Collection
Motility / Pseudo-obstruction
Also covers: Hirschsprung disease · intestinal failure · necrotizing enterocolitis · gastroschisis · intestinal atresia · constipation · soiling · outlet obstruction
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs, as defined in recent ASPEN guidelines. — Paul Wales, Intestinal rehabilitation: What is intestinal rehab? - Episode 1 · 3:03
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
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We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s. Hosted by: Todd Ponsky,
video14:33 · Dec 2021
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
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We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s. Hosted by: Todd Ponsky,
podcast14:33 · Dec 2021
Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered. — Jason Frischer, Colorectal Collaboration: Neurogastroenterology/Motility Disorders · 11:04
Colorectal Collaboration: Neurogastroenterology/Motility Disorders
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Pediatric Colorectal Surgery is a team sport. That's why this episode is about how the pediatric colorectal surgery team, lead by Dr. Jason Frischer, collaborates with the neurogastroenterology department at Cincinnati Children's Hospital M
video14:55 · Jul 2021
Over time, the colon may rehabilitate, and the patient may eventually need only laxatives, but mechanical emptying of the colon is a perfectly acceptable endpoint. — Marc Levitt, The Colorectal Quiz Episode 9: Motility Disorders Part 2 · 10:50
The Colorectal Quiz Episode 8: Motility Disorders Part 1
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Motility disorder is a team sport - that's why today, we're talking to our colleagues in Pediatric Gastroenterology, Dr. Anil Darbari from Children's National Hospital and Dr. Kahleb Graham from Cincinnati Children's Hospital. Special guest
podcast14:04 · Mar 2021
The Colorectal Quiz Episode 9: Motility Disorders Part 2
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Motility disorder is a team sport - that's why today, we're talking to our colleagues in Pediatric Gastroenterology, Dr. Anil Drabari from Children's National Hospital and Dr. Kahleb Graham from Cincinnati Children's Hospital. Special guest
podcast13:52 · Apr 2021
Colorectal Quiz: Episode 42 - HD Constipation
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In this episode of the Colorectal Quiz, Drs. Mark Levitt, Jason Frischer, and Chris Gayer discuss a complex case of persistent constipation in a patient with a history of Hirschsprung’s disease. Despite a successful pull-through surgery in
podcast14:48 · Dec 2024
Breast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation — Brad Warner, Intestinal Failure with Dr. Brad Warner · 18:11
Intestinal Failure with Dr. Brad Warner
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Discussion with Dr. Brad W. Warner about intestinal failureWhat is intestinal failure?An umbrella term for when the small bowel is unable to digest and absorb an adequate amount of nutrients to sustain a patient through enteral means alone.
podcast52:46 · Dec 2020
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Intestinal failure—insufficient gut function to absorb nutrients, fluids, and calories—requires parenteral support for ≥60 days and is most commonly caused by short bowel syndrome (congenital anomalies, NEC, volvulus) [e296-c1, e4741-c2, e4741-c4, e4741-c5, e4741-c6]. Salvageability thresholds: neonates with ileocecal valve need 10–15 cm; without valve, 15–20 cm [e296-c3, e296-c4]. Intestinal adaptation occurs over 1–2 years; enteral advancement tolerates stool outputs up to 40 cc/kg/day [e296-c7, e296-c8]. TPN targets 100–120 kcal/kg/day (50% glucose, remainder fat/protein at 2–3 g/kg/day each); lipid reduction to 1 g/kg/day 2–3×/week mitigates cholestasis [e296-c9, e296-c10, e296-c12]. Omegaven (fish oil, omega-3) and SMOF lipid (soybean/MCT/olive/fish) have replaced soybean-based intralipid [e296-c13, e296-c14]. Breast milk is optimal for adaptation (growth factors, oligosaccharides); complex formulas stimulate enterotrophic hormones better than elemental [e296-c15, e296-c16]. Surgical intervention (STEP, Bianchi, tapering) is indicated when enteral tolerance plateaus, multiple sepsis episodes occur, or bowel dilation >4–5 cm persists [e296-c18, e296-c19, e296-c22]. STEP is preferred (easier, less vascular risk) but can redilate; Bianchi can precede STEP but not vice versa [e296-c26, e296-c27, e296-c28]. Teduglutide (GLP-2 analog) reduces adult TPN by 1–2 L/week but lacks pediatric approval due to malignancy concerns [e296-c35, e296-c36]. Multidisciplinary intestinal rehabilitation programs achieve >90% long-term survival .
Constipation phenotypes require targeted workup: outlet obstruction (markers in rectum), slow transit (scattered markers), or normal transit [e4366-c4, e4366-c7, e4366-c8]. Anorectal manometry is the gold standard—absent rectoanal inhibitory reflex (RAIR) suggests Hirschsprung; high resting pressure indicates Botox candidacy; dyssynergia warrants pelvic floor therapy [e3824-c17, e3824-c19, e3888-c4, e3888-c5]. Colonic manometry identifies dysmotility: ≥2 high-amplitude propagating contractions (HAPCs) in 18–24 hours rules out colonic dysmotility; absence of HAPCs or no stimulant response confirms dysfunction [e3888-c19, e3888-c21, e3888-c29]. Segmental dysmotility <30 cm is managed conservatively; >30–50 cm is a red flag [e9506-c23, e4366-c19]. Antegrade enemas (Malone/cecostomy) succeed in 97% of segmental cases, avoiding resection [e9506-c25, e6886-c33]. Post-Hirschsprung constipation stems from sphincter/pelvic floor dysfunction, not colonic dysmotility—colonic manometry is contraindicated until distal obstruction is excluded [e9506-c14, e9506-c19, e9506-c21].
