COLORECTAL QUIZ: April 18, 2022

Ron Reeder • April 18, 2022

Happy Monday all. I hope all who celebrate had a wonderful holiday weekend – a rare calendar confluence of Easter, Passover, and Ramadan!


Last quiz I asked you about an 11 year old boy who we saw with chronic distension and constipation, with severe failure to thrive. An anorectal manometry failed to demonstrate a RAIR, but the rectal biopsy did show ganglion cells – so no Hirschsprung disease. The colon is massively distended on plain xray and on contrast study with no area of obstruction.

This patient likely has diffuse colonic dysmotility. It is a confounding diagnosis and without an obvious treatment plan in the published literature. Given his malnutrition I believe he needs a diversion – typically that would be an ileostomy to divert the nonfunctional colon. He will need assessment of the colonic motility, I expect that a colonic manometry (CMAN) when done will likely show no HAPCs throughout. I anticipate that with diversion he will thrive. Some of you suggested antegrade flushes, which could be attempted, but the malnutrition makes me want to get him better quickly, which will occur with a diversion. Based on the colonic motility evaluation, the stoma could likely be closed in the future with a simultaneous colonic resection – a Deloyer’s procedure plus a Malone or a subtotal colectomy with an ileorectal anastomosis are the two surgical options. He will need AMAN assessment of his ability to empty the rectum (balloon expulsion test), and then will need pelvic floor physiotherapy if he needs to improve his ability to empty the rectum.

 

OK, for this week’s quiz, we have a 4 year old boy previously operated on for total colonic Hirschsprung disease, with an ileo Duhamel reconstruction. He has had recurrent episodes of obstructive symptoms and several admissions for enterocolitis. His contrast study is below. What is the problem and what would be your next step?

How would you handle this case?

Here is the current list of the Colorectal Quiz podcasts, best viewed via the StayCurrent app:

Colorectal Quiz Episode 1             ARM - Low Bulbar Fistula,                                                                                https://staycurrentapp.app.link/wK2FhonUEhb  

Colorectal Quiz Episode 2             When to redo a PSARP                                                                                https://staycurrentapp.app.link/RX2eeDqUEhb

Colorectal Quiz Episode 3             Hirschprung Disease                                                                                   https://staycurrentapp.app.link/UnFRkprUEhb

Colorectal Quiz Episode 3.5       Proximal Hirschsprung Disease                                                              https://staycurrentapp.app.link/JiaWCGsUEhb

Colorectal Quiz Episode 4             Classic Hirschsprung disease - Surgical Technique                            https://staycurrentapp.app.link/qGWLoGtUEhb

Colorectal Quiz Episode 5             Proximal Hirschsprung Disease Surgical Technique                          https://staycurrentapp.app.link/AiGHjcvUEhb

Colorectal Quiz Episode 6             Bowel Management Part 1                                                                         https://staycurrentapp.app.link/SVuVYWvUEhb

Colorectal Quiz Episode 7             Bowel Management Part 2                                                                         https://staycurrentapp.app.link/b8IhkKwUEhb

Colorectal Quiz Episode 8             Motility Disorders Part 1                                                                             https://staycurrentapp.app.link/NRerIoxUEhb

Colorectal Quiz Episode 9             Motility Disorders Part 2                                                                             https://staycurrentapp.app.link/s2cVlbyUEhb

Colorectal Quiz Episode 10          Total Colonic Hirschsprung Disease Part 1                                            https://staycurrentapp.app.link/fEtTMRyUEhb

Colorectal Quiz Episode 11          Total Colonic Hirschsprung's Part 2                                                         https://staycurrentapp.app.link/MNqS9yzUEhb

Colorectal Quiz episode 12         Newborn ARM Part 1                                                                                   https://staycurrentapp.app.link/x5UL6DBUEhb

Colorectal Quiz Episode 13         Newborn ARM Part 2                                                                                    https://staycurrentapp.app.link/YqVpTmCUEhb

Colorectal Quiz Episode 14          ARM Newborn Part 3                                                                                    https://staycurrentapp.app.link/x9mUY7CUEhb

Colorectal Quiz Episode 15          Bowel Management in Spinal Pts. Need for a urologist Part 1               https://staycurrentapp.app.link/etX3mPDUEhb

Colorectal Quiz Episode 16          Bowel Management in Spinal Pts. Need for a urologist Part 2               https://staycurrentapp.app.link/5C7GsJIDEhb

Colorectal Quiz Episode 17          Cloaca Part I                                                                                                     https://staycurrentapp.app.link/YGPmYZPEPhb

Colorectal Quiz Episode 18          Cloaca Part II                                                                                                    https://staycurrentapp.app.link/vUEzQxG80hb 

