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Contrast Enema for Hirschsprung Disease

Video Published 2019-01-11 Updated 2026-06-10

Timestops (8)

Contrast Enema Technique for Neonates

Identifying Transition Zone on Imaging

Normal Contrast Enema Appearance

Hirschsprung Disease Radiographic Findings

Long Segment Disease Patterns

Case Study: Two-Day-Old with Meconium Delay

Rectosigmoid Index Limitations

Role of Rectal Biopsy

Topic Overview

A technical discussion of contrast enema technique for diagnosing Hirschsprung disease in neonates and infants. The speakers emphasize the importance of proper catheter selection (avoiding inflated Foley balloons that can obscure distal transitions), gravity infusion of hypertonic iodinated contrast (osmolality ~400), and early maximal distention imaging to visualize transition zones. A key teaching point is that radiographic transition zones in long-segment disease are unreliable—a case initially read as small left colon syndrome proved to be total colonic aganglionosis with terminal ileal transition. The panel debates whether rectal biopsy is mandatory even when contrast enema suggests benign diagnoses like meconium plug or small left colon; consensus leans toward biopsy in nearly all distal obstructions except clear meconium ileus with clinical improvement.

Key Takeaways

Use gravity infusion without inflated rectal balloon to avoid missing ultra-short segment Hirschsprung and distal transitions. (0:41)
Image early at maximal distention; delayed films distend aganglionic segments and obscure the transition zone. (1:31)
Proximal transition zones on enema are unreliable for predicting histologic extent—plan more invasive surgery when uncertain. (9:10)
Perform rectal biopsy for small left colon and meconium plug; radiographic appearance cannot reliably exclude Hirschsprung. (10:18)
Contrast enema is diagnostic only at ≥35-36 weeks gestational age; below this, colonic immaturity mimics pathology. (4:08)

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

Speaker 1 — guest
Speaker 2 — guest
Speaker 3 — host
Speaker 4 — guest
Dr. Pena — guest

Chapters

0:00Contrast enema technique for Hirschsprung diagnosis — Description of institutional technique: hypertonic iodinated contrast (osmolality 400), gravity infusion via rectal tube, lateral rectosigmoid imaging at early maximal distention, and AP imaging to terminal ileum if colon appears small.
2:43Normal anatomy and Hirschsprung variants — Image review of normal enema (rectum larger than proximal colon), ultra-short segment disease (easily missed with inflated Foley), rectosigmoid transition, long-segment disease to splenic flexure, and total colonic aganglionosis.
4:18Gestational age limitations — Discussion of minimum gestational age for reliable contrast enema: 35-36 weeks suggested threshold; younger premature infants have immature colons that do not follow diagnostic rules and overlap with necrotizing enterocolitis risk.
4:52Interactive case: small left colon vs long-segment Hirschsprung — Audience poll on 2-day-old with failure to pass meconium showing abrupt splenic flexure transition. Majority vote small left colon; case revealed to be total colonic Hirschsprung with terminal ileal transition, illustrating unreliability of proximal transition zones.
8:27Panel debate: rectal biopsy indications — Discussion of whether rectal biopsy is mandatory when contrast enema suggests benign diagnoses (small left colon, meconium plug). One panelist performs biopsy in nearly all distal obstructions; others would omit biopsy only in clear meconium ileus with clinical response.