- Neonatal short bowel salvageability: 10–15 cm with ileocecal valve, 15–20 cm without; adaptation takes 1–2 years with stool outputs ≤40 cc/kg/day tolerated during enteral advancement.
- STEP is preferred lengthening procedure (easier, less vascular risk) but can redilate requiring redo; Bianchi can precede STEP but not vice versa; taper preferred if length >90–100 cm.
- Anorectal manometry differentiates outlet obstruction (absent RAIR, high resting pressure) from pelvic floor dysfunction (dyssynergia); colonic manometry requires ≥2 HAPCs in 18–24 hours to exclude dysmotility.
- Post-Hirschsprung constipation stems from sphincter/pelvic floor dysfunction, not colonic dysmotility—colonic manometry contraindicated until distal obstruction excluded; Botox and biofeedback are first-line.
Expert statements from the recordings in this collection.
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Failure of medical management is defined as appropriate treatment with no appropriate response
Kahleb Graham2:51
Patients who cannot take treatment (e.g., kids with autism or other cognitive problems) are considered to have failed medical management
Kahleb Graham3:04
Patients with persistent symptoms or pain with treatment, or failure to grow, are considered to have failed medical management
Kahleb Graham3:04
Failure of retrograde enemas is considered failure of medical management
Kahleb Graham3:21
Reliance on rectal therapy or retrograde enemas with continued soiling causing significant effect on functioning is considered failure of medical management
Anil Darbari3:35
General pediatricians typically prescribe osmotic laxatives (MiraLax, lactulose) and stimulant laxatives (Senna, bisacodyl), but there are other medications GI specialists use that pediatricians are not accustomed to prescribing
Anil Darbari3:57
Some children stool every day but don't completely evacuate
Anil Darbari4:58
Initial evaluation includes history (triggers, stooling frequency, sensation of complete emptying), physical exam (abdominal distension, palpable stool, rectal exam), and diagnostic imaging (abdominal X-ray, water-soluble contrast enema)
Anil Darbari4:46
In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step is diagnostic studies including contrast enema to assess colonic dilation, redundancy, and ensure normal ratio
Kahleb Graham5:27
Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy
Jason Frischer8:06
Contrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well
Jason Frischer7:12
The rectoanal inhibitory reflex (RAIR) is the response where the internal anal sphincter relaxes when the rectum becomes distended with stool
Anorectal manometry uses a catheter with sensors measuring pressure and a balloon to assess anal sphincter function and its relationship to the rectum
Anil Darbari9:35
High pressures on anorectal manometry may suggest underlying inability to relax, causing a functional obstruction
Anil Darbari10:00
Patients with Hirschsprung disease have an absent rectoanal inhibitory reflex (RAIR)
Anil Darbari10:09
Anorectal manometry provides information about defecation dynamics by having patients bear down, squeeze, and attempt to defecate, comparing sensation to defecate with internal anal sphincter response
Anil Darbari10:19
Doctor Levitt states he doesn't know how he survived without anorectal manometry testing
In the past, surgeons did not understand the major role the sphincter played in many patients
Colonic motility assessment is critical because in the past, colons or sigmoid colons were resected based on appearance, but patients had motility disorders and did not need resection
Marc Levitt7:36
Many dilated colons will respond to treatment
Marc Levitt7:54
Anorectal manometry is critical for determining whether a patient needs surgery or resection, as patients with motility disorders do not need surgery
Colorectal Collaboration: Neurogastroenterology/Motility Disorders
Manometry is a catheter-based study of pressure changes within the lumen of the gut, involving visual pattern recognition of tracings to identify deviations from normal.
Ajay Kaul1:24
Colonic motility has four key components: diameter of the colon, tone, compliance of the colonic wall, and contraction pressures (how strong the contractions are).
Ajay Kaul1:34
In megacolon, tone and compliance are usually abnormal, but colonic manometry may still show normal high-amplitude propagated contractions and transit may be normal.
Ajay Kaul1:58
There are three types of constipation: normal transit constipation, slow transit constipation (problem with neuromuscular integrity of colonic wall), and outlet obstruction or withholding (most common in anorectal malformation children).
Ajay Kaul2:35
In a Sitz marker study, a patient should be able to pass all ingested radio-opaque markers in 5 days; markers remaining at 5 days indicate abnormal transit.
Ajay Kaul3:19
When Sitz markers are collected in the dilated rectum at 5 days, this is indicative of outlet obstruction or withholding.
Ajay Kaul3:48
When Sitz markers are scattered all over the colon at 5 days, this is indicative of slow transit constipation.
Ajay Kaul4:06
Scintigraphy studies colonic transit by tracking the geometric center of an ingested isotope and can identify specific colonic locations with transit issues.
Ajay Kaul4:15
The smart pill is a large capsule that measures pH, temperature, and pressure to assess transit from mouth to anus, but its size limits use to children approximately 10-12 years old or older.
Ajay Kaul4:51