Steven Kraus

594 statements · 4 topics · summaries given as host listed separately

Colorectal / ARM & Hirschsprung · guest expert

Featured statements

▶ Ep 18 · 23:10
Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 10 · 14:16
if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 1 · 23:01
Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part
quote · Enterocolitis
▶ Ep 1 · 10:33
The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate.
quote · Enterocolitis
▶ Ep 4 · 30:59
I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is.
quote · Enterocolitis
▶ Ep 1 · 24:40
if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time.
quote · Enterocolitis

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Evaluation & Management Of Hirschsprung's Disease

▶ Ep 10 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 10 · 1:02
opinion Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art. ↗
▶ Ep 10 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 10 · 1:02
opinion Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art. ↗
▶ Ep 10 · 1:41
clinical Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 10 · 1:41
clinical Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 10 · 3:23
clinical In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 10 · 3:23
clinical In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 10 · 3:57
clinical The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases. ↗
▶ Ep 10 · 3:57
clinical The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases. ↗
▶ Ep 10 · 5:32
clinical Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease. ↗
▶ Ep 10 · 5:32
clinical Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease. ↗
▶ Ep 10 · 5:43
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 10 · 5:43
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 10 · 6:58
clinical Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis. ↗
▶ Ep 10 · 6:58
clinical Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis. ↗
▶ Ep 10 · 8:14
clinical Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise. ↗
▶ Ep 10 · 8:14
clinical Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise. ↗
▶ Ep 10 · 8:14
quote enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 10 · 8:14
quote enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 10 · 9:46
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 10 · 9:46
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 10 · 10:33
epidemiological The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies. ↗
▶ Ep 10 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 10 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 10 · 10:33
epidemiological The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies. ↗
▶ Ep 10 · 11:04
clinical Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate. ↗
▶ Ep 10 · 11:04
clinical Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate. ↗
▶ Ep 10 · 11:20
epidemiological The false positive transition zone rate on enema is up to 43%. ↗
▶ Ep 10 · 11:20
epidemiological The false positive transition zone rate on enema is up to 43%. ↗
▶ Ep 10 · 11:35
epidemiological Radiologist agreement on transition zone location is fairly high at 90%. ↗
▶ Ep 10 · 11:35
epidemiological Radiologist agreement on transition zone location is fairly high at 90%. ↗
▶ Ep 10 · 11:47
quote the concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss. ↗
▶ Ep 10 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location is only about 62% overall. ↗
▶ Ep 10 · 11:47
quote the concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss. ↗
▶ Ep 10 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location is only about 62% overall. ↗
▶ Ep 10 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%. ↗
▶ Ep 10 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%. ↗
▶ Ep 10 · 13:54
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%. ↗
▶ Ep 10 · 13:54
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%. ↗
▶ Ep 10 · 13:54
quote if you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%. ↗
▶ Ep 10 · 13:54
quote if you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%. ↗
▶ Ep 10 · 14:05
clinical If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization. ↗
▶ Ep 10 · 14:05
clinical If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization. ↗
▶ Ep 10 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 10 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 10 · 14:29
opinion In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization. ↗
▶ Ep 10 · 14:29
opinion In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization. ↗
▶ Ep 10 · 21:42
clinical Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains. ↗
▶ Ep 10 · 21:42
clinical Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains. ↗
▶ Ep 10 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly. ↗
▶ Ep 10 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly. ↗
▶ Ep 10 · 23:01
clinical Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe. ↗
▶ Ep 10 · 23:01
clinical Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe. ↗
▶ Ep 10 · 23:01
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part ↗
▶ Ep 10 · 23:01
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part ↗
▶ Ep 10 · 23:30
clinical If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus. ↗
▶ Ep 10 · 23:30
clinical If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus. ↗
▶ Ep 10 · 23:47
clinical Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants. ↗
▶ Ep 10 · 23:47
clinical Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants. ↗
▶ Ep 10 · 24:03
clinical A true lateral image with femurs superimposed is essential to visualize the presacral space properly. ↗
▶ Ep 10 · 24:03
clinical A true lateral image with femurs superimposed is essential to visualize the presacral space properly. ↗
▶ Ep 10 · 24:18
clinical In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum. ↗
▶ Ep 10 · 24:18
clinical In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum. ↗
▶ Ep 10 · 24:40
quote if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 10 · 24:40
clinical If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis. ↗
▶ Ep 10 · 24:40
clinical If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis. ↗
▶ Ep 10 · 24:40
quote if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 10 · 25:04
clinical Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology. ↗
▶ Ep 10 · 25:04
clinical Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology. ↗
▶ Ep 10 · 25:30
clinical In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small. ↗
▶ Ep 10 · 25:30
clinical In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small. ↗
▶ Ep 10 · 25:42
clinical In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung. ↗
▶ Ep 10 · 25:42
clinical In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung. ↗
▶ Ep 10 · 26:03
clinical Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy. ↗
▶ Ep 10 · 26:03
clinical Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy. ↗
▶ Ep 10 · 26:15
clinical In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced. ↗
▶ Ep 10 · 26:15
clinical In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced. ↗
▶ Ep 10 · 28:06
clinical Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 10 · 28:06
clinical Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 10 · 29:30
clinical The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure. ↗
▶ Ep 10 · 29:30
clinical The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure. ↗
▶ Ep 10 · 29:51
clinical A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum. ↗
▶ Ep 10 · 29:51
clinical A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum. ↗
▶ Ep 10 · 30:51
clinical When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests. ↗
▶ Ep 10 · 30:51
clinical When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests. ↗
▶ Ep 10 · 31:07
opinion If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain. ↗
▶ Ep 10 · 31:07
opinion If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain. ↗
▶ Ep 10 · 34:18
clinical In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view. ↗
▶ Ep 10 · 34:18
clinical In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view. ↗
▶ Ep 10 · 34:55
clinical A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space. ↗
▶ Ep 10 · 34:55
clinical A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space. ↗
▶ Ep 10 · 35:51
clinical The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end. ↗
▶ Ep 10 · 35:51
clinical The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end. ↗
▶ Ep 10 · 36:13
clinical In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction. ↗
▶ Ep 10 · 36:13
clinical In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction. ↗

