So first I just wanna clarify the difference between uh true fecal incontinence versus pseudo fecal incontinence with overflow. It's very important to know the difference because the treatment that you're going to give to each patient is completely different. So this, Presentation is gonna be very short and then we're gonna go to the case presentations. So patients that suffer from true fecal incontinence are those that do not have the ability to have bowel control, either because they were born this way or because it was acquired. Patients with congenital true fecal incontinence, patients that were born with myelomeningocele, large sacrococcygeal tumors, patients with absent sacrum, and the anorectal malformation with bad prognosis for bowel control that we have already discussed, bladder neck fistula, complex cloaca, sacral ratio of less than 0.4, presacral mass and tetrachord. So here you can see an X-ray film showing an absent sacrum, as the patient comes to the clinic, all patients have the same complaint, they will all tell you that they are truly fecally incontinent, and it's your job as the clinician to determine if this patient is true fecal incontinence or not. And just with this X-ray, you can tell that this patient is truly fecal incontinent because there is no sacrum. Here is an MRI that you can see that the patient has a large presacral mass and I can show you here with the arrow. Here's the presacral mass so you know that this patient will also be a true fecal incontinence in patients that. Have a pre-sacral mass. Usually upon inspection of their anus, we can see this image that we like to call a funnel anus. It almost looks like that the skin is more inside than usually. And the explanation for that is that the presacral mass is actually pushing in the column and that, that's the reason why the anus looks like someone is pulling from inside, and this is as we previously mentioned, bad prognosis for bowel control. Acquired through fecal incontinence, those are the patients that were operated for Hisprung disease and now they have a damaged anal canal or patients born with anorectal malformation with good prognosis for bowel control, but unfortunately, they received a bad operation and had complications like the hissing and had to be re-operated and therefore they were changed from a good prognosis to now a bad prognosis for bowel control. So here's an image you have already seen of patients with damaged anal canal. You can see that the mucosa was anastomosis to the skin. So this patient suffers from true fecal incontinence. Here's another patient you can see a more petullose anus and you can see a severe diaper rash. This patient suffers from true fecal incontinence. Here you can see in a case of anorectal malformation in which there was the hisscence, the anus is mislocated. This patient needs re-operation. They suffer also from fecal incontinence. And my image is frozen, can you pass? So when you detect that the patient has true fecal incontinence, the treatment for this patient is enema. It's an artificial way to clean the column and to avoid bowel movements during 24 hours. Now when the patient suffers from pseudo fecal incontinence, those patients are the ones that have ability to have bowel control, but they suffer from constipation. The group of patients that belong to pseudofecal incontinence are anorectal malformation with good prognosis for bowel control. They have a good operation, patients that suffer from severe idiopathic constipation, and some patients with Hiprung disease that, Received a good operation and have an intact anal canal. Next. So those patients we just have to treat their constipation. Once we achieve the adequate amount of laxative, they will empty on a daily basis and they will be clean in the underwear. Next, that's the last slide. So now we're gonna move to the case discussion and I ask the panelists, our panelists to be present again. Because now we're gonna see if the audience knows how to differentiate between a patient that suffers from true fecal incontinence and a patient that suffers from pseudo fecal incontinence. If, while we are bringing the, the presentation, if there is any question, please just type in and we will try our best to answer. So the first case is a 6 year old male patient born and operated due to rectal bladder neck fistula. He had a good surgical repair, has a sacred ratio of 0.3, and no tetrachord. The question is, what does this patient suffer from? Is it true fecal incontinence or pseudo fecal incontinence? And everybody can please answer. I see many people already answered. Looks like we're getting a lot of ones. I think they know everything. Maybe we can just finish the show and go home, very good, so we're gonna, the answer is the true fecal incontinence. Remember if the patient has a sacred ratio of less than 0.4, that's fecal incontinence, very good, so the treatment is enemas for this patient. The next one is a 4 year old female patient born and operated due to perineal fistula. Had a good surgical repair, sacral ratio 0.8, no tetrachord, suffering from constipation. What does she suffer from? True fecal incontinence, pseudo fecal incontinence, or emotional disturbance? Just give a minute for the uh the studio audience to wait, OK, we're getting a lot of 2s, everyone's saying 2. Monica, do you agree? I agree. Very good. So this patient suffers from pseudo fecal incontinence, that's constipation and overflow soiling, so the treatment is laxative for this patient. So we're gonna change to the next one, a 3 year old male patient born and operated due to Hisprung disease. On exam under anesthesia, he has a destroyed anal canal and he has a normal sacrum. So what does this patient suffer from? Pseudo fecal incontinence, true fecal incontinence, hypermotility or enterocolitis? And we're getting all the answers. So, all the 2, we're getting all 2s. Do you agree? You think people are right? Do you think they're right, Todd? I agree. Very good. I have a question for you. Um, there was a question back when the previous question, uh, about does Release of the tethered cord or removal of the presacral mass improve the continence. So no, removing the presacral mass does not improve the continence because what is related to the continence is the sacral defect, so the nerve damage that was produced before. So what the mass causes is a compression in the rectum, so sometimes it improves a little bit the constipation, but that's not the reason why we operate the patient. So it doesn't change the prognosis for bowel control. And let me say the patients have mass, the degree of compression they produced on the rectum is variable. If the compression is very severe and the patient has a rectal stricture, removal of the sacred mass doesn't cure the stricture. The rectum doesn't distend. The rectum is congenital stricture and you need the removal of the presacrald mass, resection of the stricture area and pull down of normal rectum. So don't expect that the patient operated. Uh, removing the sacred mass is going to become continent, doesn't become continent. Don't expect that the constipation is going to be cured because the constipation is consecutive to the nerve damage. Then the question is why to resect the presacral mass? Well, the presaccular mass must be resected because Uh, most of them are their moist, teratomas, lipomas, or anterior meningocele or a combination of all of those, but we have seen patients that had a persistent mass that was never resected and had an episode of infection that produced severe meningitis and other problems, so it must be resected, and we have two patients that the masses actually were malignant, so the mass must be resected anyway. And if you need an MRI to be sure that there is no connection with the with the dura. Because if there is an anterior meningoce component, you have to join forces with a pediatric neurosurgeon to remove the mass. Now, the question about the tetrachord, I'm going to ask my panelists to help on that because you will see that there are big. Difference depending on which country you are, regardless, uh, regarding operation for tetracord. I know here in the United States if they detect a tetracord they do, uh, release the cord, but we don't think it improves bowel control. So, uh, Ramon, can you, can you hear us here? Ramon Ruiz. OK, uh, let's try Ernesto Leva, can you hear us? Yes, can you hear me? Yeah, how do you deal with the tethered cord? Um, more than the, the work initially is divided into two groups. In our center we don't, uh, ask for surgical treatment until the time uh symptoms come. That means we usually don't operate and treat the score. When I was working before, uh, the other group of neurosurgeons operate on the