Colorectal Quiz Episode 12: Newborn ARM Part 1

Published: 2021-06-07

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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

Amanda Jensen — host
Rod Girardo — host
Dr. Frischer — guest
Dr. Levitt — guest

Chapters

0:00Introduction and Historical Context — Hosts introduce the episode on anorectal malformations, noting the condition occurs in 1 in 5,000 live births. Dr. Levitt provides historical context from the Talmud describing early treatment attempts.
2:03Male Presentations: Rectal-Urethral Fistulas — Discussion of male newborns with meconium passing through the urethra, indicating rectal-urethral fistulas. Covers classification by urethral location and the significance of flat bottom appearance indicating high rectum location and poor prognosis.
6:11Perineal Fistulas: Bucket Handle and Black Ribbon — Detailed examination of perineal fistula variants including bucket handle malformation and black ribbon malformation with meconium in scrotal raphe. Discusses management strategies including gentle dilation to avoid surgery in unstable patients.
10:16No-Fistula Defects and Summary — Brief discussion of the rare no-fistula defect (5% of cases), its association with trisomy 21, and typical location at bulbar urethral level. Summary of the four male anorectal malformation types covered.

Key claims

0:22Anorectal malformations occur in 1 in 5,000 live births — Rod Girardo
0:42Anorectal malformations occur when the anus, rectum, and nerves do not develop properly during fetal growth — Rod Girardo
2:25More than 90% of anorectal malformation patients have their actual anatomy ascertained on physical exam alone — Dr. Frischer
4:3595% of boys with anorectal malformations have a fistula somewhere — Dr. Levitt
4:45The vast majority of male anorectal malformations enter into the urinary tract — Dr. Levitt
5:58The presence of a flat bottom, meaning absence of a normal midline groove, is usually associated with a very high located rectum and usually associated with a bad prognosis — Dr. Levitt
7:08With bucket handle malformation, you can be very confident that you have a perineal fistula — Dr. Levitt
7:22You can gently dilate a perineal fistula under a bucket handle to get meconium out and spare the baby a trip to the OR if they are too ill — Dr. Levitt
8:20In black ribbon malformation, the fistula parallels the urethra for a long distance with potential for urethral injury — Dr. Levitt
9:30In male patients with perineal fistula, the fistula is always located anterior to the center of the sphincter — Dr. Frischer
9:50No surgical repair should be done before the first 24 hours because a patient may pass meconium through the tiny orifice and the perineal fistula should be identified — Dr. Frischer
10:16The no fistula defect is quite rare, only about 5% of cases — Dr. Levitt
10:28The no fistula defect is not surprising if you had a trisomy 21 patient — Dr. Levitt
10:36The no fistula defect is almost uniformly at the same level as a bulbar urethra — Dr. Levitt
3:40Rectal-urethral fistulas are categorized by location on the urethra: bulbar, prostatic, or bladder neck — Dr. Frischer
5:16It is nice to put a little gauze to check the urine for particulate matter to detect rectal-urethral fistula — Dr. Levitt
5:41Newborns with rectal-urethral fistulas will need colostomies and then ultimately distal colostograms and then definitive surgery — Dr. Frischer

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:

Anorectal Malformations in Male Newborns: What the Perineal Exam Reveals

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Discipline

Anorectal malformations occur in 1 in 5,000 live births 0:22. The rectum develops but fails to open where it should, instead connecting — in 95% of male cases — to the urinary tract or opening onto the perineum in an abnormal location 4:35 4:45. The term "imperforate anus" is misleading; these structures are perforate, just not in the right place [q3]. More than 90% of these patients can have their anatomy determined by physical examination alone, making the newborn perineal exam the primary diagnostic tool 2:25. The pediatric colorectal surgeon's expertise lies in reading that exam to predict internal anatomy, guide initial management, and determine prognosis — often within the first 24 hours of life.

The Core Clinical Problem

The newborn presents without a normal anal opening. The question is not whether a connection exists but where it terminates. In males, the rectum nearly always fistulizes somewhere 4:35. The vast majority enter the urinary tract at varying levels — bulbar urethra, prostatic urethra, or bladder neck 4:45 3:40. A minority open onto the perineum anterior to where the anus should be 9:30. Roughly 5% have no fistula at all, a variant associated with trisomy 21 10:16 10:28. The location of the fistula determines both the surgical approach and the functional prognosis. A high rectal-bladder neck fistula implies poor pelvic musculature and worse continence outcomes; a perineal fistula can sometimes be managed without a colostomy.