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 18 · 1:02
opinion In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art. ↗
▶ Ep 18 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 18 · 1:02
opinion In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art. ↗
▶ Ep 18 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 18 · 2:26
clinical Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 18 · 2:26
clinical Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 18 · 3:23
clinical In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 18 · 3:23
clinical In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 18 · 3:35
clinical Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel. ↗
▶ Ep 18 · 3:35
clinical Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel. ↗
▶ Ep 18 · 4:00
epidemiological The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases. ↗
▶ Ep 18 · 4:00
epidemiological The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases. ↗
▶ Ep 18 · 5:04
clinical Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis. ↗
▶ Ep 18 · 5:04
clinical Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis. ↗
▶ Ep 18 · 5:32
clinical Seeing air in the rectum does not rule out Hirschsprung disease. ↗
▶ Ep 18 · 5:32
clinical Seeing air in the rectum does not rule out Hirschsprung disease. ↗
▶ Ep 18 · 6:18
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 18 · 6:18
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 18 · 6:58
clinical Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon. ↗
▶ Ep 18 · 6:58
clinical Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon. ↗
▶ Ep 18 · 8:14
quote Enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 18 · 8:14
clinical Enterocolitis in a newborn is Hirschsprung disease until proven otherwise. ↗
▶ Ep 18 · 8:14
clinical Enterocolitis in a newborn is Hirschsprung disease until proven otherwise. ↗
▶ Ep 18 · 8:14
quote Enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 18 · 8:32
clinical Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case. ↗
▶ Ep 18 · 8:32
clinical Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case. ↗
▶ Ep 18 · 10:22
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 18 · 10:22
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 18 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 18 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 18 · 10:33
epidemiological The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies. ↗
▶ Ep 18 · 10:43
opinion The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%. ↗
▶ Ep 18 · 10:43
opinion The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%. ↗
▶ Ep 18 · 11:04
clinical Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema. ↗
▶ Ep 18 · 11:04
clinical Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema. ↗
▶ Ep 18 · 11:10
clinical Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed. ↗
▶ Ep 18 · 11:10
clinical Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed. ↗
▶ Ep 18 · 11:20
epidemiological The false positive transition zone rate is up to 43%. ↗
▶ Ep 18 · 11:35
epidemiological A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%. ↗
▶ Ep 18 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss. ↗
▶ Ep 18 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%. ↗
▶ Ep 18 · 13:43
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%. ↗
▶ Ep 18 · 14:05
clinical If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location. ↗
▶ Ep 18 · 14:05
clinical If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location. ↗
▶ Ep 18 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 18 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 18 · 14:39
clinical In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation. ↗
▶ Ep 18 · 14:39
clinical In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation. ↗
▶ Ep 18 · 21:42
clinical Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon. ↗
▶ Ep 18 · 21:42
clinical Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon. ↗
▶ Ep 18 · 22:05
clinical If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this. ↗
▶ Ep 18 · 22:05
clinical If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this. ↗
▶ Ep 18 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly. ↗
▶ Ep 18 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly. ↗
▶ Ep 18 · 23:10
clinical Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe. ↗
▶ Ep 18 · 23:10
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it. ↗
▶ Ep 18 · 23:10
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it. ↗
▶ Ep 18 · 23:10
clinical Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe. ↗
▶ Ep 18 · 23:30
clinical If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present. ↗
▶ Ep 18 · 23:30
clinical If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present. ↗
▶ Ep 18 · 23:47
clinical Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants. ↗
▶ Ep 18 · 23:47
clinical Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants. ↗
▶ Ep 18 · 24:03
clinical On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view. ↗
▶ Ep 18 · 24:03
clinical On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view. ↗
▶ Ep 18 · 24:11
clinical On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone. ↗
▶ Ep 18 · 24:11
clinical On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone. ↗
▶ Ep 18 · 24:22
clinical In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum. ↗
▶ Ep 18 · 24:22
clinical In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum. ↗
▶ Ep 18 · 24:40
quote If you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 18 · 24:40
clinical If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time. ↗
▶ Ep 18 · 24:40
clinical If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time. ↗
▶ Ep 18 · 24:40
quote If you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 18 · 24:51
clinical Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon. ↗
▶ Ep 18 · 24:51
clinical Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon. ↗
▶ Ep 18 · 25:04
clinical Rectosigmoid transition cases are usually concordant pathologically and radiologically. ↗
▶ Ep 18 · 25:04
clinical Rectosigmoid transition cases are usually concordant pathologically and radiologically. ↗
▶ Ep 18 · 25:30
clinical In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease. ↗
▶ Ep 18 · 25:30
clinical In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease. ↗
▶ Ep 18 · 25:47
clinical The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung. ↗
▶ Ep 18 · 25:47
clinical The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung. ↗
▶ Ep 18 · 26:03
quote I would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy. ↗
▶ Ep 18 · 26:03
clinical Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy. ↗
▶ Ep 18 · 26:03
clinical Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy. ↗
▶ Ep 18 · 26:03
quote I would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy. ↗
▶ Ep 18 · 26:15
clinical If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy. ↗
▶ Ep 18 · 26:15
clinical If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy. ↗
▶ Ep 18 · 27:30
clinical If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition. ↗
▶ Ep 18 · 27:30
clinical If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition. ↗
▶ Ep 18 · 28:06
clinical Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 18 · 28:06
clinical Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 18 · 29:51
clinical A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition. ↗
▶ Ep 18 · 29:51
clinical A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition. ↗
▶ Ep 18 · 30:59
quote I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is. ↗
▶ Ep 18 · 30:59
clinical If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach. ↗
▶ Ep 18 · 30:59
clinical If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach. ↗
▶ Ep 18 · 30:59
quote I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is. ↗
▶ Ep 18 · 34:18
clinical In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view. ↗
▶ Ep 18 · 34:18
clinical In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view. ↗
▶ Ep 18 · 34:59
clinical It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space. ↗
▶ Ep 18 · 34:59
clinical It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space. ↗
▶ Ep 18 · 35:56
clinical The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork. ↗
▶ Ep 18 · 35:56
clinical The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork. ↗
▶ Ep 18 · 36:13
clinical In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction. ↗
▶ Ep 18 · 36:13
clinical In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction. ↗
Steven's statements about Enterocolitis 97 statements

