Motility / Pseudo-obstruction
Also covered as: Hirschsprung disease · intestinal failure · necrotizing enterocolitis · gastroschisis · intestinal atresia · constipation · soiling · outlet obstruction
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
Fundamentals
2 items
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Watch →
We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s. Hosted by: Todd Ponsky,
video14:33 · Dec 2021
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Listen →
We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s. Hosted by: Todd Ponsky,
podcast14:33 · Dec 2021
Diagnosis & Workup
1 item
Colorectal Collaboration: Neurogastroenterology/Motility Disorders
Watch →
Pediatric Colorectal Surgery is a team sport. That's why this episode is about how the pediatric colorectal surgery team, lead by Dr. Jason Frischer, collaborates with the neurogastroenterology department at Cincinnati Children's Hospital M
video14:55 · Jul 2021
Case-Based Learning
3 items
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Listen →
Motility disorder is a team sport - that's why today, we're talking to our colleagues in Pediatric Gastroenterology, Dr. Anil Darbari from Children's National Hospital and Dr. Kahleb Graham from Cincinnati Children's Hospital. Special guest
podcast14:04 · Mar 2021
The Colorectal Quiz Episode 9: Motility Disorders Part 2
Listen →
Motility disorder is a team sport - that's why today, we're talking to our colleagues in Pediatric Gastroenterology, Dr. Anil Drabari from Children's National Hospital and Dr. Kahleb Graham from Cincinnati Children's Hospital. Special guest
podcast13:52 · Apr 2021
Colorectal Quiz: Episode 42 - HD Constipation
Listen →
In this episode of the Colorectal Quiz, Drs. Mark Levitt, Jason Frischer, and Chris Gayer discuss a complex case of persistent constipation in a patient with a history of Hirschsprung’s disease. Despite a successful pull-through surgery in
podcast14:48 · Dec 2024
In-Depth Reviews
1 item
Intestinal Failure with Dr. Brad Warner
Listen →
Discussion with Dr. Brad W. Warner about intestinal failureWhat is intestinal failure?An umbrella term for when the small bowel is unable to digest and absorb an adequate amount of nutrients to sustain a patient through enteral means alone.
podcast52:46 · Dec 2020
Summaries and takeaways+ Show
Summary of this collection+ Show
Key points, with the moment each was said+ Show
Featured picks for families are being prepared — the summaries above are written for you.
Takeaways+ Show
Intestinal failure—insufficient gut function to absorb nutrients, fluids, and calories—requires parenteral support for ≥60 days and is most commonly caused by short bowel syndrome (congenital anomalies, NEC, volvulus) [e296-c1, e4741-c2, e4741-c4, e4741-c5, e4741-c6]. Salvageability thresholds: neonates with ileocecal valve need 10–15 cm; without valve, 15–20 cm [e296-c3, e296-c4]. Intestinal adaptation occurs over 1–2 years; enteral advancement tolerates stool outputs up to 40 cc/kg/day [e296-c7, e296-c8]. TPN targets 100–120 kcal/kg/day (50% glucose, remainder fat/protein at 2–3 g/kg/day each); lipid reduction to 1 g/kg/day 2–3×/week mitigates cholestasis [e296-c9, e296-c10, e296-c12]. Omegaven (fish oil, omega-3) and SMOF lipid (soybean/MCT/olive/fish) have replaced soybean-based intralipid [e296-c13, e296-c14]. Breast milk is optimal for adaptation (growth factors, oligosaccharides); complex formulas stimulate enterotrophic hormones better than elemental [e296-c15, e296-c16]. Surgical intervention (STEP, Bianchi, tapering) is indicated when enteral tolerance plateaus, multiple sepsis episodes occur, or bowel dilation >4–5 cm persists [e296-c18, e296-c19, e296-c22]. STEP is preferred (easier, less vascular risk) but can redilate; Bianchi can precede STEP but not vice versa [e296-c26, e296-c27, e296-c28]. Teduglutide (GLP-2 analog) reduces adult TPN by 1–2 L/week but lacks pediatric approval due to malignancy concerns [e296-c35, e296-c36]. Multidisciplinary intestinal rehabilitation programs achieve >90% long-term survival .