Key claims

0:03Iodinated water-soluble contrast with osmolality approximately 400 is used, similar to colon prep agents — Speaker 1
0:21Hypertonic contrast helps make the diagnosis and attempts to clean the colon — Speaker 1
0:26Neonates can become dehydrated if contrast remains in the colon due to hyperosmotic effect — Speaker 1
0:41Gravity infusion from a bag with large-bore tubing is used rather than injection — Speaker 1
1:03Moderate-pace infusion (not slow) allows rapid visualization of distal and proximal segments to identify transition zone — Speaker 1
1:24Lateral rectosigmoid imaging is performed — Speaker 1
1:31Early maximal distention is best for seeing transition zone; delayed imaging can distend the aganglionic distal segment and obscure the transition — Speaker 1
1:51AP rectosigmoid image is obtained; if colon appears small in neonate, entire colon is filled with attempt to reflux into terminal ileum to identify other diagnoses — Speaker 1
2:0812-14 French Foley catheter is used in full-term neonates; smaller size in premature infants — Speaker 1
2:43Normal rectum is larger than proximal colon (toward splenic flexure) — Speaker 1
3:01Inflated Foley balloon positioned in distal rectum will miss ultra-short segment Hirschsprung every time — Speaker 1
3:15Tube without balloon should be used, or balloon should be pushed further proximally to avoid obscuring distal colon — Speaker 1
3:30Rectosigmoid transition Hirschsprung cases are usually concordant pathologically and radiologically — Speaker 1
5:51Rectosigmoid transition is located at approximately S2 vertebral level — Speaker 1
5:55Distal rectal Hirschsprung is distal to S1-S2; more proximal is typical rectosigmoid transition — Speaker 1
6:20Small left colon syndrome typically has transition at splenic flexure that is very abrupt — Speaker 1
7:54Rectosigmoid index (rectum larger than sigmoid) is a useful principle but insufficient—must image to splenic flexure — Speaker 1
9:10Proximal transition zones on contrast enema cannot accurately predict histologic transition location — Speaker 1
9:28Uncertain proximal transition should prompt more invasive surgical approach (laparoscopic or open) rather than transanal — Speaker 1
4:30Contrast enema is reliable for diagnosis at gestational age 35-36 weeks and above — Speaker 1
4:08Below 35-36 weeks gestational age, enema does not follow diagnostic rules due to colonic immaturity and overlap with necrotizing enterocolitis — Speaker 1
10:18Rectal biopsy should be performed in almost any patient requiring contrast enema for distal obstruction, including meconium plug and small left colon — Speaker 2
10:44Rectal biopsy may be omitted in clear meconium ileus with reflux into terminal ileum and clinical improvement — Speaker 4
10:58Rectal biopsy would not be performed if diagnosis is clearly meconium (ileus) — Dr. Pena
11:03Rectal biopsy should be performed for small left colon appearance because it cannot be reliably distinguished from Hirschsprung — Dr. Pena

Cases discussed

6:032-day-old male with failure to pass meconium, contrast enema showed abrupt splenic flexure transition initially interpreted as small left colon syndrome

Points of disagreement

10:00Indications for rectal biopsy when contrast enema suggests benign diagnosis
- Speaker 2: Perform rectal biopsy in almost any distal obstruction requiring contrast enema, including meconium plug, small left colon, and even meconium ileus
- Speaker 4: Omit biopsy in clear meconium ileus with reflux to terminal ileum and clinical improvement; perform biopsy for small left colon
- Dr. Pena: Omit biopsy if clearly meconium; perform biopsy for small left colon because cannot distinguish from Hirschsprung

Open questions

What is the optimal surgical approach (transanal vs laparoscopic vs open) when contrast enema suggests proximal transition but exact histologic level is uncertain?
Should rectal biopsy be mandatory in all neonatal distal obstructions, or can it be safely omitted in clear meconium ileus with clinical response?

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:

Contrast Enema Technique and Interpretation Pitfalls in Hirschsprung Disease

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

Foundational Technique: Hypertonic Contrast and Infusion Method

The contrast enema for suspected Hirschsprung disease uses iodinated water-soluble contrast with osmolality approximately 400, similar to colon prep agents 0:03. This hypertonic property serves dual purposes: it helps make the diagnosis and attempts to clean the colon 0:21. The hyperosmotic effect carries risk—neonates can become dehydrated if contrast remains in the colon 0:26. Infusion technique matters: gravity infusion from a bag with large-bore tubing at moderate pace allows rapid visualization of both distal and proximal segments to identify the transition zone 0:41 1:03. Slow infusion is a mistake.

Critical Timing: Early Distention Reveals the Transition

Early maximal distention is best for seeing the transition zone; delayed imaging can distend the aganglionic distal segment and obscure the transition 1:31. This principle contradicts the intuition that waiting allows better filling. The aganglionic segment is not a rigid lead pipe—it is soft tissue that will distend over time, erasing the radiographic transition that guides surgical planning.

The Foley Balloon Error That Misses Ultra-Short Segment Disease

An inflated Foley balloon positioned in the distal rectum to prevent leakage will miss ultra-short segment Hirschsprung every time 3:01. The solution: use a tube without a balloon, or push the balloon further proximally to avoid obscuring the distal colon 3:15. This is not a minor technical point—it is the difference between diagnosis and discharge with persistent obstruction. The normal rectum is larger than the proximal colon toward the splenic flexure 2:43; if the catheter balloon obscures the distal rectum, you cannot assess this relationship.