Open the Enterocolitis collection →

Evaluation & Management Of Hirschsprung's Disease

▶ Ep 1 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 1 · 1:02
opinion Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art. ↗
▶ Ep 1 · 1:41
clinical Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 1 · 3:23
clinical In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 1 · 3:57
clinical The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases. ↗
▶ Ep 1 · 5:32
clinical Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease. ↗
▶ Ep 1 · 5:43
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 1 · 6:58
clinical Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis. ↗
▶ Ep 1 · 8:14
clinical Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise. ↗
▶ Ep 1 · 8:14
quote enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 1 · 9:46
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 1 · 10:33
epidemiological The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies. ↗
▶ Ep 1 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 1 · 11:04
clinical Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate. ↗
▶ Ep 1 · 11:20
epidemiological The false positive transition zone rate on enema is up to 43%. ↗
▶ Ep 1 · 11:35
epidemiological Radiologist agreement on transition zone location is fairly high at 90%. ↗
▶ Ep 1 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location is only about 62% overall. ↗
▶ Ep 1 · 11:47
quote the concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss. ↗
▶ Ep 1 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%. ↗
▶ Ep 1 · 13:54
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%. ↗
▶ Ep 1 · 13:54
quote if you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%. ↗
▶ Ep 1 · 14:05
clinical If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization. ↗
▶ Ep 1 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 1 · 14:29
opinion In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization. ↗
▶ Ep 1 · 21:42
clinical Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains. ↗
▶ Ep 1 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly. ↗
▶ Ep 1 · 23:01
clinical Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe. ↗
▶ Ep 1 · 23:01
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part ↗
▶ Ep 1 · 23:30
clinical If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus. ↗
▶ Ep 1 · 23:47
clinical Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants. ↗
▶ Ep 1 · 24:03
clinical A true lateral image with femurs superimposed is essential to visualize the presacral space properly. ↗
▶ Ep 1 · 24:18
clinical In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum. ↗
▶ Ep 1 · 24:40
quote if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 1 · 24:40
clinical If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis. ↗
▶ Ep 1 · 25:04
clinical Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology. ↗
▶ Ep 1 · 25:30
clinical In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small. ↗
▶ Ep 1 · 25:42
clinical In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung. ↗
▶ Ep 1 · 26:03
clinical Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy. ↗
▶ Ep 1 · 26:15
clinical In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced. ↗
▶ Ep 1 · 28:06
clinical Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 1 · 29:30
clinical The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure. ↗
▶ Ep 1 · 29:51
clinical A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum. ↗
▶ Ep 1 · 30:51
clinical When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests. ↗
▶ Ep 1 · 31:07
opinion If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain. ↗
▶ Ep 1 · 34:18
clinical In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view. ↗
▶ Ep 1 · 34:55
clinical A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space. ↗
▶ Ep 1 · 35:51
clinical The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end. ↗
▶ Ep 1 · 36:13
clinical In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction. ↗