score. I have no answer. In my point of view, I agree with the fact that that doesn't make any difference in terms of continent. OK, Michael. In our institution, our pediatric neurosurgeons are fairly aggressive. I think their bias is that it may help more with bladder function, and I don't think it helps with anorectal function personally. I agree with, uh, with the other, discussants, but some people think it has more utility for, um, bladder function, although I kind of think that getting the constipation under control is almost as equally important in that situation. All right, Ramon, are you back on here? Yes, but I didn't hear the question. Question is how do you deal with tethered cord in Spain? OK, we talked with the neurosurgery, neurosurgeon, so. But I think we haven't had any any case in almost 5 years. Good. All right, OK, so we're gonna move to the, can I make a, can I make a question? Yes, have a nice one. Good. Can I ask you the question is, uh, in your center and to you, Andrea, and uh opinion, in your center, do you prefer if you have a set of score always a eurodynamics that is at 0.0, and then you start to check the follow up. I couldn't understand anything. I just understood the word tetrachord and urodynamics. The question is, do you test for eurodynamics? We usually, we usually perform a urodynamics study when you've got a tetra score, yeah, yeah. Actually, the neurosurgeon only sees the patient if the patient has a urodynamics performed in our center. I'm very skeptical about the whole issue. I think it's one of the most, uh, Controversial issues that we, we, we deal with and our parents agonize asking questions about the test cord and we don't have the answer and I don't think anybody has the answer. I don't think there are really scientific approach to this problem. I have seen neurosurgeons. First of all, there are degrees of te cord. Some patients have a teta cord that I can diagnose with an MRI. Some of the patients don't have tete cord, but they have a fixed cord. And even when it's not located, the corus is not located very low, some neurosurgeons operate. I have seen patients that one neurosurgeon says to operate, the other one says not to operate. I have seen patients that have been operated for tetecor 5 times. I have patients that have tetacord that had never been operated, and they play soccer. They have bowel and urinary control. So as far as I'm concerned, we need a serious scientific approach to this controversial problem. And also we have evidence that in, in countries with socialized medicine. The neurosurgeons operate much less ethical than in patients where the neurosurgeons get paid for operations. So that tells you something about ethical and not ethical. All right. There's, there's probably about 7 or 8 questions. I don't know if you want to go to those now or do you want to keep going? Sure, let's go. OK, I like that. So, uh, the next question was about, um, the diagnosis of, let's see here, um, how does, how does one approach a hypertonic anus in post-op Hirschprung's disease? That's coming from Saudi Arabia that that that question about hypertonic anus is a manometric question because the the the person who asked that question is a person that that works with a gastroenterologist that does manometry and believes manometries. So we don't deal with that, that's why we don't do manometry, so I don't know what to do about that. We don't believe that exists. Tight ass occurs not only his disease but in in other offices, you know, bureaucrats, offices, lawyers, doctors, every day, every, everybody has the right to have a tight ass, right? Amen. We got, we got lawyers in the room that that can be, uh, that have, I don't know what you think about lawyers can have a tight ass or not, but, uh, all right, we got a lot more questions here, um. So, uh, we have, it says here, this is coming from, it's in Spanish and it's translated into English here. Uh, so it says we have 3 of these, we resect the mass. The 3 were operated on by the neurosurgeon. So my guess is this is tethered cord, but we didn't, um, re, resect the stenosis. We made several plasties for making it wider, the stenosis, but the stenosis was just in the, uh, pectiny, the pectine line. Uh, and the dilations were like an anorectal malformations they did after that. After some months, we resect the sigmoid, uh, in two for the constipation, but they are, they are continent and one we are waiting because it's only a few months old. So that was a comment, uh, from Doctor Vasquez. Um, it's a consultation. It is. Uh, is this cure when we're talking about the sacral malformation, the presacral mass, and the inner rectum malformations, is this not curorino? You can call the Corino triad. For the Corino triad, you need the tree. You need the anorectal malformation. You need the sacral defect, and you need the pre-sacral mass. So we have seen. Pre-sacral mass with sacral defect without the anorectal malformation. We have seen anorectal malformation pre-sacral mass in normal sacrum. So that's why we don't necessarily use the curarino triad, but you can use it. That's exactly what we're talking about. And also the curarino is defined as he sacrum. And rectal malformation and and pre-sacred mass. When the pre-sacred mass is in the center, you don't have a hemisacrum, you have a bified sacrum, and that's why we don't like, first of all, we don't like eponymous, and second, we don't use that terminology. It's important to say presacred mass, the location of the sacred mass, the size of the pre-sacred mass, and the usually associated with te core. OK. Do you want to go on. So the next question a 5 year old male patient born and operated due to a giant sacrococcygeal teratoma. What does this patient suffer from? Pseudo fecal incontinence, through fecal incontinence, hypermotility, or emotional disturbance? Everybody can answer. Maybe while we're waiting for the the audience to answer, we can go to some of the panelists and see what their thoughts are. Sure. Who wants to talk? Stephanie, are you back? Dr. Alshaus wants to talk. Go ahead, Michael. Yeah, doc, I always want to talk. So I, I think, I think sometimes there's a combination of both things in here depending upon how big it was, how well the operation was performed, and how much innervation problems there are, whether it was a different type, an external like a Type 1 versus a Type 4. So I think you can get both one or two. So I think that's almost like a trick question. That's a good answer. Usually when that's why I put the word giant when it's a giant sacrococcygeal tumor in long term those patients have bad prognosis for for bowel control, so they are fecally incontinent, but there are patients with sacrococcygeal tumors that are continent. That's true, but I put the word giant so we would avoid the confusion. Well, in some, and I agree, but sometimes the giant ones have a really narrow stalk and, and a different attachment. So that's, that, that's a little bit, there's a little bit of a gray zone there. I, I've had a type 3 sacrococcygeal teratoma that was quite large, and the patient is, you know, suffering more from constipation than actual fecal incontinence. So I don' I think it's an absolute. Very good. So the next one is a 10 year old female patient complaining of fecal incontinence. Normal sacrum, no tetrachord, and that's the contrast enema. So be ready to answer. What does she suffer from? True fecal incontinence, poor fiber intake, overflow, pseudo fecal incontinence, colonic hyper hypermotility, or milk allergy. Anybody wants to comment? Jeff, do you want to comment? We're getting a lot of 3s. All the faculty are writing 3s. Very good. And so is the viewing audience. 