Beyond the Rectosigmoid Index: Image to the Splenic Flexure

The rectosigmoid index—rectum larger than sigmoid—is a useful principle but insufficient 7:54. Imaging must extend to the splenic flexure. Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt 6:20, and this can mimic or coexist with Hirschsprung disease. A case demonstrating splenic flexure transition radiographically proved to be total colonic aganglionosis with terminal ileal histologic transition 9:10. The radiographic transition zone proximal to the rectosigmoid junction cannot accurately predict the histologic transition location 9:10.

Proximal Transitions Demand Invasive Surgical Approach

When the contrast enema suggests a proximal transition zone, the surgical approach must change. An uncertain proximal transition should prompt a more invasive surgical approach—laparoscopic or open—rather than transanal 9:28. The transanal pull-through assumes you know where the transition is; when the enema shows a proximal transition, you do not know, and the histology may be even more proximal than the imaging suggests.

Gestational Age Threshold: When the Enema Lies

Contrast enema is reliable for diagnosis at gestational age 35-36 weeks and above 4:30. Below this threshold, the enema does not follow diagnostic rules due to colonic immaturity and overlap with necrotizing enterocolitis 4:08. The immature colon can appear uniformly small and mimic total colonic disease when it is simply premature. In this population, the enema cannot distinguish pathology from immaturity.

The Biopsy Decision: When Radiographic Clarity Is Insufficient

Rectosigmoid transition Hirschsprung cases are usually concordant pathologically and radiologically 3:30. The rectosigmoid transition is located at approximately S2 vertebral level; distal rectal Hirschsprung is distal to S1-S2 5:51 5:55. But when the enema shows small left colon appearance, rectal biopsy should be performed because it cannot be reliably distinguished from Hirschsprung 11:03. One discussant performs rectal biopsy in almost any patient requiring contrast enema for distal obstruction, including meconium plug and small left colon 10:18. Another would omit biopsy only in clear meconium ileus with reflux into terminal ileum and clinical improvement 10:44. Dr. Pena would not perform biopsy if the diagnosis is clearly meconium, but would biopsy small left colon because he cannot distinguish it from Hirschsprung radiographically 10:58 11:03.

The most emphasized point: the contrast enema is a guide, not a map. When it suggests proximal disease, prepare for the histology to be even more extensive than the imaging predicts.

Takeaways from this story

Inflated Foley balloon in distal rectum will miss ultra-short segment Hirschsprung every time—use non-balloon tube or position proximally
Early maximal distention reveals transition zone; delayed imaging distends aganglionic segment and obscures the diagnostic finding
Proximal radiographic transitions cannot predict histologic transition location—case with splenic flexure transition proved to be total colonic
Contrast enema unreliable below 35-36 weeks gestational age due to colonic immaturity mimicking pathology
Small left colon appearance requires rectal biopsy—cannot be reliably distinguished from Hirschsprung radiographically

Contrast Enema in Hirschsprung Disease: Technique, Interpretation, and Diagnostic Limits

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 trainees · Explainer · AI-written, human-reviewed

Why This Subspecialty Exists

Hirschsprung disease—congenital absence of ganglion cells in the distal bowel—presents as neonatal intestinal obstruction. The contrast enema exists as a distinct diagnostic tool because it can non-invasively identify the transition zone between aganglionic and ganglionic bowel, guide surgical planning, and distinguish Hirschsprung from mimics like small left colon syndrome and meconium plug. When performed correctly, it changes management. When performed poorly, it misses the diagnosis entirely.

The Core Clinical Problem

A neonate fails to pass meconium in the first day or two of life. The differential includes Hirschsprung disease, small left colon syndrome, meconium plug, meconium ileus, and in premature infants, necrotizing enterocolitis. The contrast enema attempts to answer: Is there a transition zone? Where is it? Can we see the terminal ileum to rule out other pathology?

The challenge is that the immature neonatal colon does not always follow adult radiologic rules, and several conditions produce overlapping appearances.

