Hirschsprung Disease – PediaCast 287

This is Pediacast. Welcome to Pediacast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike. Hello, everyone, and welcome once again to Pediacast. It's a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is episode 287 for May 21st, 2014. We're calling this one Hirschsprung disease. I want to welcome everyone to the program. So I have a feeling that this episode of Pediacast is going to end up being one of our most popular shows. And I'll even step out on the ledge and make a prediction here. The day will come probably sooner rather than later when this particular show will be one of our most listened to episodes of the program. Now, most of my regular listeners, you're probably scratching your heads right now and asking yourselves, what in the world is Hirschsprung disease? I've never heard of it. And why is this episode going to be so popular? I mean, is it a common condition? Not particularly so. About one in 5,000 kids affected. Not nearly as common as other diseases that we've covered on the program. So what gives? Well, the reason I see this episode heading into the Pediacast Hall of Fame is because of our guest. Dr. Mark Leavitt is an international star of sorts in the world of pediatric colorectal surgery. And when he talks, people listen. So I know once we tag this episode with the topic and our guest, he'll be off to the races. This show will be off to the races. Of course, this begs the question for my faithful followers, in other words, those of you who listen every week and weren't necessarily lured in by doing a Google search for the topic or the guest, begs the question, what exactly are Dr. Leavitt's credentials? And again, what in the world is Hirschsprung disease? So complete answers to both questions will be coming up on the other side of the break. But rest assured, we'll cover Hirschsprung disease in our usual nuts and bolts fashion with the definition, cause, symptoms, treatment, complications, long-term outlook, and the latest research topics. First, I do want to remind you about our 700 Children's blog. It's available over at 700childrens.org. And we have a fantastic cadre of physician authors for you. Some recent topics, preventing child abuse in your community, how you can help. A new grass pollen allergy treatment. Infant sleep machines may damage hearing. We previously covered that on Pediacast. But send a link to the blog post to parents that you know, especially those with newborns at home, because I think there's some helpful information there. Five ways to avoid knee pain. And new cardiac MRI leads to better diagnosis. That's one for the more tech-minded parents out there. We have something for everyone over at 700childrens.org. I also want to remind you, Pediacast is your show. So if you have a question for me or want to point me in the direction of a news article or a journal article, or you have a question that you'd like us to answer here on the program, it's easy to get in touch. Just head over to Pediacast.org and click on the contact link. I also want to remind you the information presented in Pediacast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination. Also, your use of this audio program is subject to the Pediacast Terms of Use Agreement, which you can find at Pediacast.org. All right, let's take a quick break. We'll get Dr. Mark Levitt settled into the studio, and we'll be back to talk about Hirschsprung disease right after this. All right. We are back. Dr. Mark Levitt is a pediatric surgeon and surgical director of the Center for Colorectal and Pelvic Reconstruction at Nationwide Children's Hospital. He's published over 120 manuscripts and 60 book chapters relating to colorectal disease in children. And before you think he is only a prolific author, be advised that Dr. Levitt has also delivered over 400 local, regional, national, and international presentations of his work. He's been invited as a visiting professor all over the world and has directed countless colorectal training courses attended by international crowds of established surgeons and surgical trainees. But does he see patients? Why, yes, he does. In fact, with over 5,000 colorectal procedures under his belt, it's safe to say Dr. Levitt has helped more kids with Hirschsprung disease than any other surgeon in the world. That's what we're talking about today, Hirschsprung disease. And it's with a warm welcome that we say hello to Dr. Levitt. Thanks for joining me on the show. Oh, pleasure to be here. Thanks. Really appreciate you stopping by. And actually, we talked about the 700 Children's blog. You did a blog post on there, Colorectal and Pelvic Reconstruction, Why Nationwide Children's. We're going to be covering a lot of the same information that was in that blog post but in much more detail. But folks may want to take a look at the blog post as well, and I'll include a link in the show notes for this episode, 287, over at pdacast.org. So let's start with a simple definition in a nutshell. What is Hirschsprung disease? So Hirschsprung