How the Approach Works

The exam begins with inspection. Meconium visible at the urethral meatus indicates a rectal-urethral fistula 3:40. Placing gauze over the penis to check for particulate matter in the urine can confirm this when meconium has not yet appeared 5:16. These infants will require a diverting colostomy, followed by distal colostography to map the fistula, and then definitive posterior sagittal anorectoplasty months later 5:41.

The presence of a "flat bottom" — absence of the normal midline gluteal groove — is a critical prognostic sign. It indicates a very high rectum and is associated with poor outcomes 5:58. This finding suggests the pelvic floor musculature is poorly developed, which limits the potential for continence even after repair.

Perineal fistulas present differently. The most recognizable variant is the "bucket handle malformation," a midline skin bridge running from the expected anal location forward along the perineum 7:08. This structure reliably indicates a perineal fistula lying just beneath it 7:08. If the infant is too unstable for surgery — a cardiac lesion requiring stabilization, for example — the fistula can be gently dilated to decompress the bowel and defer operative repair 7:22.

Another perineal variant is the "black ribbon malformation," in which meconium tracks along the scrotal raphe. Here the fistula parallels the urethra for a considerable distance, creating significant risk of urethral injury during repair 8:20. In all male perineal fistulas, the opening lies anterior to the center of the sphincter complex 9:30.

Crucially, no repair should be attempted in the first 24 hours 9:50. Some perineal fistulas have tiny orifices that only declare themselves when meconium is passed. Operating before this window closes risks misclassifying the defect and performing the wrong operation.

The no-fistula defect is rare and almost always occurs at the level of the bulbar urethra 10:16 10:36. It is overrepresented in trisomy 21 10:28. These patients require colostomy and delayed pull-through, similar to those with rectal-urethral fistulas.

Where Practice is Contested

The discussion does not address contested ground in initial management. The classification system described here — based on fistula location — is widely accepted. The 24-hour observation period before definitive diagnosis is standard teaching 9:50. The use of gentle dilation for bucket handle malformations in unstable patients is presented as accepted practice 7:22, though the episode does not discuss criteria for when this is appropriate versus proceeding directly to colostomy.

When to Involve This Team

Any newborn without a visible, normally positioned anus requires immediate pediatric surgical consultation. Do not wait for meconium to appear or for imaging. The physical exam findings in the first 24 hours guide the entire treatment algorithm. If you are performing the newborn exam and see a flat bottom, meconium at the urethral meatus, or a bucket handle deformity, the infant needs a pediatric surgeon before leaving the delivery hospital. These patients also require screening for VACTERL-associated anomalies — cardiac, esophageal, spinal, and renal defects — within the first 24 hours, though the specifics of that workup are not covered in this discussion. The colorectal surgeon coordinates this evaluation and determines whether the infant can undergo primary repair or requires staged reconstruction beginning with colostomy.

Takeaways from this story

A flat bottom on exam indicates high rectum and poor prognosis — flag this finding immediately for surgical consultation.
Bucket handle malformation reliably indicates perineal fistula beneath, which can be gently dilated if surgery must be deferred.
Wait 24 hours before repair — tiny perineal fistulas may only declare themselves when meconium passes through the orifice.
Meconium at urethral meatus means rectal-urethral fistula; these infants need colostomy, not primary repair.
More than 90% of anorectal malformations can be diagnosed by physical exam alone — imaging is adjunctive, not primary.

Newborn Anorectal Malformation Evaluation: What the Perineum Tells You

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 specialists · Teaching arc · AI-written, human-reviewed

The physical examination determines management in more than 90% of newborns with anorectal malformations 2:25. The challenge is not imaging or laboratory work — it is knowing what you are looking at when you examine the perineum, and what each finding predicts about anatomy, prognosis, and urgency.