How the Approach Works

Technique

The discussants use iodinated water-soluble contrast with osmolality approximately 400, similar to bowel prep agents 0:03. This hypertonic solution serves dual purposes: diagnostic imaging and therapeutic colonic lavage 0:21. The hyperosmotic effect carries risk—neonates can become dehydrated if contrast remains in the colon, requiring close monitoring 0:26.

Gravity infusion from a bag with large-bore tubing is preferred over injection 0:41. Moderate-pace infusion—not slow—allows rapid visualization of both distal and proximal segments to identify the transition zone 1:03. The rationale: early maximal distention best reveals the transition, because delayed imaging can distend the aganglionic distal segment and obscure the very finding you are seeking 1:31.

Lateral rectosigmoid imaging is performed first 1:24, followed by AP imaging 1:51. If the colon appears small in a neonate, the entire colon is filled with attempted reflux into the terminal ileum to identify alternative diagnoses 1:51. A 12-14 French Foley catheter is standard in full-term neonates, smaller in premature infants 2:08.

Catheter Positioning: A Critical Technical Point

An inflated Foley balloon positioned in the distal rectum to prevent leakage will miss ultra-short segment Hirschsprung every time 3:01. The balloon obscures the distal colon. Use a tube without a balloon, or position the balloon more proximally 3:15. This is not a minor technical detail—it is the difference between making and missing the diagnosis.

Interpretation

Normal anatomy: the rectum is larger than the proximal colon toward the splenic flexure 2:43. Rectosigmoid transition Hirschsprung—the most common variant—shows a transition at approximately the S2 vertebral level 5:51, and these cases are usually concordant radiologically and pathologically 3:30. Distal rectal disease lies below S1-S2; more proximal transitions are typical rectosigmoid variants 5:55.

Small left colon syndrome typically shows a very abrupt transition at the splenic flexure 6:20. Long-segment Hirschsprung extends to or beyond the splenic flexure. Total colonic aganglionosis presents as a uniformly small-caliber colon without a clear transition.

Where the Method Breaks Down

The rectosigmoid index—rectum larger than sigmoid—is a useful principle but insufficient. Imaging must extend to the splenic flexure 7:54. The discussants presented a case with an abrupt splenic flexure transition that appeared radiologically to be small left colon syndrome. It proved to be total colonic Hirschsprung with the histologic transition in the terminal ileum 9:10. The lesson: proximal transition zones on contrast enema cannot accurately predict the histologic transition location 9:10. When the transition appears proximal, this should prompt a more invasive surgical approach—laparoscopic or open rather than transanal—because you cannot reliably know where ganglionic bowel begins 9:28.

Gestational Age Limitations

Contrast enema is reliable at 35-36 weeks gestational age and above 4:30. Below that threshold, the immature colon does not follow diagnostic rules, and findings overlap with necrotizing enterocolitis 4:08. In very premature infants, the enema may be technically feasible but diagnostically unreliable.

Where Practice Is Contested

The panel debated whether rectal biopsy is mandatory when the enema suggests a benign diagnosis like small left colon or meconium plug. One discussant performs biopsy in almost any distal obstruction requiring contrast enema, including meconium plug and small left colon 10:18. Others would omit biopsy only in clear meconium ileus with reflux into the terminal ileum and clinical improvement 10:44. Dr. Pena would not biopsy if the diagnosis is clearly meconium but would biopsy for small left colon appearance because it cannot be reliably distinguished from Hirschsprung 10:58 11:03.

This is not academic. The case presented as small left colon was total colonic Hirschsprung. The enema can mislead.

When to Involve This Team

Refer for contrast enema when a term or near-term neonate (≥35-36 weeks) fails to pass meconium in the first day or two of life and distal intestinal obstruction is suspected. Do not rely on contrast enema alone in premature infants below 35 weeks. If the enema shows a proximal transition zone or equivocal findings, involve pediatric surgery early—the radiologic transition may not reflect the histologic one, and surgical planning depends on knowing the limits of the study.