Colorectal Quiz Episode 19          Hirschsprung Disease - The Obstructed Patient Part 1                     https://staycurrentapp.app.link/gBzrAtLKLib

Colorectal Quiz: Episode 20         Hirschsprung Disease – The Obstructed Patient Part 2                    https://staycurrentapp.app.link/W7kEcqB6vjb

Colorectal Quiz Episode 21          The History of Hirschsprung Disease                                                      https://staycurrentapp.app.link/QXtFg2UlTjb

Colorectal Quiz Episode 22          Hirschsprung Disease - the Soiling Patient Part 1                               https://staycurrentapp.app.link/OII38hVhQkb

Colorectal Quiz Episode 23          Hirschsprung Disease The Soiling Patient Part 2                                 https://staycurrentapp.app.link/DA4WEDIcXlb

Colorectal Quiz Episode 24          Cloaca Part 3                                                                                                    https://staycurrentapp.app.link/3uuEG49mkmb

Colorectal Quiz Episode 25          Perineal Groove                                                                                             https://staycurrentapp.app.link/PxlGWtfswmb

Colorectal Quiz Episode 26          Perianal Crohn's Disease                                                                            https://staycurrentapp.app.link/qQbadIDjTmb

Colorectal Quiz Episode 27: Delayed Hirschsprung Disease                                                                                          https://staycurrentapp.app.link/v37xYPDSDnb 

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula                                                               https://staycurrentapp.app.link/lLH7KQr20nb

Colorectal Quiz Episode 30:        Tethered Cord                                                                                                                 https://staycurrentapp.app.link/sE57H6IPzob

Colorectal Quiz Episode 31:        Müllerian Anomalies in patients with ARM

https://staycurrentapp.app.link/FuQyrjuC8ob

Colorectal Conundrum: January 29, 2024

By Ron Reeder • January 29, 2024
Colorectal Conundrum for January 29: A male with a rectoperineal fistula undergoes a PSARP with mobilization of the rectum, both anterior and posterior rectal walls. In the days following surgery he starts to drain urine around the anoplasty consistent with a urethral injury. He is also voiding via the penis. A cystogram is shown below. How would you manage this situation? Answer: This patient has suffered from a urethral injury, and urine is draining out the posterior urethra into the perineum around the anoplasty. The key first step is to divert the urine with a suprapubic tube. A colostomy is not necessarily needed. The fistula might heal with diversion. If after a month or so a cystogram shows the persistence of the fistula, then a redo is needed with re-mobilization of the rectum, fully lifting the anterior rectal wall off of the urinary tract, and repair the urethra, with coverage of the posterior urethra with an ischiorectal fat pad. Then a voiding trial a month later with ultimate removal of the SP tube.

Colorectal Conundrum: January 22, 2024

By Ron Reeder • January 22, 2024
Colorectal Conundrum for January 22nd: In the previous week’s case, of an imperforate hymen, the MRI showed dilation all the way down to the perineum. Management involved a perineal – introital – incision to drain the fluid. If that were not the case and you had a dilated vagina but the distal extent was far away from the introital area, how might you handle that hydrocolpos? Answer: If this were a case of hydrolpos with normal anus and normal urethra, and the vagina cannot be drained by the introitus like an imperforate hymen, then drainage needs to be from above. IR or laparoscopy is an ideal approach to get a drain in the dilated structure (remember this could be bilateral, so both sides may need to be drained. Drainage is to relieve distension and most concerning its potential cause of distal ureteral obstruction causing hydronephrosis. Once the material hormones have dissipated the hydrocolpos will resolve and can be dealt with later in life via a laparoscopic distal vaginal pull-through, after the onset of puberty. In such a patient, I would follow closely with ultrasound 6 months after thelarche (breast budding).

Colorectal Conundrum: January 16, 2024

By Ron Reeder • January 16, 2024
Colorectal Conundrum for January 16: A newborn female is noted to have abdominal distension. On exam the uretha and anus are normal, and there appears to be a bulge in the hymen. The has an MRI with the image shown below. What would be your treatment plan? What are the variations in such a case and how would you manage each? Answer: This could be a case of imperforate hymen, but the MRI is key – how high up is the obstruction? How large is the hydrocolpos? In this case, it appears that a perineal incision might all that is needed as the dilation extends all the way down to the perineum. That is the most common scenario. An incision at the level of the hymen should drain out the fluid and no further intervention should be needed. Of course a careful exam needs to check to be certain you see a urethra – sometimes such a bulge could be a paraurethral cyst. For the next week’s question – what would you do if the perineal approach was inadequate – i.e. could not reach the dilated lumen.
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