disease is essentially a problem with the colon in that the colon doesn't empty. So babies can't get their stool out. And the reason for this is that the nerves in the wall of the colon are absent for the bottom part of it. And the more upstream part of the colon that's trying very hard to empty can't because downstream there is a blockage caused by the lack of these nerves. So when you don't have the nerves, the intestine isn't able to squeeze, so you can't get the stool moving. Well, actually, if you don't have the nerves, the bowel is not able to relax. So the downstream part that's affected by the disease is squeezed and can't unsqueeze. Gotcha. So the natural state of the large bowel is the squeezed state. Correct. And it's supposed to squeeze, unsqueeze, squeeze, and unsqueeze as the stool moves through. And in the section that has Hirschsprung disease, it's squeezed tight. And the part that's above this area is trying very hard to empty and can't because downstream from it is a blocked area. And that part then gets very distended, wider. And then the stool that's sitting in there that can't get through has bacteria in it. And then the bacteria, because they're not moving through, have an opportunity to grow. And it's sort of like a swamp. And then that can cause a serious infection, which is called enterocolitis. Now, we talked about one in about 5,000 kids being affected. Do you see a difference between boys and girls? Well, girls are a little bit more commonly affected. But it's not such a dramatic difference that we basically pretty much see most. We see at least a half and half boys and girls. It seems to be a little more genetically connected, which we'll talk about in a little while, I predict, in the girl population. But, you know, of the patients that I see, about half are boys and are about half are girls. Sure. Do you see any difference with different ethnic groups or any racial differences with Hirschsprung disease? Nope, not at all. We do see Hirschsprungs a little bit more commonly in some syndromic patients. Like, for example, Down syndrome has a higher incidence of Hirschsprung disease than the regular population. But mostly this is just a random genetic event. And the babies are born at normal time, at term, and then they get into trouble with the bowels. You talked about there being a possible genetic component to this. So do you see if one family member has Hirschsprung that it's more likely someone else in the family will have it? Yes, it is slightly more common. We know of a number of families, and this is something that is actively being studied, but we actually know a number of families, in fact, with even a grandparent, a child, and then a new generation child. So three generations worth of Hirschsprung disease. Wow. I've seen patients who have siblings. I've seen patients who have twins, both of whom have Hirschsprung disease. So clearly there's a genetic linkage. It has yet to be isolated, but there's a lot of work being done, and we're actually collaborating with Hopkins on the genetic work of Hirschsprung disease. So it's something if families know that there's Hirschsprung in the family, it's something they should let their doctor know if mom's pregnant that there's a high incidence of it, so they can just be sort of more vigilant that that could be going on once the baby's born. For sure. In fact, this just happened this week where a family with Hirschsprung disease and a sibling, the mother was pregnant again and was worried about Hirschsprung disease, and within 24 hours the baby was born and already is at Children's and has Hirschsprung disease and will get very quick treatment because we were very up on the fact that the Hirschsprung was a possibility. Now, do we know what causes this lack of nerves to migrate down the intestine? Do we have any idea what the initiating factor there is? No. We don't really understand it. We just know that the nerves are supposed to migrate down, and for some reason they don't make it. Yeah. And normally it's kind of interesting the way in some of the more tech-minded parents out there who listen to the program, it's kind of interesting how the nerve ganglia sort of start at the top of the bowel and then migrate down, and so you usually don't see segments of bowel without nerves in midstream. Is it always from the bottom up? Yeah, that's right. The development of the intestine sort of flows down, and the blood vessels, arteries, veins, and nerves all sort of go down that path. Nerves need to make it all the way downstream, and they start from top down. So if there's a problem, it's always from bottom up. There's no skip areas. Now, what signs and symptoms go along with Hirschsprung disease? So how does a baby present that we may be worried could have this? So this usually happens in the newborn period where the baby is born at term and then doesn't empty the bowels well. Usually in the first 24 hours, most babies are supposed to pass a poop, and if they don't, you get a little suspicious, and if it's been over 24 or 48 hours and