Constipation phenotypes require targeted workup: outlet obstruction (markers in rectum), slow transit (scattered markers), or normal transit [e4366-c4, e4366-c7, e4366-c8]. Anorectal manometry is the gold standard—absent rectoanal inhibitory reflex (RAIR) suggests Hirschsprung; high resting pressure indicates Botox candidacy; dyssynergia warrants pelvic floor therapy [e3824-c17, e3824-c19, e3888-c4, e3888-c5]. Colonic manometry identifies dysmotility: ≥2 high-amplitude propagating contractions (HAPCs) in 18–24 hours rules out colonic dysmotility; absence of HAPCs or no stimulant response confirms dysfunction [e3888-c19, e3888-c21, e3888-c29]. Segmental dysmotility <30 cm is managed conservatively; >30–50 cm is a red flag [e9506-c23, e4366-c19]. Antegrade enemas (Malone/cecostomy) succeed in 97% of segmental cases, avoiding resection [e9506-c25, e6886-c33]. Post-Hirschsprung constipation stems from sphincter/pelvic floor dysfunction, not colonic dysmotility—colonic manometry is contraindicated until distal obstruction is excluded [e9506-c14, e9506-c19, e9506-c21].
- Neonatal short bowel salvageability: 10–15 cm with ileocecal valve, 15–20 cm without; adaptation takes 1–2 years with stool outputs ≤40 cc/kg/day tolerated during enteral advancement.
- STEP is preferred lengthening procedure (easier, less vascular risk) but can redilate requiring redo; Bianchi can precede STEP but not vice versa; taper preferred if length >90–100 cm.
- Anorectal manometry differentiates outlet obstruction (absent RAIR, high resting pressure) from pelvic floor dysfunction (dyssynergia); colonic manometry requires ≥2 HAPCs in 18–24 hours to exclude dysmotility.
- Antegrade enemas succeed in 97% of segmental dysmotility cases; resection reserved for pan-colonic slow transit or failure of conservative therapy including Malone/cecostomy.
- Post-Hirschsprung constipation stems from sphincter/pelvic floor dysfunction, not colonic dysmotility—colonic manometry contraindicated until distal obstruction excluded; Botox and biofeedback are first-line.
For patients & families
When a child's intestine cannot move food and waste normally, doctors call this a motility problem or pseudo-obstruction [e4741-c7, e4741-c8]. The bowel muscle or the nerves controlling it don't work together properly, so even though the intestine is present, it acts as if something is blocking it . Some children are born with these conditions; others develop them after surgery or illness [e4741-c5, e4741-c6]. Doctors use special tests — like manometry, which measures pressure inside the bowel, and transit studies with tiny markers or scans — to understand where and how the intestine is struggling [e4366-c1, e6853-c5, e6853-c8]. Treatment often starts with medications (laxatives, stimulants) and sometimes special flushing routines through a small surgical opening (a Malone) to help the bowel empty [e6886-c29, e9506-c27]. Most children improve with these approaches; surgery to remove part of the colon is reserved for those who don't respond [e6886-c31, e6886-c32]. A team of specialists — surgeons, gut doctors, dietitians, nurses — works together to find what helps each child . The goal is a bowel that empties reliably, even if that means ongoing help rather than a cure .
When a child's intestine cannot move food and waste normally, doctors call this a motility problem or pseudo-obstruction [e4741-c7, e4741-c8]. The bowel muscle or the nerves controlling it don't work together properly, so even though the intestine is present, it acts as if something is blocking it . Some children are born with these conditions; others develop them after surgery or illness [e4741-c5, e4741-c6]. Doctors use special tests — like manometry, which measures pressure inside the bowel, and transit studies with tiny markers or scans — to understand where and how the intestine is struggling [e4366-c1, e6853-c5, e6853-c8]. Treatment often starts with medications (laxatives, stimulants) and sometimes special flushing routines through a small surgical opening (a Malone) to help the bowel empty [e6886-c29, e9506-c27]. Most children improve with these approaches; surgery to remove part of the colon is reserved for those who don't respond [e6886-c31, e6886-c32]. A team of specialists — surgeons, gut doctors, dietitians, nurses — works together to find what helps each child . The goal is a bowel that empties reliably, even if that means ongoing help rather than a cure .
The doctors in this collection+ Show
All expert statements+ Show
Every expert statement below comes from the recorded discussions, with its speaker and moment.