3s. Very good. That's the correct answer. It's a patient that simply suffers from constipation and overflow, so the answer is number 3. Very good. Now the next one is a 12 year old female patient with myelomeningocele complaining of soiling in the underwear. So here is the contrast enema. Any of our faculty want to comment on this contrast enema? Anything that is different in patients with myelomeningocele that you usually observe? Maybe while we're waiting for a second, or go ahead, someone was going to say something, and then I want to address Ernesto's question about the anatomy. A lot of times these patients, a lot of the times these patients are contrast enemas look almost normal, uh, if not redundant, the colon. They're not typically dilated. So what we see is that the myelomeningocele patients, they don't have the dilated colon. They sometimes have redundancy, but they don't have the dilated colon, even if they suffer from fecal incontinence but severe dysmotility, so they are constipated and fecal incontinent. Ernesto, what was your, what was your comment or question about the anatomy? the question of anatomy was of the previous case, not this. Right, right, right. My concern, I didn't understand if it was a visa or whatever or only a piece of the continent. Yeah, can you speak, say that a little louder there again, Ernesto. Yeah, I told, I didn't understand, probably, probably I missed the point. I didn't understand that it was the previous piece of repair or something else. On the previous patient, so let me go back and see what's the previous patient because I don't even remember this one, this one, no, the patient was normal. She just comes to you complaining of fecal incontinence because that's the way the patients come to us to in clinic and saying that she was fecal incontinent but she had a normal sacrum and no tetrachord. No operations. OK, so can I ask the panelists how many of them believe in the diagnosis of, uh, NID NID. How many of the faculty, believe in the diagnosis of NID? This is going to open up a neuronal intestinal dysplasia. It's going to open up a whole I don't believe. So, so let's ask. Andrea. So I don't believe, I think if we give, if we give biopsies to pathologists all over the world, you're going to come up with many diagnosis and everything is going to be different. I, I don't believe. But in addition. In addition to that, that, uh, Andrea said there is not a single study that is uh that I call topographic study of neurointestinal dysplasia, you know, we surgeons. Use the histologic diagnosis to determine what part of the bowel is sick and what part is not sick, so we can go ahead and remove that part that is abnormal and preserve normal bowel. There is not one topographic study. There is not, nobody ever published the neuronal dysplasia goes from here to here and therefore has to. Be resected and there is no standard treatment for this. There are many confusing reports. Patients that have so-called neuronal dysplasia that did not receive any treatment and got better. Patients that have a colostomy, patients that receive laxatives, patients that had an arbitrary resection. So it's a, it's a chaos that that diagnosis. Somebody's complaining about background noise. It's actually George. Uh, Doctor Sassa, I think we're hearing some background noise from your phone. OK, uh, why don't we, uh, move on to the next one. OK, so let me advance the slides a little bit because we went back from one question. Whatever you guys did that helped, the background noise is gone. So this is a 15 years old female patient with anorectal malformation, unknown type complaining of fecal incontinence and that's the X-ray. So take a look carefully in this X-ray and try to predict if this patient will be fecally continent or fecally incontinent. And then you can answer what's her problem overflow, pseudo fecal incontinence, low transit constipation, true fecal incontinence, hypermotility, or what I'm sure Dr. Finger will choose poor pubor rectalis tone. So people are answering and everybody's saying 3. People are very good. I'm impressed. Everybody knows everything. Congratulations. Andrea. We have a question that you might choose to just put off till later, but there's a question from Tom Curran, who I just saw at ABSA. Hey Tom, uh, he says, does anybody do rectosigmoid resection for severe chronic functional constipation with mega rectum but normal anatomy? So we leave, that's a very good question, we're gonna actually talk about that during the treatment of constipation but just briefly, um. With our protocol of determining the amount of laxative that the patient needs, 85% of the patients respond and do well just with laxatives. Now, this 15% that does not respond to laxatives, we offer them a sigmoid resection in desperation because we don't have anything else to offer. And the results are variable, we have 50% improved. And the other 50% does not improve, so it's very important to discuss with the family and explain that that the operation is a trial, but we do not have uh specific results depending on how much we resect. And this should be always your last resource. First, just remember that the majority of the patients do respond to our laxative protocol and we will go into details on how we do our laxative protocol later on today. So the next case is an 8 year old male patient born and operated due to Hisstrong's disease complaining of constant soiling. Here is the contrast enema and in the examination under anesthesia there is an intact anal canal. So look carefully, try to determine what type. of operation this patient has and let's try to answer the question. What does he suffer from? Aalagia of the internal sphincter, neuronalintestinal dysplasia. There you go, Ernesto. Overflow pseudo fecal incontinence, through fecal incontinence or hypermotility. So anybody, any of our faculty or panelists, do you want to comment on what operation this patient had? Just by looking at the contrast enema. Swab, does it, does it make sense to make a biopsy on that body it looks like a swab potentially. Anybody else has a different opinion, Dr. Ernesto Saraoave. Sorry, say again. It It's possible from the films that this patient had a Duamel procedure too. It's really hard to tell, um, but they tend to have some constipation and, you know, retained fecal material in the rectum. So this image, it shows a giant Duhamel pouch. You can even see the staple line. And those patients usually suffer from constipation. So the answer here is what everybody answered, and I see Doctor Anna Pala said do Hamel operation. Very good. And the patient suffers from 3, overflow, pseudo fecal incontinence, and we just have to treat them with laxatives. Very good. So I think that's the end of the case discussions and we are ready to move to our next talk on bowel management with enemas unless we have any questions from the audience and we will be happy to answer. Otherwise we're gonna move to our next talk and that's one of the most important ones because we're gonna explain you the basics on how to determine the enema and how to play with the enema to get the patient clean in the underwear. Any questions? Well, there was a question back when Tom Curran, you answered Tom Curran's question about resecting the uh rectosigmoid. He asks, I'm going back here now, um, Uh, for those that you were sick, do you do a transanal procedure? So we're trying to stay away for the using the Tranzano for idiopathic constipation. We have used but we were afraid because some of our patients had a transient period in which they were fecally incontinent. And if you can imagine a patient comes to you complaining of Constipation and at the end you do an operation and he ends up being fecal incontinent, I think that's the worst result that you can possibly have. So currently we are not doing transanal for idiopathic constipation. So, I have a question from Laurie Compton that I'm going to field first to Monica. It says how much is too much laxative? So, I don't, are you touching on the laxatives? Yeah. Do you want to put it off till later or do you want to answer it briefly now? So, um, We believe there is not too much. Uh, we want to see the patient respond. So how we find the dosing is we make sure that the patient responds. Um, too much would be if the patient is symptomatic. So if we have reached the amount of laxatives that empties the colon and Doctor, We'll probably go into it, um, more in depth. Um, but the patient is symptomatic with too much cramping or nausea, vomiting. Um-hum. Then that is the point we have reached too much. Right. Now, I, and so I, I have other questions about this, and if you want, I'll hold off till the laxative. About the laxatives? Yeah, we can wait. We're going to talk a lot about that. OK. Yes, yeah, we have a few more questions, um, can you please comment on alagia of the anal sphincter? Is that alacia of the anal sphincter is another manometric concept. So if you believe in manometrics, you believe in calasia. I don't believe in manometrics, so I don't believe in calasia. And another thing is that calasia is defined as a lack of relaxation of the internal sphincter. Internal sphincter is another monometric concept, is not an anatomic concept. If you see the anatomy of the internal sphincter, please show it to us because I'm desperately looking for that mysterious structure. So this is something similar to the lower esophageal sphincter. Those are, those are functional concepts, but not necessarily anatomical. So it's, uh, if the calacea is the manometry makes the diagnosis of calasia when they inflate the balloon in the, in the colon. And they expect a relaxation of the, the drop of pressure in the anal canal. If there is, that's called relaxation reflex. When there is no relaxation