they still have not stooled their meconium, you get a little bit more suspicious of Hirschsprung disease, although there are a number of other reasons why babies may not stool. Hirschsprung is only one of them. Well, then what happens is the baby's abdomen gets distended. It looks like it's full of air, and then the baby can be irritable and can throw up. And usually around that time, someone is concerned enough to try to do an investigation, figure out whether we're dealing with a case of Hirschsprung disease. And I suppose you said the baby can be fussy, and they probably don't eat well, and they could start to have vomiting as well, too. Now, what if only the very bottom is affected? Do they present in such a dramatic fashion, or could this be something that then maybe gets missed in the newborn period and could present in an older child? Yeah, it's rare, but patients can definitely get out of the newborn period if the Hirschsprung disease is in a very limited portion. And they can actually eat and stool, but never really stool well and always be a little bit distended, but not so much that it draws the attention of a clinician. Sure. And then at some point, the feeding isn't so great, or they're distended, or they're constantly constipated. And then someone says, I wonder if this is one of those rare cases of Hirschsprung disease that's in a little bit of an older child. And then you do the investigation at that point. So it's something kind of to keep in the back of your head if you have a child who's really struggling with constipation issues. Certainly, most kids that struggle with constipation issues, older kids, it's going to be functional constipation. But there is the possibility that it could be one of these rare older kids with Hirschsprung disease. I think those rare Hirschsprung patients have a couple important features for the clinician. First of all, they usually don't grow well. If it's just regular old constipation, its growth and nutrition is usually not a problem. But Hirschsprung, they sort of have this inability to develop well and to grow well. They're also often distended. Their bellies are very distended, usually with air. And then they may have suffered some episodes of diarrhea, which in fact, in retrospect, were enterocolitis, which is the serious form of diarrhea that Hirschsprung's patients get. And you ask a careful history, they say, yes, in fact, he had or she had several episodes of diarrhea to decompress all of this distended bowel. So if you have those features like impactions and constipation, but in addition, episodes of diarrhea and failure to grow or having poor nutrition, that should make you very suspicious that this may be a rare older Hirschsprung's case. Sure. That's great. What other conditions can cause similar signs and symptoms? So if you have a baby who's not passing stool in the immediate newborn period, other than Hirschsprung disease, what other kind of conditions do you entertain? So the clinician needs to make sure there's a way for the stool to actually pass out because there are babies, believe it or not, that are born without an opening for stool. That's called an anorectal malformation or also known as imperfored anus. Careful inspection of that anatomy should reveal the fact that there's a way for the stool to get out. There is a hole, but sometimes there's no hole. Other causes of distention, the baby may have gone through with the mother very difficult delivery. And the mother may have had, for example, a drug called magnesium sulfate, which was intended to slow down the contraction process. That can make the bowels very, very slow for a few days. In addition, hypothyroidism, so a low level of thyroid hormone, can make the bowels very, very slow. And if the baby was subjected to any narcotic via the mother through the placenta, the bowels can get very sleepy and not empty well. And then on a rare occasion, there are actually anatomic problems with the colon, things like colonic atresia or small left colon syndrome, some surgical conditions which cause distention. Great. Cystic fibrosis can sometimes present with some stool problems in the immediate newborn period as well. Yeah, that's actually a very good addition. Cystic fibrosis usually has a pretty classic looking x-ray that distinguishes it, but certainly cystic fibrosis is one of those causes of difficult stooling in the newborn. Great. And imperfored anus is one that you take care of as well. Yeah, in addition to Hirschsprung disease, the other big disease that we handle a lot of are patients born with an anatomic problem of the anus. Now, how do you go about differentiating these things, though? So how is Hirschsprung disease diagnosed? So, first of all, you have to suspect it. And then usually the baby gets an abdominal examination and you feel the distended abdomen. You obviously check that there's a proper anal opening. And then usually we go to a plain abdominal x-ray. And with that x-ray, you can see if the colon is, in fact, the part of the bowel that's dilated. That makes you