would start with a contrast enema to see the degree of colonic dilatation and or redundancy and to make sure that the ratio is normal. Um, so here you have a contrast study. Um, you can see the images. If you're using the app, you can just see the images right away. Um, and Jason, you wanna just give me your feeling about what this image says to you, as if you're in an art museum looking up a beautiful picture, and how, what is it saying to you? It's saying that this is not a Monet, that is for certain. That being said, such a dad joke. You know, there's a few things. I agree with the contrast study, and it gives you a roadmap of the colon. I see stool in the distal rectum. What about the path of the sigmoid? Curvy, tortuous sigmoid colon, likely we would call. Redundant. What does that mean? I don't know, because there's probably a lot of people with redundant colons that stool perfectly normally, and we don't have imaging of it. And then when it comes to considering the dilation, is it the chicken or the egg, or was it dilated and redundant before, or did it happen because of maybe an outlet obstruction type pictures. So the contrast study is not a great predictor on how the patient is going to respond to medical or surgical management. You know, I have seen crazy looking colons that responded really nicely, and then alternatively, you can have colons that look totally normal on the contrast study, but they don't respond at all to treatment. So who needs a motility expert, particularly in the group of functional constipation patients. So the motility. utility of the colon becomes critical to how we end up taking care of these patients because Mark remembers not too long ago when we used to take out a colon or a sigmoid colon based on how it looked, and guess what, the patient had a motility disorder, they didn't need a resection. Many of these colons will listen to us, so to speak. They will respond to treatment. Here's Doctor Fisher with some more considerations regarding the contrast enema. We use water-soluble contrast, not barium. It helps us empty the colon, so it acts as a cleanout for the patient if they're going to start a new medical therapy. And lastly, it, it really helps the family and the child, if they're old enough to understand some of the anatomy, um, and some of the issues going on. So I really do think it's a great tool. So never forget that reviewing the diagnostic imaging with the family can really help them understand and ultimately build rapport. Alright, so let's reset a little bit, we have a 10 year old male, he has severe constipation with soiling, poor appetite, we got this contrast enema, he's very dilated, full of stool. The next step, say it with me now, anorectal manometry. The anorectal manometry showed an absent rare. And what Doctor Levitt means is RAIR or rectoanal inhibitory reflex. Basically when the rectum becomes distended with stool, the internal anal sphincter has to relax, this child doesn't have that response. Could, could we stop one second? That, that blows my mind, that with that contrast study, we see an absent rare. To better understand why Doctor Frischer's mind was so blown, let's just talk about why you even get anorectal manometry. To get a better understanding of the anal sphincters and also its relationship to the rectum, so you, you, you have a catheter that has a balloon tied to it. The catheter has sensors on it that are measuring pressure. And as you blow up the balloon, you can measure. Pressures and me and measure of responses, particularly how the internal anal sphincter responds. So, how do you interpret some of these results? High pressures may suggest that there may be some, some underlying issue going on with the inability to relax and essentially causing a, a functional obstruction. What about a patient who has Hirschprung disease? They would not have a rare. They would have an absent rare. So, what other information can we get from this anorectal manometry? You can also get information learning about defecation dynamics, so you can have patients bear down, you can have them squeeze and try to defecate, and then you can kind of compare when they have the sensation to defecate versus what their internal anal sphincter. is actually doing in response to that. So you actually get a whole bunch of information from a baseline standpoint as well as a functional standpoint. It's a very functional kind of test. And Doctor Levitt finds a lot of value in this test. I don't know how I survive without this test. I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played. In a lot of our patients. I think it's vital. So, I wanna, I wanna move along with this case, because it's gonna get very interesting now. The A man was done, and the a man showed an absent rare. It does get a lot more interesting, but unfortunately we're out of time for this week, so we gotta pick up next week. Before we get out of here, let's summarize. Our PSGI colleagues helped us to understand the diagnosis and management for patients with motility disorders, and it all starts in your clinic with a really good history, physical exam, really understand the nature of these patients with constipation. diarrhea, understand the bowel regimen that they were on previously from perhaps their pediatrician, maybe there are some medications that our GI colleagues are more comfortable with, you could try those as well, rectal enemas, things of that sort. Then you want to move on to imaging, you could start with a plain abdominal X-ray, sometimes that's helpful, but oftentimes you might have to move on to Contrast enema, that can be diagnostic and therapeutic. Based on that result, you may have to move on to anorectal manometry, which is critical when you have a conversation between GI and surgery and you're trying to determine, does this patient need a surgery, do they need a resection, because if they have motility disorder, that's a surgery that they do not need to have. So That concludes motility disorders part one. I know what you're thinking. Yes, we have a joke. There were 2 wind turbines in a field, in a wind field generating electricity, and they were having a conversation amongst themselves, these wind turbines. And one of them said to the other, hey, what kind of music do you like? And the other one said, come on, isn't it obvious? I'm a heavy metal fan. Terrible. It's terrible. Alright, so it's not open mic night at the Improv, but if you have a better joke, that you want Doctor Fishisher or Doctor Levitt to tell at the end of their colorectal quiz, you can leave a comment, if you're listening to this podcast in the Stay Current in pediatric surgery app. You could do a lot of things. I mean, you could look at the images, including the contrast enema, X-ray, things like that, while you're listening to the podcast. You can connect with other surgeons, you can leave this podcast entirely, watch a video on a PSARP, look up whatever you want about pediatric colorectal surgery in our app. You can download it now, it's in the Apple App Store, it's in the Google Play Store. You're gonna love it. But until then, I'm Rod from Cincinnati Children's, and remember, Knowledge should be free.

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