The fistula is the rule, not the exception

95% of boys with anorectal malformations have a fistula 4:35, and the vast majority enter the urinary tract 4:45. The term "imperforate anus" is misleading — these patients are perforate, just not where they should be [q3]. When you see meconium at the urethral meatus, you know the rectum communicates with the urethra somewhere along its length 3:40. The location matters: bulbar, prostatic, or bladder neck fistulas each carry different operative considerations, but all require colostomy, distal colostogram, and definitive posterior sagittal repair 5:41. Place gauze in the diaper and check the urine for particulate matter if the diagnosis is not immediately obvious 5:16.

Flat bottom means high rectum, poor prognosis

The presence of a normal midline groove — the vertical crease between the buttocks — tells you the pelvic floor musculature developed. Absence of that groove, a flat bottom, indicates a very high rectum and is associated with poor functional prognosis 5:58. This is not subtle. When you see it, you know the child will need colostomy and that continence outcomes will be compromised even after optimal repair. The flat bottom is often the first clue that you are dealing with a high malformation before any imaging is obtained.

Bucket handle: the perineal fistula you can count on

A bucket handle malformation — a midline skin bridge from the expected anal location toward the perineum — allows you to be confident the fistula is perineal 7:08. This matters because perineal fistulas in males are always anterior to the center of the sphincter 9:30, and the fistula orifice sits just beneath that skin bridge. If the infant is too unstable for the operating room — coarctation, respiratory distress, sepsis — you can gently dilate the perineal fistula to decompress the bowel and defer definitive repair 7:22. This is the one scenario where temporizing without colostomy is reasonable.

Wait 24 hours before declaring the anatomy

No repair should occur in the first 24 hours 9:50. Meconium may pass through a tiny perineal fistula orifice that was not visible on initial exam. Premature operative intervention based on an incomplete examination leads to incorrect procedures. Let the baby declare the anatomy. If meconium appears at the perineum, you have a low lesion. If it appears in the urine, you have a urethral fistula. If the bottom remains flat and nothing passes, you likely have a high lesion and should proceed to colostomy.

Black ribbon: the urethral injury risk

When meconium tracks along the scrotal raphe in a black ribbon pattern, the fistula parallels the urethra for a long distance 8:20. This creates significant risk for urethral injury during posterior sagittal anorectoplasty. The urethra and rectum run side by side, and dissection planes are less distinct than in other fistula types. Recognizing this pattern on newborn exam does not change initial management — the child still needs colostomy — but it flags the case as technically demanding and warns the surgeon that urethral preservation will require meticulous dissection.

The 5% without a fistula

The no-fistula defect is rare, about 5% of cases 10:16, and almost uniformly located at the level of the bulbar urethra 10:36. It is more common in trisomy 21 10:28. These children still require colostomy and posterior sagittal repair, but the absence of a fistula simplifies the dissection — there is no urethral or vaginal connection to divide. The level is intermediate, neither as favorable as perineal nor as challenging as bladder neck.

The newborn perineum tells you the level of the rectum, the presence and location of the fistula, the quality of the pelvic musculature, and the likely functional outcome. Imaging adds precision, but the physical exam drives the initial decision: primary anoplasty, colostomy, or temporizing dilation. More than 90% of the time, you can make that decision in the nursery 2:25.

Takeaways from this story

Flat bottom (absent midline groove) indicates high rectum and predicts poor continence outcomes before any imaging.
Bucket handle malformation confirms perineal fistula; gentle dilation can decompress bowel if infant too unstable for OR.
Wait 24 hours before repair—meconium may pass through tiny perineal fistula not visible on initial exam.
Black ribbon meconium along scrotal raphe signals fistula paralleling urethra, increasing urethral injury risk at repair.
Check urine for particulate matter with gauze in diaper when rectal-urethral fistula suspected but not yet declared.

Reading the Newborn Perineum: What Physical Exam Reveals in Anorectal Malformations

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

Physical examination determines anatomy in most cases

More than 90% of newborns with anorectal malformations can have their anatomy determined by physical examination alone 2:25. This makes the perineal exam the primary diagnostic tool, not imaging. The skill lies in knowing what you are looking at — and what it predicts about the rectum's location and the child's prognosis.