suspicious of Hirschsprung disease. We then do a more fancy x-ray in which we inject contrast material into the colon. It's called a contrast enema. Some people use the term barium enema. I don't like that term because we don't use barium. Barium is a sort of an old-fashioned substance and we use a better water-soluble contrast material now. But some people use that as the term to describe the test. And that is a key test because what that shows is that the bottom part of the colon is narrow and the more upstream part of the colon is dilated. And then you really have a very strong suspicion that this is Hirschsprung disease. And then we finalize the diagnosis with what's called a rectal biopsy where we take a very tiny bit of tissue right near the anal area on the inside, send that off to the laboratory, and the pathologist can look at that very small piece of colonic tissue. And if the specimen is missing ganglion cells, and if the nerves around the ganglion cells are very thick, that is Hirschsprung disease. You need both those criteria to nail the diagnosis. Then you have a confirmed case of Hirschsprung disease, and then treatment can commence. Sure. Is there any difference in the way that's diagnosed in those rare older kids that may present? Yeah, well, not really any difference. The older kids may have a more dramatic contrast study because they've had more months or years of distention of the colon, but it's the same process. You suspect it, you get a contrast study, and you confirm with a rectal biopsy. Great. Now, how do you go about treating Hirschsprung disease? So the first thing you must do is intervene on the obstructing problem, and that does not require surgery. You need to get the stool and the liquid and the gas out of the baby to break the cycle of the bacteria overgrowth that's being caused by the fact that the bacteria is not moving, and I call that stasis. How do you do that? You take a catheter, a tube, a rubbery tube, and you insert it into the anus, slides right in, and then all the fluid and gas rush out. You might want to step out of the way when you do that. I learned the hard way that you always stand to the side of the baby when you do that. The first time I didn't, but I never repeated that mistake. But that's very an impressive experience, and it really improves the baby's condition quite rapidly. All the distention just relieves, and you have to sort of wash the inner lining of the colon. We call this an irrigation. This is not an enema. Enema is you inject the fluid and you walk away. And irrigation is you literally are washing the inside of the colon. As you put in fluid, you're getting fluid to come back, trying to get all the air and the liquid out. And it's a very satisfying experience when the baby's belly becomes less distended. And they stop crying too. They feel so much better. And that has to be repeated because the cycle will repeat itself if you don't get the stool out because there's no way for them to get the stool out on their own. And we do sort of an irrigation like that for several days sometimes just to decompress, make the baby happy. Sometimes even doing that and letting the baby go home, eat, and then come back for their surgery. But if the conditions are right, we can do irrigations for a few days and then fix them surgically. Great. Talk a little bit about the surgical fix. What do you do? So that is a really neat operation that has changed dramatically. I think of all the things in pediatric surgery, the area that has improved the most for babies is Hirschsprung's disease. Because as recently as 15 or 20 years ago, the management of Hirschsprung's disease would have involved a colostomy, which is a way for the colon to empty onto the abdomen in a bag, diverting the stool from going out the anus, then what's called a pull-through procedure, and then a colostomy closure. Each of those, about a three or four operation occurring over the first six to seven months of that baby's life. Nowadays, with modern techniques, we can actually do the entire operation all through the anus with no incision on the abdomen at all. Wow. And occasionally, if we need a little help, we can use laparoscopy, which is very tiny instruments with no actual incision to help manipulate the colon. But imagine that you could have what was in the past was three operations over six months, now could be an operation done exclusively through the anus itself with no scars, done in the first week of life, and the baby goes home several days thereafter. Yeah, that's amazing. Now, we talked a little bit about the complications, and you'd mentioned enterocolitis and that sort of swamp of stool and bacteria. If Hirschsprung disease is not caught, other than the baby being uncomfortable, sort of what progresses from that enterocolitis that could be a problem, complication-wise? Yeah, so enterocolitis is a very serious condition because essentially the baby is having a diarrhea, but unable to get the diarrhea out. This is something I think a lot of pediatricians don't quite understand