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 4 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 4 · 1:02
opinion In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art. ↗
▶ Ep 4 · 2:26
clinical Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 4 · 3:23
clinical In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 4 · 3:35
clinical Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel. ↗
▶ Ep 4 · 4:00
epidemiological The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases. ↗
▶ Ep 4 · 5:04
clinical Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis. ↗
▶ Ep 4 · 5:32
clinical Seeing air in the rectum does not rule out Hirschsprung disease. ↗
▶ Ep 4 · 6:18
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 4 · 6:58
clinical Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon. ↗
▶ Ep 4 · 8:14
clinical Enterocolitis in a newborn is Hirschsprung disease until proven otherwise. ↗
▶ Ep 4 · 8:14
quote Enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 4 · 8:32
clinical Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case. ↗
▶ Ep 4 · 10:22
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 4 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 4 · 10:43
opinion The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%. ↗
▶ Ep 4 · 11:04
clinical Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema. ↗
▶ Ep 4 · 11:10
clinical Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed. ↗
▶ Ep 4 · 14:05
clinical If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location. ↗
▶ Ep 4 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 4 · 14:39
clinical In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation. ↗
▶ Ep 4 · 21:42
clinical Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon. ↗
▶ Ep 4 · 22:05
clinical If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this. ↗
▶ Ep 4 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly. ↗
▶ Ep 4 · 23:10
clinical Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe. ↗
▶ Ep 4 · 23:10
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it. ↗
▶ Ep 4 · 23:30
clinical If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present. ↗
▶ Ep 4 · 23:47
clinical Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants. ↗
▶ Ep 4 · 24:03
clinical On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view. ↗
▶ Ep 4 · 24:11
clinical On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone. ↗
▶ Ep 4 · 24:22
clinical In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum. ↗
▶ Ep 4 · 24:40
clinical If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time. ↗
▶ Ep 4 · 24:40
quote If you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 4 · 24:51
clinical Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon. ↗
▶ Ep 4 · 25:04
clinical Rectosigmoid transition cases are usually concordant pathologically and radiologically. ↗
▶ Ep 4 · 25:30
clinical In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease. ↗
▶ Ep 4 · 25:47
clinical The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung. ↗
▶ Ep 4 · 26:03
quote I would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy. ↗
▶ Ep 4 · 26:03
clinical Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy. ↗
▶ Ep 4 · 26:15
clinical If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy. ↗
▶ Ep 4 · 27:30
clinical If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition. ↗
▶ Ep 4 · 28:06
clinical Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 4 · 29:51
clinical A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition. ↗
▶ Ep 4 · 30:59
quote I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is. ↗
▶ Ep 4 · 30:59
clinical If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach. ↗
▶ Ep 4 · 34:18
clinical In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view. ↗
▶ Ep 4 · 34:59
clinical It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space. ↗
▶ Ep 4 · 35:56
clinical The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork. ↗
▶ Ep 4 · 36:13
clinical In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction. ↗
Steven's statements about Enterocolitis 97 statements

Open the Enterocolitis collection →

Evaluation & Management Of Hirschsprung's Disease

▶ Ep 1 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 1 · 1:02
opinion Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art. ↗
▶ Ep 1 · 1:41
clinical Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 1 · 3:23
clinical In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 1 · 3:57
clinical The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases. ↗
▶ Ep 1 · 5:32
clinical Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease. ↗
▶ Ep 1 · 5:43
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 1 · 6:58
clinical Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis. ↗
▶ Ep 1 · 8:14
clinical Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise. ↗
▶ Ep 1 · 8:14
quote enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 1 · 9:46
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 1 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 1 · 10:33
epidemiological The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies. ↗
▶ Ep 1 · 11:04
clinical Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate. ↗
▶ Ep 1 · 11:20
epidemiological The false positive transition zone rate on enema is up to 43%. ↗
▶ Ep 1 · 11:35
epidemiological Radiologist agreement on transition zone location is fairly high at 90%. ↗
▶ Ep 1 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location is only about 62% overall. ↗
▶ Ep 1 · 11:47
quote the concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss. ↗
▶ Ep 1 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%. ↗
▶ Ep 1 · 13:54
quote if you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%. ↗
▶ Ep 1 · 13:54
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%. ↗
▶ Ep 1 · 14:05
clinical If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization. ↗
▶ Ep 1 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 1 · 14:29
opinion In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization. ↗
▶ Ep 1 · 21:42
clinical Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains. ↗
▶ Ep 1 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly. ↗
▶ Ep 1 · 23:01
clinical Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe. ↗
▶ Ep 1 · 23:01
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part ↗
▶ Ep 1 · 23:30
clinical If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus. ↗
▶ Ep 1 · 23:47
clinical Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants. ↗
▶ Ep 1 · 24:03
clinical A true lateral image with femurs superimposed is essential to visualize the presacral space properly. ↗
▶ Ep 1 · 24:18
clinical In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum. ↗
▶ Ep 1 · 24:40
clinical If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis. ↗
▶ Ep 1 · 24:40
quote if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 1 · 25:04
clinical Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology. ↗
▶ Ep 1 · 25:30
clinical In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small. ↗
▶ Ep 1 · 25:42
clinical In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung. ↗
▶ Ep 1 · 26:03
clinical Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy. ↗
▶ Ep 1 · 26:15
clinical In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced. ↗
▶ Ep 1 · 28:06
clinical Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 1 · 29:30
clinical The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure. ↗
▶ Ep 1 · 29:51
clinical A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum. ↗
▶ Ep 1 · 30:51
clinical When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests. ↗
▶ Ep 1 · 31:07
opinion If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain. ↗
▶ Ep 1 · 34:18
clinical In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view. ↗
▶ Ep 1 · 34:55
clinical A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space. ↗
▶ Ep 1 · 35:51
clinical The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end. ↗
▶ Ep 1 · 36:13
clinical In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction. ↗