and the patient has normal ganglion cells, then they call that alasia. Uh, I don't believe in that diagnosis. I just saw another question about the presacral mass. If it should be resected before the posterior ser, it should be resected during the posterior serial. That's the best approach to actually, uh, remove the mass. So, so here's what's fun, uh. This is how this conference is a little different than others. We love that this is two-way learning and three-way interaction. So Kamalesh Powell, you want us to poll the audience about this allaia or you keep about the, the high-toned anal sphincter. Go ahead and write down what poll you want us to ask. If anyone in the audience wants us to ask the rest of the audience a poll, write it down and we'll go ahead and put it up there. Uh, so, uh, we'll wait for that when you send in your, your comment. You wrote that the children are symptomatic with very high resting anal tone in addition to the lack of relaxation. So, uh, I, I think that's been addressed enough. I, I don't know if you want to address it anymore or we can just move on. Um, OK. I think we can. OK, so, so we're gonna move now to a very important portion of this talk that is, uh, how to treat a patient that is fecally incontinent and um hopefully by the end of the talk you'll totally understand that. So this I know you have, we have already discussed the patients that will need enemas, you already know because you've been answering all the questions correct, so I'll just move to the next slide because you already know. So once the patient comes and you determine that this this patient is fecally incontinent, the first study that we do. Is a contrast enema and just with a simple contrast enema without bowel prep because we want to see the characteristics of the column, we did we determined that there are two groups of patients, those that are fecally incontinent and have a dilated colon, meaning it's a column that moves very slow. And those that have a fely incontinent but have a non-dilated column. Just by looking at the image, I know that this is a column that tends to constantly move. It's a hyper modal column. So we divide those two groups because each group will receive a different treatment. So here's a characteristic image of the first group, a patient that is fecally incontinent and has a dilated column. So for those patients what we need is a large volume enema, a very concentrated enema because the difficult portion in those patients is to clean that column. But once you clean the column, you have the advantage that this column does not have a tendency to move. So this column will stay quiet and for the next 23 hours until it's time to give again the other enema. Now here's the image of the other group. That it's a non-dilated column. It's a column that is constantly moving. As you can imagine, this one, the easy portion is to clean the column. You do not need a very large enema and it's usually just plain saline. But you have to find a way to keep this column quiet until the next, until it's time for the next enema in the next 23 hours. So for those patients besides the enema, we recommend a constipating diet. We try to limit the amount of snacks because we want to avoid the. Gastrocolic reflex, so we usually tell parents to try the best that they can, 3 meals per day, even though we understand how difficult it is for kids, and we add loperamide, that's the Imodium, and fiber to try to keep this column as quiet as possible until it's time for the next enema. So what do we use as our enema components? The base of our enema is saline solution. And we usually use between 200 and 1000 mLs and the irritants that we add to the enema to make it more concentrated are the liquid glycerin between 10 and 30 mL, Castile soap, that's a mild hand soap, between 9 and 36 mL and we leave as our last resource the phosphate, the fleet because that's the one that irritates the column. The most. The reason why we leave the fleet enema as our last resource is because we have seen a small group of patients that were using fleet enema for a long time and they come back to us with a narrow spastic column, almost like an inflammatory reaction and after we stopped the fleet they improve. So that's why we try to use the fleet as our last resource. And it's very important that the fleet, the dose of the. Fleet that we respect whatever is prescribed because otherwise they can have electrolyte disturbances. So patients lasting between 3 and 4 years we use half of a pediatric fleet that's 33 mLs. Patients between 4 and 10 years of age, we use one pediatric fleet that's 66 mLs and patients more than 10 years, we use an adult fleet, 133 mLs. We do this as a one week program. Unfortunately, we do not have a recipe based on weight and height that the child can come here and that's the formula and that's gonna work for everybody, no, each column, each child behaves in a way, so it takes us one week to determine what's the perfect enema for that child. And we daily monitor the results of our enema with an abdominal X-ray film. That's the only way to know if the enema that you prescribed is working. And when we look at the abdominal X-ray film, what we wanted to see clear without stool is the left column and the rectum. We believe that this stool, It's in the right column, we'll have the next 23 hours to reach the rectum. So we wanna have a completely clean left column and rectum after the enema. And the most important concept is that it's trial and error. That's the only way that we can determine which enema works for each child. So daily we modify the type of the enema during this one week period based on the X-ray film and the clinical results. So in Cincinnati, the way we do it is on Friday is our first day, is our clinic day. So patients do the contrast enema on Thursday, then on Friday they come to clinic and we prescribe one enema. The first one is just a guess. They go to their hotel. They do their enemas Saturday and Sunday and Monday they come to the hospital just for an abdominal X-ray film and they call our nurses to give reports on how many accidents, how many bowel movements in the toilet, if it was painful, if there was any reaction and based on these comments and the abdominal X-ray film, we made the we can make the modifications and recommendations for a new enema. One thing that is very important is to never give laxatives and enemas simultaneously in patients with fecal incontinence. And you have to remember those patients are patients that do not have bowel control. What we are trying to do with the enema is to artificially clean the colon and have a predictable bowel movement immediately after you give the enema. So if you think that you give the enema. The patient has a bowel movement and then you give the laxatives, the patient will have many, many, many bowel movements after all, unpredictable, so the patient is gonna be worse. So if you're giving enemas, no laxatives for this patient. So now let's see how we can modify our enema in which circumstance we would modify our enema. So for example, we prescribed an enema and let's say a child came, it's uh 6 years old and I decided to start with 400 saline and 20 mLs of glycerin. So the parents report that the underwear is not clean, and we say accidents when there is stool in the underwear and the abdominal film shows significant amount of stool in the left column. That means that the enema that I prescribed was not concentrated enough to clean this column. So I have to either increase the volume to clean more or increase the concentration of the enema. So in my example if the patient was with 400 saline and 20 of glycerin, I can try to give today 400 saline and 30 mL of glycerin for example. Another scenario, you give the enema and we like to say Monica will go more in detail on how to give the enema, but we say that the entire process should last 1 hour. But if the parents tells you that they gave the enema and it took 2 hours for the child to start evacuating, then it means that this enema. Was not concentrated enough you have to make it more irritant so the child has a bowel movement in a shorter amount of time. So in this case we would just increase the concentration again if the patient was 400 of saline and 20 of glycerin, we would just increase to 30 mL of glycerin. Now the other scenario is that you give the enema and the patient has pain, nausea or vomiting during the enema and you have two options. One is that the patient has these symptoms but with a clean X-ray. In this case you can just decrease the enema. Concentration because sometimes just the irritation gives those symptoms. Now if the X-ray is not completely clean, you cannot decrease the concentration. In this case, we just