The flat bottom signals high rectum and poor prognosis

The presence of a flat bottom — absence of a normal midline groove — is usually associated with a very high located rectum and usually associated with a bad prognosis 5:58. This is one of the first things to assess. A well-formed midline groove suggests the pelvic musculature developed normally and the rectum descended. A flat perineum suggests it did not. When you see a flat bottom and no meconium anywhere, you are likely looking at a high malformation that will require colostomy, distal colostogram, and staged repair 5:41.

Most male malformations communicate with the urinary tract

In boys, 95% have a fistula somewhere 4:35, and the vast majority of male anorectal malformations enter into the urinary tract 4:45. The fistula may connect to the bulbar urethra, prostatic urethra, or bladder neck 3:40. If you see meconium at the urethral meatus or particulate matter in the urine, the diagnosis is made 5:16. These children will need colostomy and eventual posterior sagittal anorectoplasty. The level of the fistula matters — bulbar is more favorable than bladder neck — but all require staged repair.

The bucket handle malformation identifies a perineal fistula

With bucket handle malformation — a skin bridge from anus to perineum along the midline — you can be very confident that you have a perineal fistula 7:08. This is the most favorable male malformation. The fistula is always located anterior to the center of the sphincter 9:30, and you can gently dilate it under the bucket handle to get meconium out and spare the baby a trip to the OR if they are too ill 7:22. This is the only malformation where you might temporize without colostomy if the baby has a cardiac lesion or other reason to delay surgery.

Wait 24 hours before declaring the anatomy

No surgical repair should be done before the first 24 hours because a patient may pass meconium through the tiny orifice and the perineal fistula should be identified 9:50. Rushing to the operating room before the anatomy declares itself is an error. If you see a normal-appearing perineum at birth but wait and find meconium at a tiny anterior opening the next morning, you have just changed the child's surgical plan from colostomy to primary anoplasty. The 24-hour rule is not about delay — it is about accuracy.

Black ribbon malformation carries risk of urethral injury

In black ribbon malformation, the fistula parallels the urethra for a long distance with potential for urethral injury 8:20. This is the malformation where meconium tracks along the scrotal raphe in a dark line. The surgical risk is higher because the fistula and urethra run together, and dissection can injure the urethra. Recognizing this pattern preoperatively allows the surgeon to plan for careful dissection and possible urethral catheterization to define the anatomy.

The no-fistula defect is rare and associated with trisomy 21

The no fistula defect is quite rare, only about 5% of cases 10:16. It is not surprising if you had a trisomy 21 patient 10:28. The no fistula defect is almost uniformly at the same level as a bulbar urethra 10:36, meaning it behaves surgically like a bulbar fistula even though no fistula is present. This is one of the few malformations where imaging does not show a fistula but the rectum is still relatively low.

The perineal exam in the first 24 hours determines whether the child needs colostomy or primary repair, predicts prognosis, and identifies surgical risks. The anatomy is usually visible if you know what you are looking for.

Takeaways from this story

A flat bottom indicates high rectum and poor prognosis; a normal midline groove suggests favorable anatomy.
Bucket handle malformation reliably indicates perineal fistula that can be dilated to decompress an ill newborn.
Wait 24 hours before surgery — meconium may appear through a tiny perineal fistula and change the surgical plan.
Black ribbon malformation parallels the urethra for a long distance, creating significant risk of urethral injury.
Physical exam alone determines anatomy in over 90% of cases; imaging is secondary to careful perineal inspection.

Topic overview

This educational discussion covers the clinical presentation and initial assessment of anorectal malformations (imperforate anus) in newborn males, occurring in 1 in 5,000 live births. The speakers emphasize that more than 90% of cases can be diagnosed by physical examination alone, with 95% of male patients having a fistula connecting the rectum to the urinary or perineal structures. Four main male presentations are described: rectal-urethral fistulas (identified by meconium passing through the urethra), perineal fistulas including bucket handle and black ribbon variants, and the rare no-fistula defect (5% of cases, associated with trisomy 21). The presence of a flat bottom without a midline groove indicates a high-located rectum with poor prognosis, while perineal fistulas can sometimes be managed by gentle dilation to avoid immediate surgery in unstable newborns.