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 4 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 4 · 1:02
opinion In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art. ↗
▶ Ep 4 · 2:26
clinical Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 4 · 3:23
clinical In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 4 · 3:35
clinical Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel. ↗
▶ Ep 4 · 4:00
epidemiological The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases. ↗
▶ Ep 4 · 5:04
clinical Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis. ↗
▶ Ep 4 · 5:32
clinical Seeing air in the rectum does not rule out Hirschsprung disease. ↗
▶ Ep 4 · 6:18
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 4 · 6:58
clinical Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon. ↗
▶ Ep 4 · 8:14
clinical Enterocolitis in a newborn is Hirschsprung disease until proven otherwise. ↗
▶ Ep 4 · 8:14
quote Enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 4 · 8:32
clinical Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case. ↗
▶ Ep 4 · 10:22
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 4 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 4 · 10:43
opinion The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%. ↗
▶ Ep 4 · 11:04
clinical Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema. ↗
▶ Ep 4 · 11:10
clinical Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed. ↗
▶ Ep 4 · 14:05
clinical If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location. ↗
▶ Ep 4 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 4 · 14:39
clinical In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation. ↗
▶ Ep 4 · 21:42
clinical Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon. ↗
▶ Ep 4 · 22:05
clinical If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this. ↗
▶ Ep 4 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly. ↗
▶ Ep 4 · 23:10
clinical Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe. ↗
▶ Ep 4 · 23:10
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it. ↗
▶ Ep 4 · 23:30
clinical If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present. ↗
▶ Ep 4 · 23:47
clinical Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants. ↗
▶ Ep 4 · 24:03
clinical On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view. ↗
▶ Ep 4 · 24:11
clinical On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone. ↗
▶ Ep 4 · 24:22
clinical In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum. ↗
▶ Ep 4 · 24:40
clinical If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time. ↗
▶ Ep 4 · 24:40
quote If you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 4 · 24:51
clinical Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon. ↗
▶ Ep 4 · 25:04
clinical Rectosigmoid transition cases are usually concordant pathologically and radiologically. ↗
▶ Ep 4 · 25:30
clinical In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease. ↗
▶ Ep 4 · 25:47
clinical The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung. ↗
▶ Ep 4 · 26:03
quote I would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy. ↗
▶ Ep 4 · 26:03
clinical Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy. ↗
▶ Ep 4 · 26:15
clinical If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy. ↗
▶ Ep 4 · 27:30
clinical If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition. ↗
▶ Ep 4 · 28:06
clinical Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 4 · 29:51
clinical A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition. ↗
▶ Ep 4 · 30:59
quote I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is. ↗
▶ Ep 4 · 30:59
clinical If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach. ↗
▶ Ep 4 · 34:18
clinical In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view. ↗
▶ Ep 4 · 34:59
clinical It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space. ↗
▶ Ep 4 · 35:56
clinical The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork. ↗
▶ Ep 4 · 36:13
clinical In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction. ↗
Steven's statements about Hirschsprung disease 200 statements