say slow the administration time because sometimes it's just a vasovagal uh reflect from the enema, reflect, sorry, and you have to warm the solution to body temperature. Now if the mother reports that she gave the enema, the child sat in the toilet and after they were playing, there was just some liquid accident, there was clear, clear fluid. What we tell the mum is that probably there was some fluid that was left inside the column, so we tell the parents that after the child is done sitting in the toilet, just reinsert the Foley catheter and let all the fluid drain before she's out of the toilet. This is one that sometimes we get, we don't get that often, but for example, you prescribed 400 of saline and the mother says by the time we reach 350, my child starts screaming. Then we said, well, the child determined the amount that she wants, she's gonna get 350, but just remember if you decrease only the saline solution. And you don't decrease your irritants, you're gonna make this enema more concentrated and sometimes that's what we do. Now once you have a completely clean colon and the parents describe that the child keeps having accidents, that means that this colon is moving too fast, even though you're cleaning correctly with the enema, the column keeps moving and that represents the accidents. In those cases, you are authorized to start with loperamide and constipating diet. Now Doctor Pena mentioned patients with cloacal atrophy that they have different degrees of colonic lens. When those patients, for those patients, we encourage them to every year come and try the bowel management through the stoma and it's the same concept we just prescribed an enema, the patient should have a bowel movement immediately after the enema and they should. Have an empty bag, completely empty bag for 23 hours. If that happens, it means that the bowel management works and you can offer the pull-through, and now the patient knows all the effort that they're gonna have to do in order to be clean in their underwear if they want to have a pull-through. Some patients, they do the bowel management through the stoma and they like. It so much and they say I don't wanna have any more surgery, I'll just keep doing bowel management through the stoma. We're not against that because we always say that bowel management is a matter of quality of life and quality of life should be determined by the patient, not by the doctor. So if the family is happy, we are happy they can continue doing bowel management through the stoma. And that's the end of this presentation. We're gonna move to the case discussion and I'm happy to answer any questions, but I'm sure with the case discussion we're gonna go through many scenarios that might clarify any questions that you currently have. Any comments from the panelists, from the faculty, anything that you think I didn't cover? Uh, let's bring the faculty on. Uh, perfect. And then, so let's see some of these questions. Um, I'll start from the, from the bottom up. Do you find idiopathic constipation patients with redundant sigmoid colon? If we find yes we find and we're gonna show in the talk of idiopathic constipation you're gonna see some um contrast enemas of patients with idiopathic constipation. But I I don't know what's the importance of the redundant colon. If that was the question I cannot answer. I don't know what's the importance. There are many people that are normal and have a very redundant colon and do not even suffer from constipation. OK. Go ahead. I had, I had one quick comment about, uh, glycerin. We have a lot of patients in our area whose parents have trouble finding glycerin, and our clinic nurse, Brandy and I have gone around and talked to other parents, and there's actually some pretty cool places online where you can buy it in bulk. And have it shipped to your house. That's much less expensive than going to the pharmacy to buy it. So that's usually what we recommend our families to, is to just get online and search the internet, and they can find them in gallon bulk. That's usually what we recommend. What what is that, how do you determine this is a question from Tom Sutton. How do you determine what initial volume for an enema? And then answer that also for the Malone as well. So that's a very good question. It's the first volume enema is just a guess. If you don't have any experience and you are a little afraid on how to, how to start, uh, one hint is to ask your radiologist to tell you how much volume they needed until the contrast reached the splenic flexure and. That's gonna be can be your initial enema volume but you can you have one entire week to figure it out. Usually we we don't get this information but we see a lot of contrast enemas and that's why we have a feeling on how much the patient will tolerate but a good a good hint is to ask your radiologist how much volume they needed until it reached the splenic flexion. That in the, in the everyday life in our bowel management program, the volumes that we use go from about 250, 200 cc's of saline, let's say in very small children to 1 L 1 L and a half would be the extreme for a huge, for a, for a big patient with a huge colon. So that's, that's the range that we, that we use and then usually we start with about 10 mL of glycerin and we go up in maximum cases that I remember 40 mL of glycerin perhaps and then soap, liquid soap, we start with, with the 9 cc's of liquid soap and and sometimes we go up to. To 27 or, or 36 cc's of liquid soap and um and then fleet, we try to stay away from fleet because we, we have seen some problems of colitis produced by long-term use of fleas, but we use it when we are desperate when the colon is very lazy and doesn't respond to the other irritants. Can I just make a follow-up comment on the additives for finding it? Um, the Castile soap is often able to be fine through home care companies. It can also be in like Hypermart stores. Um, the glycerin is a follow up. If they do not get online to order it, it is often not found in the pharmacies, but more so in your liquid soap aisle or in the cosmetic aisle because a lot of people use it as a facial soap, so the families can often find bottles of it in the cosmetic aisle or the hair soap aisle, the body soap aisle. Few, few quick comments and questions. Doctor Zennati, my friend, how are you? He says they start at 25 ccs per kilo. Uh, Doctor Meager says 20. So I think people sort of like to use that as a starting point, which I think is a reasonable place to start. Monica, what about diet for these patients? There's a question. So on enemas, we typically do not start with any special diet. They can have their normal diet with their enema unless we have determined that they are hypermodal or have a very short colon in which when they eat, they produce stool. So those are for specific patients. What can you give us a I have this great sheet. I don't even, I think it's from the Absa website where it's got the constipating foods and they're not, so those will be more so for the laxative, um, OK, yeah, but for those on enemas, they are on their regular diet. And let me say something, you, you mentioned the to the. What hints do we have for to, for the initial enema and you mentioned including Malone, right? OK, so, first of all, we only indicate the, we only offer the operation Malone to our patients when we already demonstrated that the Enema works. We are very much against the generalized idea of doing malone procedures without having previously determined if the enema works or not. So, so we see patients coming to our clinic who already had them Malone. But never had bowel management. The easy part for us surgeons is the Malone, because it takes about an hour because we charge a lot of money and because we get rid of the patient and send it to Cincinnati to learn how to give enemas, but that's not correct. We believe that you have to go through the bowel management. And then you determine the, uh, the, the enema that keeps the patient clean and then is the patient and the family's decision whether they want the enema from below or from above. So when we do them alone, we already know which enema, the mother knows which enema definitely guarantee works. So, as soon as we finish the operation, they can start using it successfully. OK. Uh, and then again, I'm going to open this up for the panelists if there's any comments or questions. Uh, Yeah, go ahead, Michael. Todd, yeah, yeah, Todd, I had a quick comment. I've worked out a good relationship with our radiologists when I get the unprepped contrast enema, and they'll actually put a little cursor or write-in on the screen where they'll actually tell me how much volume they used to fill the colon just as a guideline, and sometimes I'll use