Key takeaways

Physical exam alone diagnoses >90% of ARM cases; look for meconium in urine or perineal fistula variants. (2:25)
Flat bottom without midline groove indicates high rectum with poor prognosis; requires colostomy. (5:58)
Bucket handle perineal fistula can be gently dilated to decompress meconium, avoiding OR if baby unstable. (7:08)
Delay repair 24hrs to allow meconium passage through tiny perineal fistula, confirming anatomy before surgery. (9:50)
No-fistula defect (5% of cases) associates with trisomy 21 and typically sits at bulbar urethral level. (10:16)

Keywords

anorectal malformations imperforate anus rectal urethral bulbar fistula rectal urethral prostatic fistula rectal bladder neck fistula perineal fistula bucket handle malformation black ribbon malformation trisomy 21 coarctation anoplasty colostomy distal colostogram gentle dilation Cincinnati Children's

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Transcript

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Hey there listeners, this is Rod Girardo and Amanda Jensen from Cincinnati Children's. Have you downloaded the new version of the Stay Current Pediatric Surgery app? It's in the Apple App Store, it's in the Google Play Store. You definitely want it for this episode of the Colorectal Quiz because we have so many associated images that you're going to want to look at while Dr. Levitt and Dr. Frischer are talking about it. So download it today, but until then, enjoy the episode. Today we are going to talk about anal rectal malformations or imperforate anus. Amanda, how common is that? This is a congenital defect and it occurs in 1 in 5,000 live births. Okay, so what is it? It occurs when the anus, rectum, and nerves do not develop properly during fetal growth. And there are so many different anomalies that can pop up. Here's a few. It can be too small, it can be in the incorrect location, it can be absent, or it can be entering into other pelvic structures such as the urethra or the vagina. Awesome. So let's get into it. Without further ado, this is the Colorectal Quiz. There is a reference to a baby born with no anal opening and what to do about it from 2,000 years ago. That is Dr. Mark Levitt giving a history lesson about the Talmud, a specific reference to what to do when a baby is born without an anus. Then what should be done is you need to rub the area where the anus ought to be with oil and place the baby in the sun and then scratch it with a barley grain. That's probably the first medical description of an anoplasty. But I don't think we need a study to know it's probably not that effective. And I suspect all other patients who didn't have any way of getting the meconium out did not survive until more sophisticated surgical techniques came along. But we're not here for a history lesson. So Dr. Frischer, what are we going to talk about today? Anal rectal malformations in the newborn. And I love it because this episode is not just for the pediatric surgeon. This is for a broad audience. This is really relevant for neonatologists, pediatricians doing newborn exams. Of course, gastroenterologists. Don't forget the people like me, the general surgery residents, surgery residents who are interested in pediatric surgery. All of them need to know how to do a good newborn exam. The good news is more than 90% of these patients, their actual anatomy can be ascertained on physical exam alone. So that's what we're going to focus on. All right. So let's go ahead and get started. If you're listening to this in anything other than the Stay Current Pediatric Surgery app, that's okay. But if you're in the app, go ahead and scroll down under the media player. Look at the first image. Here's what they have to say about it. All right. So let's talk about, let's start with the male. What say you? What do you see in these pictures? Obviously, when you meet a newborn for the first time, you have to take everything into account. Focusing on the colorectal part and pelvic issues, the baby and picture on the left, demonstrates what I believe to be is a boy passing meconium through the urethra and out the meatus. Look, I'm not the best general surgery resident, but even I know that means there's a connection between GI tract and the urological tract somewhere. We know that when you take boys and the interrectal malformations and you try to categorize it, you could go from the most distal malformation being like a peroneal fistula. And then when you start attaching or connecting to the urogenital tract, you have connections to the urethra or to the bladder. Okay, so we have to figure out what kind of connection this is. These are usually categorized by the location on the urethra. So is it rectal urethral bulbar fistula, rectal urethral prostatic fistula, or rectal bladder neck fistula? If you're having difficulty visualizing exactly what Amanda's talking about, you need look no further than Auguste Rodin's sculpture of St. John the Baptist. The right arm is popularly used to describe the location of rectal urethral fistulas. Seriously, I'll put a link to the JPS article below. You know that 95% of boys have a fistula somewhere. The concept of imperforate anus is actually a bad term because they're all perforate. They just don't perforate into where they ought to be perforating. And the vast majority enter into the urinary tract. Okay, how about the second picture there? The second panel, so is a picture