Open the Hirschsprung disease collection →

Evaluation & Management Of Hirschsprung's Disease

▶ Ep 2 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 2 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 2 · 1:02
opinion Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art. ↗
▶ Ep 2 · 1:02
opinion Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art. ↗
▶ Ep 2 · 1:41
clinical Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 2 · 1:41
clinical Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 2 · 3:23
clinical In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 2 · 3:23
clinical In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 2 · 3:57
clinical The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases. ↗
▶ Ep 2 · 3:57
clinical The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases. ↗
▶ Ep 2 · 5:32
clinical Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease. ↗
▶ Ep 2 · 5:32
clinical Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease. ↗
▶ Ep 2 · 5:43
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 2 · 5:43
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 2 · 6:58
clinical Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis. ↗
▶ Ep 2 · 6:58
clinical Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis. ↗
▶ Ep 2 · 8:14
clinical Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise. ↗
▶ Ep 2 · 8:14
quote enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 2 · 8:14
quote enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 2 · 8:14
clinical Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise. ↗
▶ Ep 2 · 9:46
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 2 · 9:46
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 2 · 10:33
epidemiological The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies. ↗
▶ Ep 2 · 10:33
epidemiological The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies. ↗
▶ Ep 2 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 2 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 2 · 11:04
clinical Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate. ↗
▶ Ep 2 · 11:04
clinical Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate. ↗
▶ Ep 2 · 11:20
epidemiological The false positive transition zone rate on enema is up to 43%. ↗
▶ Ep 2 · 11:20
epidemiological The false positive transition zone rate on enema is up to 43%. ↗
▶ Ep 2 · 11:35
epidemiological Radiologist agreement on transition zone location is fairly high at 90%. ↗
▶ Ep 2 · 11:35
epidemiological Radiologist agreement on transition zone location is fairly high at 90%. ↗
▶ Ep 2 · 11:47
quote the concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss. ↗
▶ Ep 2 · 11:47
quote the concordance rate for the radiology and pathology, however, was not very good, uh, almost a coin toss, a little bit over a coin toss. ↗
▶ Ep 2 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location is only about 62% overall. ↗
▶ Ep 2 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location is only about 62% overall. ↗
▶ Ep 2 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%. ↗
▶ Ep 2 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%. ↗
▶ Ep 2 · 13:54
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%. ↗
▶ Ep 2 · 13:54
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%. ↗
▶ Ep 2 · 13:54
quote if you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%. ↗
▶ Ep 2 · 13:54
quote if you look at the long segment disease, meaning that somewhere in the, uh, in the descending colon of the splenic flexure or even more proximately, uh, the concordance was only about 25%. ↗
▶ Ep 2 · 14:05
clinical If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization. ↗
▶ Ep 2 · 14:05
clinical If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization. ↗
▶ Ep 2 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 2 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 2 · 14:29
opinion In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization. ↗
▶ Ep 2 · 14:29
opinion In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization. ↗
▶ Ep 2 · 21:42
clinical Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains. ↗
▶ Ep 2 · 21:42
clinical Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains. ↗
▶ Ep 2 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly. ↗
▶ Ep 2 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly. ↗
▶ Ep 2 · 23:01
clinical Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe. ↗
▶ Ep 2 · 23:01
clinical Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe. ↗
▶ Ep 2 · 23:01
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part ↗
▶ Ep 2 · 23:01
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part ↗
▶ Ep 2 · 23:30
clinical If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus. ↗
▶ Ep 2 · 23:30
clinical If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus. ↗
▶ Ep 2 · 23:47
clinical Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants. ↗
▶ Ep 2 · 23:47
clinical Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants. ↗
▶ Ep 2 · 24:03
clinical A true lateral image with femurs superimposed is essential to visualize the presacral space properly. ↗
▶ Ep 2 · 24:03
clinical A true lateral image with femurs superimposed is essential to visualize the presacral space properly. ↗
▶ Ep 2 · 24:18
clinical In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum. ↗
▶ Ep 2 · 24:18
clinical In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum. ↗
▶ Ep 2 · 24:40
clinical If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis. ↗
▶ Ep 2 · 24:40
clinical If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis. ↗
▶ Ep 2 · 24:40
quote if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 2 · 24:40
quote if you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 2 · 25:04
clinical Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology. ↗
▶ Ep 2 · 25:04
clinical Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology. ↗
▶ Ep 2 · 25:30
clinical In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small. ↗
▶ Ep 2 · 25:30
clinical In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small. ↗
▶ Ep 2 · 25:42
clinical In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung. ↗
▶ Ep 2 · 25:42
clinical In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung. ↗
▶ Ep 2 · 26:03
clinical Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy. ↗
▶ Ep 2 · 26:03
clinical Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy. ↗
▶ Ep 2 · 26:15
clinical In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced. ↗
▶ Ep 2 · 26:15
clinical In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced. ↗
▶ Ep 2 · 28:06
clinical Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 2 · 28:06
clinical Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 2 · 29:30
clinical The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure. ↗
▶ Ep 2 · 29:30
clinical The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure. ↗
▶ Ep 2 · 29:51
clinical A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum. ↗
▶ Ep 2 · 29:51
clinical A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum. ↗
▶ Ep 2 · 30:51
clinical When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests. ↗
▶ Ep 2 · 30:51
clinical When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests. ↗
▶ Ep 2 · 31:07
opinion If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain. ↗
▶ Ep 2 · 31:07
opinion If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain. ↗
▶ Ep 2 · 34:18
clinical In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view. ↗
▶ Ep 2 · 34:18
clinical In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view. ↗
▶ Ep 2 · 34:55
clinical A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space. ↗
▶ Ep 2 · 34:55
clinical A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space. ↗
▶ Ep 2 · 35:51
clinical The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end. ↗
▶ Ep 2 · 35:51
clinical The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end. ↗
▶ Ep 2 · 36:13
clinical In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction. ↗
▶ Ep 2 · 36:13
clinical In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction. ↗