that number or just look at it like, like Andrea said to get an idea about that. I think that's a great idea. That's very helpful, Ramon. Well, I think any of the panelists are going to talk about it later, but we are using an irrigation system. It's working very well. We have to do trial and error like the same in the first week, but it's working very well with tap water. OK, what is working very well? The the water? Say, say the last thing you said, Ramon. What? Can you repeat the last we couldn't hear the last, yeah. That we are using with incontinent patients an irrigation system is called Peristine. I think one of the panelists is going to talk about it after that. OK, I can comment on some of that when we get to it. We can wait. Uh, so, uh, there was, we, we'll see how we are on time. I know we have a few other questions coming from the audience. Um, we can go through the case discussions because they're, I, I'm. They're going to answer most of the questions. Let's do it then. So the, the goal of those this case discussions is just to imagine that you're having a patient in front of you and what you're gonna, you're going to do. So it's just to walk you through the process to hopefully help you with that. And now I'm sorry, one more thing. So now, now as we're going to try with this case now on the, on the original website, the Globalcast MD website, the polls will pop up as Andrea asks the questions. So please answer the polls on there, on the side of the screen in the full screen mode. You have to be in the full screen mode. Go ahead, Andrea. Yep, so it's a 14 years old that. Was repaired had a repair for anorectal malformation we don't know exactly what type but here you can have a kind of a view of the sacrum and I'm gonna show you the lateral view of the sacrum so you can kind of imagine what's the sacral ratio for this patient and I'm gonna show you now the contrast enema. So that's the contrast enema so you already know 14 years old, uh, short sacrum, and you're looking at this contrast enema. So the first question that I wanna ask you, looking at the contrast enema, the colon of this patient is a non-ilated colon or a dilated colon? And people can answer. Oh man. Mm. So, so we're getting a variety of answers and that's very good and if we, and I'm sure Doctor Pen is gonna say that I picked one that was not so good, but actually this one, if you look carefully here for example. From here, here, from here, and here you can see in the sigmoid there's a lot of redundancy and there's double image so we don't know exactly what is what but my impression and this is again it is not a perfect contrast enema, this is a patient that we believe will behave as a slow column that's my impression but during the week as you start your. Treatment you might find that actually other people were right that this was actually more towards the hyper modal type of column, so that's why it's important that you have the entire week so you can see how the column behaves, but just by looking at this one, I would think that it's more like a hypo one that moves slow. So What enema would you prescribe for this patient? Anybody wants to give a guess? So that's the abdominal X-ray the day after the contrast enema and the parents reported that the patient had many bowel movements. Usually the contrast enema helps us clean the colon, which is a good thing, and that's the X-ray on the first day. So with that contrast enema with and. With this X-ray, what enema do you want to prescribe and I'm giving you some options. It's a 14 years old, you saw the contrast enema, so 500 mL of saline plus 20mm of glycerin, 1000 mLs of tap water, 500 of saline, 30 mL of glycerin, 27 of soap and 1 adult fleet, or 200 mL of normal saline. So anybody of our panelists want to comment on that? Monica, which animal would you pick? So I think this is a little tricky because you are commenting about it being a, you think it would be a slow moving colon, which makes me initially think of 520. However, I question that the x-ray 24 hours or less than 24 hours after the contrast is completely clean of contrast, which makes me go with more of just normal saline. So I'm not sure what your thoughts. So the good thing about bow management is that there's no right or wrong. Whatever you choose, you have the next day to know if you were right or if you were wrong. So usually when we do the contrast enema, the contrast enema helps in cleaning the colon a lot. So that gives you a hint that this is not gonna be a very difficult colon to clean. So I would pick 500 of 20, but if you decided to pick something else. It's not a problem because you will have the next day to find out if your decision was good or not. So let's say that we picked 520. So here's the X-ray and the patient reports that she had. Two accidents in this 24 hour period. So, what do you want to do, Doctor P? Two accidents, this x-ray, and you're currently on 520 of glycerin. So, if you, if you look at the, uh, this x-ray, the, um, I think the descending colon is mostly clean, as well as the rectum. There's a little bit of stool in the transverse colon. So, uh, I think the enema worked and I think the patient is behaving. A little bit like hyper motility type of column. So perhaps so we our computer here doesn't have a good image. I, I hope you have a better image, but here you can see there are 2 here and there's 2 here in the descending column. Michael, were you gonna say something? I just wanted to know when, when did the accidents occur? Were they within the first several hours after the enema, or did they happen later on? That's a very good question, and it helps you to decide what to do with the enema. So you can tell me what do you want, where do you want the accidents to happen, because those are all fake scenarios. So you can tell me when do you want the accidents to happen. OK, I want them to happen, uh, shortly after I gave the enema. Very good. So if they happen shortly after you gave the enema, what, and you have a clean x-ray, let's pretend that it's completely clean. This x-ray is not clean, but let's pretend it's completely clean. have a better image there. So what would you do? Michael. It's OK, so if the colon is completely clean and I've given a 520 and they're having early accidents, but there's no stool but little accidents, I'm wondering if if it's too irritated, too concentrated, and maybe to back off on that a little bit. But if they're big accidents and the X-ray's deceiving me, then I might try to increase the volume or. Concentration a little bit and just check the x-ray again to make sure that it really is clean. Very good. And I think the other important part is to make sure that the accidents didn't happen from the time the enema was done until the time the patient went to get the x-ray, because if the x-ray is clean, but the patient had all of those accidents, you want to clarify with the family. Excellent point. Andrea, yes. Can I ask you something about this patient? Yes, you can ask me. Yeah, uh, what I learned or what I understood in this type of patients, first we have to clean the feces, and then we have to think about the enema and the continence. That means most of the time of the time when we've got chronic fecal retention, there is a sort of colitis associated to this. If we use glycerin or soap or fleet, don't you think it's more easy or it's more probable that we will have an accident during the treatment? It's better to start with that water first and then Decide which type of concentration do we have to use. So we don't, we know many people use tap water, we don't use tap water because if you think about the function of the colon, it's to absorb water, so if you just put tap water, there's a high chance that the patient will absorb that water and there are reports in the literature also of electrolyte disturbance from that. So that's the reason why we use saline solution. If you use saline solution only, many patients will not have a bowel movement because that will not irritate the colon enough. So that's when, why we, we add the concentrated ingredients like the glycerin to provoke a bowel movement, to be irritant. We want to irritate the colon to provoke a contraction and have a bowel movement. That's the goal of putting some uh irritants in the enema. But don't we need a time of a couple of days first to clean the feces? I mean only with saline. We. With 2 or 3 a day. So if we have fecal infection, we have to disinfect the patient and we disinfect with 3 enemas a day, but we don't use saline only because saline only usually does not produce a good reaction. Many patients, you put the saline only and nothing happens. The saline stays there. So usually when we want to disinfect, that's when we make the enema as concentrated as possible. Dr. Bischoff, there's a couple of comments saying that they feel that 500 would be too little because of stool in the transverse colon. Um, so I just, I want to clarify they have 520 of saline. I want to clarify it's 500 of saline and 20 of glycerin is what. The enema we're we're speaking of, but when we do the rectal enema, we are concerned about the, um, the rectum and the descending colon. We don't always, um, need to get up into the transverse because in general, it takes 24 hours for the stool and the transverse colon to reach the rectum. Very good, so whenever we are looking at the X-ray, we're looking at the left colon and the rectum. We don't worry if there are two in the transverse and in the right column, we don't worry about because as Monica mentioned we think it's gonna take 24 hours for it to reach the rectum and come out. So we wanna clean the the so since my first scenario didn't work we're gonna move to another one but here it would be a clean X-ray this one I selected as being a clean rectum, a clean descending and a clean left colon so we're gonna move to the next scenario to see if we have better luck with that. Can you move to the next one? OK, so now we have oops, now it's. Sorry, cause now this slides all moved. 