Takeaways from this story

Inflated Foley balloon in distal rectum will miss ultra-short segment Hirschsprung every time—use non-balloon tube or position proximally
Proximal transition zones cannot accurately predict histologic transition location; splenic flexure transition may be total colonic disease
Contrast enema unreliable below 35-36 weeks gestational age due to colonic immaturity and necrotizing enterocolitis overlap
Early maximal distention best reveals transition zone; delayed imaging distends aganglionic segment and obscures the finding
Small left colon syndrome cannot be reliably distinguished from Hirschsprung on enema alone—rectal biopsy recommended

Keywords

Hirschsprung disease small left colon syndrome meconium plug syndrome total colonic aganglionosis necrotizing enterocolitis meconium ileus ultra-short segment Hirschsprung long-segment Hirschsprung rectosigmoid Hirschsprung contrast enema rectal biopsy suction rectal biopsy transanal approach laparoscopic approach posterior sagittal anorectoplasty

Hashtags

#HirschsprungDisease #PediatricRadiology #NeonatalImaging #ContrastEnema

Transcript

To describe a little bit about our technique. Our techniques are very similar. We use an iodinated contrast. It's a water soluble contrast. It is a little bit hyper osmotic, and a lot of the radiologists in particular aren't really aware of all the osmoalities of all the different contrasts, but the one we use is about 400. So it's all, it's very similar to these agents that you use to clean the colon out. So not only does it help to make the diagnosis. But it also will attempt to clean the colon. And in the neonates, it's important to know that, uh, because if the contrast does stay there, uh, the, the little babies, the little neonates can get dehydrated and then they could have run into trouble. And so we make sure that the, uh, the floor, the neonatal ICU knows that. In any event, we use a rectal, uh, a rectal tube in the neonates, um, we tend, and I'll show pictures of them, uh, we use gravity infusion rather than injection. I'm not sure if it really matters a whole lot, but we use a gravity gravity drip, not from a bottle, but from a bag that has very large IV, very large tubing. And actually we get actually infuse the, the fluid at a rate that's not really slow. It's actually a moderate pace to actually show the distal part and the proximal part quickly so that you can actually see a rapid, a rapid picture of the of the transition zone. I feel that that's, you know, fairly important. We do the Lateral rectosigmoid image in the lateral view, as does my, uh, my colleague in Chicago. 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. We get an AP image of the rectosigmoid, uh, and again, if the colon and the neonate looks small, we actually fill the entire colon and attempt to reflux into the terminal ileum to make other. Diagnosis, uh, if they are there. Here's the patient in the left side down position, as you can see there. There are the tubes. In a neonate. I tend to use a Foley catheter in a full-term infant, about 12 to 14 French, and in a premature infant, if it's are a little bit premature, a little bit less, um. Here's a normal contrast enema for your, for an example. You can see the nice, well distended rectum. The presacral space is well seen. And why is it well seen? Because the femurs are on top of each other. It's a true lateral image, and you really would like to attempt to get that. Then we get a frontal view, as you can see here, all the way down, making sure that you do see the tube, but you also see a little distal to it. You don't want to cut off the rectum to miss a very distal transition. transition zone, a very distal Hirschprus, but notice that the proximal colon is much always a little bit smaller here in the toward the splendid fletcher than the rectum, and that's a normal appearance. Here's a Hirschsprung disease patient, or at least an enema that reflects Hirschsprung's disease. Note that you can see a very short segment. And if 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. And that's how sometimes the diagnosis of Hirschsprung disease is not made. They consider this rest of the colon a normal size, and it's negative. So you have to make sure you use some kind of a tube that doesn't have a balloon on it. Or at least when you have the balloon in, push the balloon in a little further so it doesn't block the end of the colon. Here's the left side. On the right side here, here's a rectosigmoid transition, the typical rectosigmoid Hirschprung's disease. These are usually concordant pathologically and radiologically. Now here's a patient who has long segment disease. Note that the rectum is very small. Here's the Foley catheter blown outside and held up against the recti anus to prevent the leakage. And you can see that there is actually a very, very small, irregular, spastic type of colon to the level of the splenic flexure. And here's total colonic Hirschsprung's disease. The rectum does look pretty small. It's not bigger than the rest of the colon like it should be. And so this, when you see a colon that's one smallish size all the way through, you have to think about total colonic disease. But you could say, well, if this is a little bit of a premature infant, it's just immature, it could be. And actually the enema in a in a in a premature infant does not follow the rules. It could be immature and look small, so you really can't tell the difference. What age would you go down to to do or