of a boy, a newborn boy, but you see a sort of flat bottom, maybe a sacral dimple. A little hard to tell. It's not at a great angle, but it looks like there's a little dimple, but no opening and no signs of meconium that I could see. Yeah, I agree. So you're sort of waiting in this case. Maybe the baby will pee some meconium. It's nice to put a little gauze to check the urine for particulate matter. I agree that bottom looks quite flat. I don't see any obvious peroneal fistula coming anytime soon. This is probably a baby with a rectal urethral fistula that has not yet declared itself. How about the treatment for these two, briefly? I think both these kiddos are going to need colostomies and then ultimately distal colostograms and then definitive surgery, which will be a subject of another podcast. As stated, the presence of a flat bottom, meaning absence of a normal midline groove, is usually associated with a very high located rectum and usually associated with a bad prognosis. All right, let's go to the second set of patient images. Again, if you're in the app, scroll down under the media player. There's a whole bunch of pictures there. Go to that second group of pictures. If you're at the art museum and you see this photo up on the wall, what does it say to you? Really questioning what kind of art museums Dr. Levitt goes to, but here's Dr. Frischer's response. It looks to be a clamp taking a bridge of skin where the anal area appears it should be or close to that area. This is a classic picture of a bucket handle malformation. Okay, so admittedly, this is really difficult to describe over audio. So please download the State Career Pediatric Surgery app. But here's my shot. So think of a bucket handle. That handle portion is the skin bridge. It's going basically from this patient's anus to their perineum along the midline. And there's a clamp under into that space. Bucket handle, you can be very confident that you have a perineal fistula. This is really important because you might have a baby that's too ill to go to the operating room. And you can be confident that right under that little bucket handle will be the perineal fistula. And you can gently dilate that to get meconium out and spare that baby a trip to the OR. If, let's say, they have a coarctation or something like that, that you don't want them going to an OR quite yet. And then you can do the definitive repair some other time. The perineal fistula in this case is obviously anterior to the sphincter's center, which you can see by a pinkish ellipse. The picture on the right, a great picture, and we see this often as well. This shows a newborn baby male. What appears to be a somewhat formed area that you could make out would be the anal sphincter complex area. But I'm guessing that there is no hole there, but I'd have to do a little bit more investigating. But within the scrotal raphe, you could see meconium traveling within the scrotal raphe. And there's one pearly bead. Sometimes you see multiple, which is the calcification of the meconium that is within the scrotal raphe. You can also be confident that this is a perineal fistula, but these are a little bit more tricky because that fistula parallels the urethra for a long distance. And when we get to the session on surgery, which is not today, it's very important to recognize that potential for urethral injury. And I don't think you have to go crazy finding that fistula. You just basically need to unroof that meconium and then find a healthy rectum and make an anoplasty. In images three and four, Dr. Frischer and Dr. Levitt are describing two different perineal fistulas. The first one being a bucket handle and the second being called a black ribbon malformation. Amanda, you're on a roll. Keep going. In the male patients with perineal fistula, one may see meconium coming out. In such case, the diagnosis is easy. The fistula is always located anterior to the center of the sphincter. So when examining these patients, it's really important to look closely for this opening. And no surgical repair should be done before the first 24 hours because a patient may pass meconium through the tiny orifice. And we should be able to identify their perineal fistula. So to summarize with a bucket handle malformation, usually one can find the fistula orifice underneath of that strip of skin that we call the bucket handle. We basically went through the scenarios in males. There's another scenario, and that is a no fistula. Quite rare. Only about 5% of cases. And not surprising if you had a trisomy 21 patient. But the no fistula defect is almost uniformly at the same level as a bulbar urethra. So in summary, today we talked about four different types of anal rectal malformations in males. As you can tell, there's a lot of variety, and that is why the physical exam is so important. Very well said, Amanda. That concludes this week's episode of the Colorectal Quiz. Dr. Leavitt and Dr. Frischer didn't leave us with a joke. So as your host, I'm going to take a little creative liberty here and give you guys a language lesson. What's the word for constipation in German? Anyone? Far from pooping. And with that, I think I've been hanging out with them for too long. Until next week, I'm Rod Girardo, and... I'm Amanda Jensen at Cincinnati Children's. And remember, knowledge should be free. I'm Amanda Jensen at Cincinnati Children's.

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