Patient 3 Months Old with Abdominal Distention and Pneumonia

Patient Case Discussion

Case Summary

OVERVIEW

This is a case of a 3-year-old boy with chronic constipation and recurrent enterocolitis, who underwent a transanal proctocolectomy and pull-through procedure for Hirschsprung disease but continued to experience complications, including enterocolitis and fecal impaction. The moderators discussed a complex case of a patient with Hirschsprung disease who has undergone surgery but is experiencing complications due to lack of follow-up care, emphasizing the importance of addressing the social problem and closely monitoring the patient's nutrition. They advised against total colectomy, recommending instead a reoperation with splenic flexure mobilization and pull-through. 

Hirschsprung's Disease and Dysmotility 

Despite treatment with antibiotics, irrigations, and laxatives, the patient's condition did not improve, leading to the creation of an ileostomy. There was discussion  on whether the colon might improve after diversion or if a colectomy would be necessary because of dysmotility, even with normal ganglionic cells present.

Next Steps

1. Continue monitoring the patient's condition post-ileostomy. 

2. Provide education and support to the mother regarding proper ileostomy care and management. 

3. Hospital social workers to address the social issues surrounding the patient's case and lack of follow-up. 

4. Schedule and ensure multiple follow-up appointments with the patient's mother. 

5. Closely monitor the patient's nutritional status because of severe malnutrition and ileostomy. 

6. Consider splenic flexure mobilization and pull-through procedure if patient's condition does not improve with current treatment. 

7. Rule out anastomosis stricture through rectal examination before considering further surgical interventions. 

8. Hospital team to develop a strategy for ensuring consistent follow-up, potentially involving social services or other support systems.

9. Follow up with the patient to ensure continued improvement in bowel movements and adherence to the bowel management program.