Good Bowel Sound Podcasts: Cow’s Milk Intolerance and Hirschspurng Disease

Two recent bowel sound podcasts had some useful clinical insights. Some of my summation below could be off a bit as I tend to listen to these while driving. So, it may be a good idea to hear the podcasts for yourself.

Victoria Martin discussed cow milk intolerance/allergic proctocolitis.

Listen now:

Dr. Martin emphasized the importance of challenging children with these diagnoses; in many, the disorder is transient. A challenge is typically done 1 month after resolution of symptoms. In those with confirmed reactions, rechallenge 6 months later is typical. The reasons for doing this:

  1. This is in keeping with international guidelines
  2. Many children do not need to stay on expensive formulas or dietary restrictions (if breastfed)
  3. This is likely to reduce the risk of developing lifelong food allergies
  4. Other pointers: generally it is not helpful to follow stool heme testing (high number of normal infants with heme-positivity). Stool calprotectin is not helpful (wide variability in infants). Flexible sigmoidoscopy is rarely needed. In those with mild symptoms, it may be reasonable to watch without intervention, especially in breastfed infants.

Related blog posts:

Jacob Langer discussed Hirschsprung disease

Listen now:

In terms of diagnosis, Dr. Langer recommended use of rectal suction biopsy as 1st step in smaller kids (less than 1 yr of age) and rectal manometry as 1st step in those older than 1 yr of age. He reviewed the three main operations:

  • Swenson -pulldown to anus
  • Duhamel -pouch: with an end-to-side anastomosis is performed with the remaining rectum
  • Soave -cuff: strip mucosa and leave a muscular cuff

He noted that he prefers Soave but that there is not clear superiority of one operation.

Other pointers:

  • Enterocolitis is #1 cause of mortality. If someone is coming in sick, worthwhile to start an in-and-out irrigation promptly. Irrigation information can be found on YouTube. From Colorado Children’s: Rectal Irrigations for Hirschsprung
  • He pioneered the use of Anal Botox for children post-operatively. Many children with obstructive symptoms related to sphincter malfunction will improve with time and this often allows a child to avoid a myectomy
  • He described workup for post-operative soiling and potential pathophysiology: muscle issues (manometry), sensory issues, functional retention with overflow, and hypermotility (sigmoid propelling stool rapidly which may improve with imodium)
  • Dr. Langer is also a musician — you can listen to his music here.

Related blog posts:

Prickly Pear Cactus, Tucson, AZ

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