with regard to Hirschsprung disease. They're very good, pediatricians are very good at treating diarrhea. Hirschsprung's patients are having diarrhea, but it's not coming out of the anus because it's blocked. So the diarrhea experience is happening inside their colon, and they're getting amazingly dehydrated, but you don't know because there's no diarrhea that you can see. What happens is the bacteria are overgrowing, and the fluid from the baby rushes in and enters the colon, getting the baby very, very dehydrated. So dehydrated that unfortunately, several times a year, even in the United States, there's a baby that dies from Hirschsprung disease, from Hirschsprung disease, enterocolitis. And in the developing world, if that baby doesn't reach medical attention, it's a very common cause of death in the newborn period. Sure. Could you also then get bowel perforation and sepsis, that sort of picture, because you've got all that fluid in the distended colon? So eventually the lining of the colon is inflamed, which allows bacteria to find its way into the bloodstream. We call that translocation. The baby can get very, very ill with an infection in the blood related to the bacteria that had been in the colon. And if the process continues, the bowel can burst in the area where it's most distended. And that can make the baby very, very ill. Luckily, that is extremely rare. And irrigations break that cycle. But if you don't make the diagnosis and if you don't do the irrigations, and if you don't do the irrigations well, that's why I think these babies really need to be managed by very sophisticated neonatal units with very good neonatal nurses that can do these irrigations well. If you don't break that cycle, it progresses to very serious problems. Yep. Which then become much harder to treat. Without a doubt. Yep. What kind of complications can arise from the treatment itself? So the operation itself, if done elegantly, should lead to a baby that stools well, has normal bowel emptying, and 100% normal bowel function. Unfortunately, that is not always the case. And one of the things we take care of a lot at Nationwide Children's is children who have had Hirschsprung's disease surgery that wasn't done perfectly well, and they have been left with some anatomic problem, which essentially is leading to problems such as, and they basically come in two forms, the inability to empty or fecal incontinence. And we see a lot of morbidity related to Hirschsprung's disease. And in almost every case, the anatomic problem can be defined and fixed. So it's important to know that Hirschsprung's is not one of these conditions that if they're not doing well, they'll just get better over time. I don't believe that. I think Hirschsprung's should be, a child with Hirschsprung's can be essentially a cure. They can stool well on their own, and they can be potty trained for stool and clean and in normal underwear. And if they're not, we're obligated to figure out why not. So there may be a lot of folks listening to this program who've had a child with Hirschsprung disease, and their experience has been that there continue to be issues. So this is something those kids really ought to be seen at a center that really focuses on Hirschsprung like we have here at Nationwide Children's. I'm passionate to try to find those patients because with a very simple algorithm of evaluation, which essentially includes a contrast study to see what the current state of the colon is, a biopsy to make sure that whatever was pulled through was good bowel, and an examination of the actual segment that was pulled through with the surgeon's eyes qualified to evaluate a Hirschsprung's case. In almost every case, we can figure out the anatomic cause, and then there is almost always a medical or surgical treatment to solve that problem, leading the baby to having a normal ability to empty. Sure. So we kind of covered there what the long-term outcome of Hirschsprung disease. It can be good. It isn't always, but if it's not, you ought to be seeing someone to figure out why. I 100% agree with that. Yep. Any way to prevent Hirschsprung disease from happening in the first place? No, I'd love to put myself out of business, but it's not. I think the answer will be when we find the genetics, and who knows, there may be some way to avoid the genetic change that occurs in the development, but we're not there yet. And we talked about cure, so this is something that if managed correctly, you hope to have a cure and not have issues down the road. Yeah, and interestingly, though, even though you have a perfectly done operation and there's no Hirschsprungs left in the baby, a lot of those babies don't empty great. They have a little bit of constipation, something we don't understand. Why would the colon that is anatomically normal still not be perfect? But those babies can be easily managed with a little bit of laxatives and some very minor modifications in their diet. Kind of like you would with functional constipation. Precisely. It's a fairly easy fix. I don't want