size would you go down to to do a contrast enema? Well, we can do contrast enemas in even young premature infants. That would be worthwhile, that would actually give you a reasonable result. Um, I 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. I'm looking at this contrast, Emma, where's the transition zone? Is it proximal 1 or distal 2? So you're going to get a poll to vote. That's Rectosigmoid, descending column, transverse column, ascending column. Everybody can vote. And we have more than now we have a oh now we changed. So actually while we're putting the pole up, could you go back and show that film again? OK, so here's the enema. It's in a right lateral position. It's not left lateral, but here's the enema and So we have 90% saying rectosigmoid. Well, that's good because that's where it is. That's where the radiographic one is, right? So here you can see that there is a transition at the rectosigmoid. The rectum and sigmoid transition is about S2 or so. So if it's a distal in the rectum, it's going to be distal to S1, S2. If it's more proximal than that, then that's the typical rectosigmoid transition. Um, now, here's a 2 year old male, I'm sorry, a 2 day old male with failure to pass meconium, and here's an enema. So There's the lateral view And there's the frontal view. So what do we call this one? Now remember too that there are other diagnoses, and one of the other diagnoses in a patient of this age is small left colon. Usually their transition is at the splenic flexure, and usually it is very abrupt, like this case. So what does everybody think? Actually we don't have the the pull for that. So actually, why don't we say, do we think this is, I can make one right now. So what do we do we think this is small left colon or meconian plug syndrome, or do we think this is Hirschsprung's disease at the splenic flexure, which is a long segment. So maybe long segment versus small left colon. OK, because this is instructive. And it actually it look, it looks at the principle of is the transition zone accurate in long segment disease. 1, small left colon. 2, meconium plug. Oh, OK. And then long segment disease, is that OK? I can change it. That's good. OK. And we have people voting in all options. Good. Looks like the majority is seeing small colon. Yes, and, and that's, that's what I thought, right? Right. That's the, that's the radiologic, um, dogma is a picture like this. This is a slam dunk, OK. And if you look at the lateral view. The rectum is or isn't bigger than the sigmoid. This is a good point about the rectosigmoid index. Is the rectosigmoid index always good? And I say no. I mean, it's, it's a good principle. If you have a bigger rectum than sigmoid, it's probably normal, but don't stop there. Go all the way up to the splenic flexure. And in this particular case, this patient. Has what has a small rectum on the scout, a small colon to the splenic flexure, and meconium plugs. There's meconium plugs in there, so this is small left colon. Well, is it? No, this was Hirschsprung disease. In fact, can you tell me where the histologic transition should be? So based on that picture that we just saw, This picture, where do you think the transition is? Is it here or is it somewhere else? So a lot of people are saying the transition is at the splenic Fletcher. OK. And actually a lot of, well, actually, About half the people are saying proximal to this planet Fletcher. Well, actually, that's pretty good. OK, so here's the picture. The answer was that this was total. colonic a ganglionosis and in fact the transition was in the terminal ileum. So I 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. And I'm not sure how they booked this case, if they did it transantally or if they did it an open procedure or laparoscopically, but I do know that it was a transition zone that was much more proximal, and I think that would make you. Uh, should make you think about doing something that's more invasive rather than just the transianal approach because you really might not know where it is. And actually, actually, as, uh, Dr. Collins was saying, is doing, uh, biopsies and going through the colon, uh, maybe even, you know, the laparoscopic approach would have been good probably for this case as well, right, uh, Todd, right. But can I ask the panels, if you get a, and we get this every once in a while, you get a contrast sentiment and it looks like small left colon. Is anyone going to not perform a rectal biopsy? I always do. So other than the game of am I right at getting question, can I make it even more broad? I would do it. I do it in almost any distal, any patient that needed a contrast enema. To rule out a distal obstruction, I'm going to be doing a suction rectal biopsy, whether it's a meconium plug or a small colon. Or whatever it is, I'm going to, I'm going to be doing a suction rectal biopsy. What about Maconium ileus? Even meconium milius. Yep, definitely. Would you not? I see a blank stare. I think if it's clearly a case of meconium ileus and you reflux into the terminal ileum and you're able to get a response and the patient clinically improves, yeah, I'm not going to do it. I haven't done a rectal biopsy. Dr. Pena, any thoughts? Perhaps I would not do it if I'm sure that it is meconium. I would not do it. But what about a picture of a small left colon? Would you always do a, I would do a biopsy. I would do it because I, I, I don't know how to distinguish this from this one.

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