Colorectal Quiz: Episode 42 - HD Constipation
Approximately one-third of Hirschsprung patients are constipated post-operatively and need proactive, aggressive management to avoid trouble
epidemiologicalMarc Levitt1:47 ↗
Hirschsprung disease is a very anatomically fixable problem and with a good operation you should get a good result
clinicalMarc Levitt1:38 ↗
Surgeons might leave behind the dilated segment right above the aganglionic segment as an anatomic reason for decompensation
clinicalMarc Levitt2:11 ↗
The most relevant reason for decompensation is that the patient never figured out how to successfully empty their sphincters and the pull-through decompensates
clinicalMarc Levitt2:22 ↗
Calretinin hangs out with ganglion cells, so normal calretinin staining provides double evidence of good ganglion cells
clinicalMarc Levitt3:14 ↗
In younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter
clinicalJason Frischer3:47 ↗
The definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues
clinicalJason Frischer4:01 ↗
If there are no ganglion cells and no calretinin staining, that is a retained Hirschsprung and the patient needs a redo to a higher level
clinicalMarc Levitt4:27 ↗
Nerve hypertrophy with good ganglion cells could represent transition zone or could represent that the bowel has decompensated over time because it hasn't emptied and gotten dilated
clinicalMarc Levitt4:38 ↗
An absent rectal anal inhibitory reflex means the internal anal sphincter doesn't relax when the rectum is distended, which can contribute to constipation
clinicalFelipe Glu6:35 ↗
Many patients are going to have an abnormal anorectal manometry but they're OK
clinicalMarc Levitt6:47 ↗
Botox helps patients learn to overcome non-relaxing sphincters by other maneuvers like pushing on their abdominal wall
clinicalMarc Levitt6:56 ↗
Many patients are completely asymptomatic doing great with Hirschsprung's that have residual absent rectal anal inhibitory reflex
clinicalMarc Levitt7:11 ↗
In Hirschsprung patients with constipation, the colon is not the problem; the problem usually is the sphincters or the pelvic floor
clinicalMarc Levitt7:39 ↗
If you get an awake anorectal manometry in a cooperative patient with a normal rectal anal inhibitory reflex and can detect the resting pressure, the evaluation is complete without anesthesia or procedure
clinicalMarc Levitt8:14 ↗
If the rectal anal inhibitory reflex is absent, you're obligated to do a biopsy and give Botox
guidelineMarc Levitt8:29 ↗
Botox is given if the resting pressure of the external sphincter is also high
clinicalMarc Levitt8:36 ↗
Pelvic floor dysynergia can be detected on anorectal manometry and is a good indication that pelvic floor physical therapy will help the patient
clinicalMarc Levitt8:41 ↗
Colonic manometry should not be done in Hirschsprung patients with obstructive symptoms because it's not the colon but the distal pull-through that's the problem
guidelineMarc Levitt9:55 ↗
Anatomic and pathologic causes must be ruled out before any colonic manometry is considered
guidelineMarc Levitt10:11 ↗
Colonic manometry in a patient with a distal obstruction is the wrong test
guidelineMarc Levitt10:18 ↗
Once distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem warranting colonic manometry
clinicalJason Frischer10:27 ↗
If there's a segment less than 30 centimeters of inadequate high amplitude propagating contractions, the approach is not super aggressive; over 30 centimeters is definitely more of a red flag
clinicalJason Frischer11:01 ↗
High amplitude propagating contractions aid in the transfer of colonic contents over long distance and often precede emptying
clinicalFelipe Glu11:17 ↗
In a PCPLC Consortium study of close to 100 patients with functional constipation and segmental dysmotility of the sigmoid, 97% successfully responded to Malone only without needing resection
epidemiologicalMarc Levitt11:54 ↗
Five years ago, surgeons were taking sigmoids out of patients with segmental dysmotility, but this practice has changed based on new data
clinicalMarc Levitt12:28 ↗
A Malone procedure is a route for medical treatment, providing antegrade access to the colon for gastroenterologists to give better medical treatment
clinicalMarc Levitt13:24 ↗
While surgery can correct the underlying anatomical problem in Hirschsprung disease, many other factors can contribute to constipation including motility disorders, pelvic floor dysfunction, and behavioral issues
clinicalFelipe Glu14:15 ↗
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Failure of medical management is defined as appropriate treatment with no appropriate response
clinicalKahleb Graham2:51 ↗
Patients who cannot take treatment (e.g., kids with autism or other cognitive problems) are considered to have failed medical management
clinicalKahleb Graham3:04 ↗
What's new+ Show