to make the, I want to say that everyone is perfect when they have a good operation. There is some tinkering that's required, but it's usually relatively minor stuff. Sure. What are the hot topics in Hirschsprung disease research right now? So there really are two, in my view. It's the genetics to find the exact gene. And the second is to try to understand enterocolitis because enterocolitis is a mystery. You know, if a normal baby without Hirschsprung disease were to get impacted or have constipation, they won't get sick like a Hirschsprung's patient will. They won't have the bacterial problem and the translocation. There's something unique about the lining of the bowel in Hirschsprung's disease that makes them more susceptible to getting so ill related to stasis of stool. And it's not something that's well understood. I think perhaps another area is to try to figure out why the colon even though it's been fixed sometimes still moves a little slow. And that's an area of very aggressive research. And my partner team in the motility group here led by Carlo DeLorenzo who is the world's expert on pediatric motility disorders is trying to investigate what are the medical reasons why colons don't empty. And that collaboration collaboration between the two teams is really going to be very exciting because I think we'll hopefully come up with some of the answers to these questions. And ultimately make a difference in a lot of kids' lives. Well, that's the goal. That's why we get up in the morning. Tell us a little bit about the Center for Colorectal and Public Reconstruction at Nationwide Children's. So my concept was to recognize that colorectal problems was only one small part of the overall series of problems that babies can get with the colon and the pelvis. So what we attempted to do and Nationwide Children's was crazy enough to agree to this idea was to take four relatively independent teams and I can tell you at all institutions around the world the four teams which include the colorectal surgical team, the urologic team, the gynecology team, and the gastroenterologist focused on motility team. Those are four different teams in most institutions. At Nationwide, those four teams have come together and have been unified in one cooperative called the CCPR, the Center for Colorectal and Pelvic Reconstruction. The idea being that if a patient has a problem at all related to the colon or the pelvis and the pelvis is the part of the body that includes the colon, the rectum, the bladder, and the gynecologic structures. If a child has a problem anywhere in that zone of the body, they just need to call one phone number or send one email and we will figure out which team members need to be mobilized to solve that problem. Very commonly, patients have a colorectal and a urologic problem. Very commonly, they have a colorectal and a GI motility problem. And then on occasion, the gynecology piece gets added in and we have partners in all four of these areas that actively meet weekly to discuss the collaborative patients. Sure. And I can imagine that this would get really frustrating for a lot of parents who are at other institutions where you have these different teams and you may have trouble getting them to communicate with one another or things get duplicated or so, I mean, this is just fantastic to be able to have all these resources in one place. That was the idea behind the center to call one phone number and then we would take it from there and figure out what clinicians, what nurses, and what doctors the family needs because normally what happens is you have to call all these different offices. You may have different appointments over about six to seven months. The doctors don't necessarily talk or communicate and then particularly relevant not only in the evaluation process but the surgery has to be cooperatively planned. So there are many times where I am both myself or one of my colorectal partners is in the operating room with urology and we are discussing the anatomy right there and deciding what part of the colon needs to be moved to make the bladder surgery easier and if all the clinicians are not assembled around that child at the same time you can't get as good an operation. And then I would imagine you also have resources like a dietician, nutrition folks if a kid would need it and mental health, psychology, social work, that kind of thing all right there in the center as well. Sure. Many aspects of the center but some of the key partners are psychology, nutrition, social work, anesthesia, radiology. Every one of the patients may need one or many of these services and they're also part of the collaborative. And with this level of expertise and cooperation among multiple disciplines I'm sure there are many children even from outside Ohio that would benefit from these services. you do see folks from out of state even out of country. So far I've taken care of patients from all 50 states and from 88 countries because there's a great need out there for colorectal solutions and yes, we hope to be a hub