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 6 · 1:02
opinion In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art. ↗
▶ Ep 6 · 1:02
opinion In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art. ↗
▶ Ep 6 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 6 · 1:02
quote years ago in the 70s, 60s, and 70s when radiography and fluoroscopy were pretty much the only modalities that were used, fluoroscopy was done by everybody and it was done very, very, very well. Nowadays, with the advent of MRI and CT and ultrasound. I think there's been a shift to the more extreme and more current modalities, and fluoroscopy is almost a lost art. ↗
▶ Ep 6 · 2:26
clinical Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 6 · 2:26
clinical Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities. ↗
▶ Ep 6 · 3:23
clinical In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 6 · 3:23
clinical In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction. ↗
▶ Ep 6 · 3:35
clinical Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel. ↗
▶ Ep 6 · 3:35
clinical Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel. ↗
▶ Ep 6 · 4:00
epidemiological The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases. ↗
▶ Ep 6 · 4:00
epidemiological The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases. ↗
▶ Ep 6 · 5:04
clinical Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis. ↗
▶ Ep 6 · 5:04
clinical Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis. ↗
▶ Ep 6 · 5:32
clinical Seeing air in the rectum does not rule out Hirschsprung disease. ↗
▶ Ep 6 · 5:32
clinical Seeing air in the rectum does not rule out Hirschsprung disease. ↗
▶ Ep 6 · 6:18
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 6 · 6:18
clinical The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph. ↗
▶ Ep 6 · 6:58
clinical Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon. ↗
▶ Ep 6 · 6:58
clinical Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon. ↗
▶ Ep 6 · 8:14
quote Enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 6 · 8:14
clinical Enterocolitis in a newborn is Hirschsprung disease until proven otherwise. ↗
▶ Ep 6 · 8:14
quote Enterocolitis in a newborn, in my mind is Hirstprung's disease until proven otherwise. ↗
▶ Ep 6 · 8:14
clinical Enterocolitis in a newborn is Hirschsprung disease until proven otherwise. ↗
▶ Ep 6 · 8:32
clinical Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case. ↗
▶ Ep 6 · 8:32
clinical Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case. ↗
▶ Ep 6 · 10:22
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 6 · 10:22
clinical The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease. ↗
▶ Ep 6 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 6 · 10:33
epidemiological The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies. ↗
▶ Ep 6 · 10:33
quote The false negative rate, if you look at a bunch of studies, is between 20% and 25%. That's a lot. That's a pretty high false negative rate. ↗
▶ Ep 6 · 10:43
opinion The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%. ↗
▶ Ep 6 · 10:43
opinion The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%. ↗
▶ Ep 6 · 11:04
clinical Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema. ↗
▶ Ep 6 · 11:04
clinical Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema. ↗
▶ Ep 6 · 11:10
clinical Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed. ↗
▶ Ep 6 · 11:10
clinical Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed. ↗
▶ Ep 6 · 11:20
epidemiological The false positive transition zone rate is up to 43%. ↗
▶ Ep 6 · 11:35
epidemiological A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%. ↗
▶ Ep 6 · 11:47
epidemiological The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss. ↗
▶ Ep 6 · 13:27
epidemiological For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%. ↗
▶ Ep 6 · 13:43
epidemiological For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%. ↗
▶ Ep 6 · 14:05
clinical If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location. ↗
▶ Ep 6 · 14:05
clinical If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location. ↗
▶ Ep 6 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 6 · 14:16
quote if you want to do a repeat enema and you want to get a better look at where the transition zone is, you really can't reliably say that that second enema is going to give you a better indication of where it is. So repeat enemas in kids with long segment disease, in my experience, is. Futile. ↗
▶ Ep 6 · 14:39
clinical In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation. ↗
▶ Ep 6 · 14:39
clinical In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation. ↗
▶ Ep 6 · 21:42
clinical Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon. ↗
▶ Ep 6 · 21:42
clinical Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon. ↗
▶ Ep 6 · 22:05
clinical If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this. ↗
▶ Ep 6 · 22:05
clinical If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this. ↗
▶ Ep 6 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly. ↗
▶ Ep 6 · 22:31
clinical Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly. ↗
▶ Ep 6 · 23:10
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it. ↗
▶ Ep 6 · 23:10
clinical Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe. ↗
▶ Ep 6 · 23:10
quote Early maximal distention is actually the best to see the transition zone because if you wait a long time, you can actually get distention of the distal part, which is, uh, which is the, the, the, uh, the Hirsch involving the Hirschsprung's disease, which is the distal part. And that's because it's not a lead pipe. It is a soft piece of tissue, and you can, uh, distend it. ↗
▶ Ep 6 · 23:10
clinical Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe. ↗
▶ Ep 6 · 23:30
clinical If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present. ↗
▶ Ep 6 · 23:30
clinical If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present. ↗
▶ Ep 6 · 23:47
clinical Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants. ↗
▶ Ep 6 · 23:47
clinical Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants. ↗
▶ Ep 6 · 24:03
clinical On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view. ↗
▶ Ep 6 · 24:03
clinical On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view. ↗
▶ Ep 6 · 24:11
clinical On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone. ↗
▶ Ep 6 · 24:11
clinical On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone. ↗
▶ Ep 6 · 24:22
clinical In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum. ↗
▶ Ep 6 · 24:22
clinical In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum. ↗
▶ Ep 6 · 24:40
clinical If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time. ↗
▶ Ep 6 · 24:40
clinical If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time. ↗
▶ Ep 6 · 24:40
quote If you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 6 · 24:40
quote If you have a Foley catheter that's blown up in here and you put the Foley here to prevent leakage, you'll miss this every single time. ↗
▶ Ep 6 · 24:51
clinical Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon. ↗
▶ Ep 6 · 24:51
clinical Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon. ↗
▶ Ep 6 · 25:04
clinical Rectosigmoid transition cases are usually concordant pathologically and radiologically. ↗
▶ Ep 6 · 25:04
clinical Rectosigmoid transition cases are usually concordant pathologically and radiologically. ↗
▶ Ep 6 · 25:30
clinical In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease. ↗
▶ Ep 6 · 25:30
clinical In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease. ↗
▶ Ep 6 · 25:47
clinical The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung. ↗
▶ Ep 6 · 25:47
clinical The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung. ↗
▶ Ep 6 · 26:03
clinical Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy. ↗
▶ Ep 6 · 26:03
quote I would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy. ↗
▶ Ep 6 · 26:03
quote I would probably say anything greater than 35 to 36 weeks. If you go back further and you get into patients with necrotizing enterocolitis and that when that becomes much more, uh, uh, uh, uh, uh, prevalent, then I think you're not gonna have the same, uh, diagnostic, uh, accuracy. ↗
▶ Ep 6 · 26:03
clinical Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy. ↗
▶ Ep 6 · 26:15
clinical If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy. ↗
▶ Ep 6 · 26:15
clinical If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy. ↗
▶ Ep 6 · 27:30
clinical If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition. ↗
▶ Ep 6 · 27:30
clinical If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition. ↗
▶ Ep 6 · 28:06
clinical Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 6 · 28:06
clinical Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt. ↗
▶ Ep 6 · 29:51
clinical A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition. ↗
▶ Ep 6 · 29:51
clinical A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition. ↗
▶ Ep 6 · 30:59
quote I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is. ↗
▶ Ep 6 · 30:59
clinical If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach. ↗
▶ Ep 6 · 30:59
quote I just want to bring home the point that if you have a proximal transition zone, you really can't accurately say where that transition is. ↗
▶ Ep 6 · 30:59
clinical If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach. ↗
▶ Ep 6 · 34:18
clinical In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view. ↗
▶ Ep 6 · 34:18
clinical In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view. ↗
▶ Ep 6 · 34:59
clinical It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space. ↗
▶ Ep 6 · 34:59
clinical It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space. ↗
▶ Ep 6 · 35:56
clinical The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork. ↗
▶ Ep 6 · 35:56
clinical The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork. ↗
▶ Ep 6 · 36:13
clinical In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction. ↗
▶ Ep 6 · 36:13
clinical In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction. ↗