10 years old male patient with prosthetic fistula and tetrachord. So here is his contrast enema, just by looking at this contrast enema and knowing that he's 10 years old, so let's see, first of all, do you think that he suffers from that's the abdominal X-ray 24 hours after the enema. So what do you see in this simple abdominal X-ray film? Anybody wants to comment? Well, Monica's point about the lack of contrast clearance is a good one because, you know, you can see this boy's retained quite a bit of contrast the day afterwards, so his colon looks like it's on the slow side. Very good. So just gives this gives you an information that this is a column that moves very slow. He did the contrast enema the day before and today we're seeing. An abdominal X-ray film that still has contrast on it. Very good. So now you're all gonna get the answer correct. So based on this contrast enema and the abdominal X-ray the next day, do you think this is a hyper motto column or a hypomotto column? 1 or 2? Very good, everybody's answering number 2. This is a column that moves slow and that's why we still have contrast material in there. So what enema do you want to start on him? 700 of normal saline plus 1 pediatric fleet, 400 of saline and 20 of glycerin, 1000 mL of tap water or 200 mLs of saline? Wow. People are voting everywhere. And the, so So it's kind of funny we have half the audience in Adobe and half the audience at Globalcast MD. The Globalcast MD audience is almost all 2s. I think it's 100%. Twos. But we, are you in this question or are you in the first one? This is the one just now, the one you just asked. Perfect. Yes. So that would be a good option. Remember why I don't pick number one, because I leave pediatric fleet as my last resource. So I don't start with pediatric fleet. I only use for those that really need an extremely concentrated enema. So I already mentioned why I don't use, uh, a tap. Water and why I don't use saline solution only because we all agree that this is a patient that the colon moves slow, so we need irritant. So the best option for this one, I'm not saying it's the correct because we will need the entire week to know if that's correct, but the best option would be 400 of saline and 20 mL of glycerin. A lot of people wrote one and two. Michael, did you want to talk about that? No, I just think for a 10-year-old boy, in my experience, 400 mLs is going to be a little on the light side as far as the volume. I think if someone would have gone a little bit higher, that would be pretty typical as a start enema to 400, 500. It's very interesting, Ramon. But it's not so dilated. It's hypomotile, but it's not so dilated, so you don't have to put a large amount of volume, I think. You see, in the, in the way the, the bowel management works in in Cincinnati, we dedicate one entire week from Monday to Friday and typically around 1 p.m. in a classroom, we see the surgeons and the nurses and the nurses show the films of the patient and mentioned what uh described what the parents told them. And frequently we have the same disagreement that you are seeing here. Somebody may say, well, 700, I know I prefer 400, and, and, and, and we decide for whatever one of those because next day we are going to see if that person was right or wrong. And for instance, if Mike also has what. With us in the bowel management and he suggested 700 we say and fleet we will we'll say yes perhaps and tomorrow we'll see what happens or the other way around we'll see 420 and if tomorrow the patient has a lot of stool in the colon, then Mike Mike would say, say, you see, I told you. It needs 700, so it's trial and error and we tell the parents, we tell the parents it's going to take a week. It doesn't, we never promised two days and, uh, and so and usually by uh at the end of the week, we got the right, uh, the right enema. Stephanie, what are your thoughts on this? I know you were raising your hand a little bit ago. Um, you asked me? Hello. Yes, I'm sorry. I just, I saw you a while ago raising your hand and we didn't have you on the phone. Is there any comments that you wanted to, I had a problem. Well, um, but we have a bit of a different start to do the enema, and I'll have the opportunity to show to you a bit later the way we do it. For me it's usually we're trying the amount of the anima not to be so much of a guess, and that's the point about doing hydrocolonic sonography. But I think I'll have the opportunity to show that later, so we don't guess, we try to measure with sonography with the help of sonography. Great, we'll talk about that later. Thank you. So let's pretend that for this case we selected 400 of saline and 20 mLs of glycerin and now we're gonna see what happened. So the parents reported 3 accidents, so there were stool and this is the X-ray, we can see better the X-ray in that screen. So with this X-ray first of all try to think in your mind, is this a clean x-ray? Is there some stool in there? Is my enema good enough to clean all the rectum and all the left column? I think you have to see there. So with this X-ray. And with 3 accidents, what changes do you want to make to the enema of this child? Do you want to decrease the concentration to instead of 40 saline and 20 of glycerin to 400 saline and 10 of glycerin? Do you want to decrease the concentration to. 400 of saline and 9 mL of soap. Do you want to increase the concentration to 400 of saline and 30 mL of glycerin or do you want to increase the concentration to 400 mLs of saline, 20 of glycerin, and 9 mLs of soap? So everybody can vote on what you wanna do. Guys are so Ernesto is saying increase the volume, that could be an option also. But first, what's the diagnosis for the x-ray? So do you think this x-ray is clean or this x-ray has a lot of stool? I just want to say, see, I told you so. So what do you think? Do you think this is a clean X-ray? Anybody wants to say clean X-ray? Jeff is saying a lot of stool. A lot of left sided stool there and distal stool. Very good. So we see stool in the rectum and in the left side. So that means we have to change our enema. We have to either increase the volume or increase the concentration of the enema. Mike, you are, you are not allowed for the next meeting, OK? You, you are, you, you, you are, you are not allowed as as a, as a member of the. Because of your, of your conflictive opinions, OK. So I think most people voted in number 3, increase the concentration to 40 saline and 30 of glycerin. I agree. I think that's the best option. So let's see what happened. We did that. He's getting his hat back on. What is that hat? What is that? That's the rainbow fish of shame. I have to. John Lilly used to make us wear hats when we made mistakes. So in Dr. Pena's honor, I'll wear the rainbow hat of shame. I lost track of my slides. So the patient reports two accidents. That's the new X-ray on the next day. So now with this X-ray, do you think this X-ray looks better than the day before? Is it worse than the day before? Is there more stool, less stool? What do you think just by looking at the X-ray? Yeah it looks like it might be a little better, but there's still, still some stool on the left side. Very good. So Jeff is saying it looks better, but there's still some stool in the left side and the patient had two accidents. So I agree. Let's see what we can do then. You want to decrease the concentration back to 420, decrease the concentration to 409, increase to 400 of saline, 30 of glycerin