for caring for these children and not only having them come to Nationwide for help, we recognize that many of these patients cannot do that but we're very focused on education. we try to write a lot we go forth with the team around the world to do teaching and actually perform surgery. Our team has several upcoming trips in the next couple of years we're going to Cape Town, South Africa soon to collaborate with the Red Cross Hospital there that is becoming the colorectal center for the continent of Africa. We have collaborations with the Netherlands and Germany in Europe. we are headed next year to Costa Rica to create a collaborative for Central America and then back to Asia we were just in China back to Asia in Thailand will be in August of 2015. Wow, that's really amazing and making a difference for kids all around the world. That's great. That's the goal. It's really easy folks out there maybe listening and thinking how do I get my kid involved here because they have one of these issues or they've had surgery and things aren't going so well. We want to make it easy for families to get in touch with you and also for practitioners so if there's pediatricians, family practice doctors, nurse practitioners who are listening right now and a particular family or child comes to mind we want to make it easy for folks to get in touch with you. So those of you out there listening it's easy just go to pediacast.org click on the show notes for episode 287 that's this particular episode and we'll have a link there that says connect now with a colorectal specialist and if you click that link it'll take you to the welcome center you put in some demographic details and how you want to get connected and folks from our colorectal center will get back in touch with you and we can make the connection and go from there. Yeah and I would suggest that we're happy to provide advice we're happy to work with clinicians around the country and the world don't necessarily that we need the patient to be seen because there's a lot of skilled clinicians out there that just need a little advice or how to do the workup so we are open for those kind of communications as well the family wants to contact us and just ask various questions we have to figure out whether they need to be seen in person but we really want to have open access to try to solve these problems as quickly as we can. It's great we really appreciate you stopping by and talking to us today about Hirschsprung disease my pleasure thanks for having me yep absolutely all right we are going to take a quick break and I will be back to wrap things up right after this all right we are back with just enough time to say thank you to all my listeners out there really appreciate you taking time out of your day to make PDA Cast a part of it by the way if you found PDA Cast today because maybe you were doing a google search for Hirschsprung disease or Dr. Mark Leavitt in other words if this is your first listen to the program be sure to head over to PDA Cast.org we have 286 other shows for you covering a plethora of pediatric and parenting topics also want to thank Dr. Mark Leavitt surgical director of the Center for Colorectal and Pelvic Reconstruction at Nationwide Children's Hospital thanks to him for joining us and sharing his expertise on Hirschsprung's disease don't forget if you know someone who could benefit from a Dr. Leavitt's work just head over to PDA Cast.org look for episode number 287 that's this one and you'll find a convenient link connect now with a colorectal specialist at Nationwide Children's so I have to do it's easy and we'll get back in touch with you that does wrap up our time together PDA Cast is a production of Nationwide Children's Hospital don't forget PDA Cast and our single topic short format program PDA Bytes are both available on iHeartRadio Talk which you'll find on the web at iHeart.com and the iHeartRadio app for mobile devices our show archive which at last count includes 287 programs as well as our show notes transcriptions terms of use and contact page are available at our landing site which again is PDA Cast.org we're also on iTunes under the kids and family section of their podcast directory you'll find PDA Cast on Stitcher TuneIn Downcast iCatcher PodBay and most other podcasting apps for iPhone and Android we're also on Facebook Twitter Google Plus and Pinterest and of course we really appreciate you connecting with us there and sharing retweeting and repinning all of our posts so you can tell your own online audience about our little show we also appreciate you talking us up with your family friends neighbors and co-workers anyone with kids or anyone who takes care of children and as always be sure to tell your child's doctor about the program posters are available under the resources tab at PDA Cast.org until next time this is Dr. Mike saying stay safe stay healthy and stay involved with your kids so long everybody this program is a production of Nationwide Children's thanks for listening we'll see you next time on PDA Cast PDA Cast