Summaries Steven gave as host · 24 summaries

Recaps of other experts' statements, not Steven's own clinical position.

Summaries Steven gave as host · Colorectal / ARM & Hirschsprung 6 summaries

Open the Colorectal / ARM & Hirschsprung collection →

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 18 · 10:33
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies. ↗
▶ Ep 18 · 11:20
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false positive transition zone rate is up to 43%. ↗
▶ Ep 18 · 11:35
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%. ↗
▶ Ep 18 · 11:47
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss. ↗
▶ Ep 18 · 13:27
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%. ↗
▶ Ep 18 · 13:43
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%. ↗
Summaries Steven gave as host · Enterocolitis 6 summaries

Open the Enterocolitis collection →

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 4 · 10:33
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies. ↗
▶ Ep 4 · 11:20
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false positive transition zone rate is up to 43%. ↗
▶ Ep 4 · 11:35
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%. ↗
▶ Ep 4 · 11:47
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss. ↗
▶ Ep 4 · 13:27
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%. ↗
▶ Ep 4 · 13:43
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%. ↗
Summaries Steven gave as host · Enterocolitis 6 summaries

Open the Enterocolitis collection →

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 4 · 10:33
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies. ↗
▶ Ep 4 · 11:20
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false positive transition zone rate is up to 43%. ↗
▶ Ep 4 · 11:35
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%. ↗
▶ Ep 4 · 11:47
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss. ↗
▶ Ep 4 · 13:27
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%. ↗
▶ Ep 4 · 13:43
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%. ↗
Summaries Steven gave as host · Hirschsprung disease 6 summaries

Open the Hirschsprung disease collection →

Radiology and Image Diagnosis of Hirschsprung Disease

▶ Ep 6 · 10:33
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies. ↗
▶ Ep 6 · 11:20
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The false positive transition zone rate is up to 43%. ↗
▶ Ep 6 · 11:35
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%. ↗
▶ Ep 6 · 11:47
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss. ↗
▶ Ep 6 · 13:27
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%. ↗
▶ Ep 6 · 13:43
host summary Steven Kraus summarizes what Dr. Rodrigo Ocelami said: For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%. ↗