and add soap now or increase to 400 of saline, 30 of glycerin and a pediatric fleet. So now everybody is voting on 3. Very good. I'm happy because I think this scenario went well. The other one was a disaster, but this one is going well. And then you made this change and the patient reports that he had no accidents. He's completely clean in the underwear and you have this X-ray and if you can look carefully, you can you have a clean rectum and a clean left colon. Very good. So in this one, we all succeeded. Doctor Leva is asking, go ahead. Oh, I just had a quick question. What's your rationale for not increasing the volume on this? I mean, I know you don't want to decrease the concentration, but you know, increasing both glycerin and maybe adding more soap and giving more volume because it would seem, um. As Mike had pointed out that this kid probably needed more volume as well. You could try that. There's nothing wrong, but usually my first attempt is to try to increase the concentration because children, especially young kids, they don't tolerate much volume, but you can definitely try and if it works, that's the answer that you chose correctly. But I agree with your point. If you increase the saline to also increase the glycerin so that you don't lose the potency of it. Right. Uh, Doctor Leva is asking no pain with this concentration. Some kids, they are very sensitive to the concentration and what the, it's not pain, they report severe cramp and sometimes we have to decrease the concentration because of that and we also tell the. Parents to slow the administration, that usually helps also. And Monica will tell you how to do that. And also, if you have a patient cramping severely, sometimes the glycerin is more irritating for some patients, so we'll decrease the glycerin, but increase the Casteel soap and some tolerate that better. And that Doctor Leva is asking any risk of colitis, what, what do you, what do you mean, Ernesto, when you say any risk of colitis? Uh, I mean, when we, when we increase the concentration in uh, in, um, enema, I see that most of the patients has uh uh appearance of uh blood in the stool after the enema. Or they have severe cramps, as Andrea said. Or they lost, they lose uh mucus through the anus. And uh we are not happy with the, with the soap, for example. We don't use the soap here. Uh, what we, what we play is with saline solution and sometimes we add the fleet. But as you said before, Doctor Pena, we also use fleet very seldom because uh the risk of subsequent colitis is quite reasonable. When, when, um, when we see a patient that, that we use a lot of irritants and the patient comes back with a, with a completely clean colon, radiologically speaking and it still passing accidents, that means that means that we are irritating the colon a little too much. We don't talk about colitis because we don't have a histologic diagnosis to talk about that. But uh if you want to call that colitis, that's OK, but that means we are using too much irritant and we decrease the amount of irritants. When I talk about chronic use of fleet, patients that disappear for 10 years, they were using only fleet phosphate enema and then come back later having many accidents, we do a contrast cinema. And we see a a spastic colon very narrow with spasms and, and sometimes they pass blood and the endoscopy shows severe colitis, those are, those are the cases that I was referring to. Great, so we're gonna do another scenario and uh this is gonna be a little tricky so pay a lot of attention. This is a 9 year old male patient with Hisprung disease status quo post pull through that has a damaged anal canal. So this image is just to show you the importance. The importance of having a contrast enema to know exactly where the colon is located. So if you see all the colon in this patient is actually in the right side of the patient. So if you are examining the X-rays in the during the following days and you're just looking at the left side of the patient. You might think that your enema is working so that's the importance of always having a contrast enema to know exactly where you should be looking. So as you can see he has a short column, this short piece of column is dilated, but it's a short piece of column so those patients are a little tricky. So what enema do you want to start him on? Pediatric fleet only 300 mLs of saline, 1000 mL of tap water, or 300 mL of saline and 10 mLs of glycerin? So most people are answering number 4, 300 mL of saline and 10 mLs of glycerin. I think this is a good choice. So let's say we decided for that. And here is the abdominal X-ray and the parents reported 5 accidents. Now look at the X-ray, tell me if you think that this X-ray is clean, if your enema is working, or if we have to improve the enema to clean this colon more. So what do you think? Do you think this is a clean colon? Doctor Alshaus, do you wanna comment? Yeah, I don't, I can still see, uh, on my, um, crystal clear globalcast X-ray picture here, uh, uh, there's stool in the rectum. It appears to me. Very good. So there is a lot of stool in the rectum, so that means that we have to improve our enema, and most of the audience is saying that it's not clean. So what change do you want to do to the enema? Do you want to decrease the concentration? Concentration to 300 of saline only. Do you want to decrease the volume to 250 + 10 of glycerin? Or do you wanna increase the concentration of the enema to 300 of saline and 20 mLs of glycerin? Or do you wanna just give a pediatric fleet? And most people are answering now. And I see that most people are saying number 3, increase the concentration to 300 of saline plus 20 mL of glycerin and I think we all agree that that would be a good decision. So let's see what happened. So the patient had 2 accidents and here is the X-ray. So what do you think of the X-ray? Is the rectum clean? It's not clean. There is still stool? No, no, no, still stool stool not completely clean. Very good. So we are all good in looking at the x-ray and finding the stool. Very good. So what changes do you want to make now? Do you want to decrease the concentration, #1? Do you want to decrease the volume 2, do you want to increase to 330 of glycerin? Or do you want to do a pediatric fleet only and everybody is sensing number 3, increase to 330 of the glycerin, everybody agrees that would be a good decision. And here's the X-ray and the patient is reported to be clean, so you all succeeded again. Oops, we have one more scenario. I thought we were done, but we have one more. So let's look at this contrast enema. What do you think, Ramon? Do you think this colon moves fast, or do you think this colon moves slow? The left colon looks like a fast colon because it's a narrow column. It's very good. So the X-ray on the next day. What do you think? A lot of stool? Does this patient need this infection? I think it seems like liquid. I think it's full of liquid. It seems it seems like a completely clean column. Might be some liquid, but I don't see any hard stool for sure. So what enema do we wanna, we already said that it's hyper. So what enema do you want to start him on 300 of saline only, 300 of saline and 1 pediatric fleet, 1000 mLs of tap water, 300 of saline, 30 of glycerin, and 27 of soap. Number one, Number one, very good. So let's pretend I based on the images that I saw these patients have a severe hypermotility. In other words, that colon is moving very fast. So I predict that in addition to the saline, the pure saline enema, the patient will need a constipating diet and will need Imodium. OK. And I don't know, I don't know the case, OK, by the way. I think we moved that already. So we'll see if Doctor Pena is right or wrong in the next, so in the next day somebody's moving my slides, don't move my slides. So in the next day, here's the x-ray and the patient had 6 accidents. So do you think you were right? I told you. So now what do you want to do then? Do you want to increase the concentration? Remember we started him on 300 mL of saline only, so do you want to go to 330 of glycerin? Do you want to decrease to 100 of saline or do you want to add Imodium? So many people are saying at Imodium, remember we have a clean x-ray, completely clean x-ray, and the patient is having multiple accidents. That means that this colon is really, really hyper. We have to slow it down so the patient can be clean. How would that Imodium and constipating diet. And I think also in response to Dr. Ponsky earlier, this is the patient that would benefit from doing more like three meals a day without a lot of snacking for the gastrocolic reflux. Um. Very good. So this patient will probably need saline enema, Imodium, and constipating diet. Very good. So that will end.
