This case presentation describes a 2-year-old boy named Kowshik Alom who was admitted with chronic constipation since birth and gradual abdominal distention. He had difficulty passing stool and required suppositories. Examination found abdominal distention but no other abnormalities. Tests including barium enema x-ray were performed. He was diagnosed with Hirschsprung disease and underwent transverse colostomy with biopsy. Unfortunately, the patient died on the second postoperative day likely due to aspiration and cardiorespiratory failure.

1. LONG CASE PRESENTATION
(HIRSCHSPRUNG DISEASE)
DR.RAGHU NATH KARMAKER
PHASE B RESIDENT
DEPT. OF PAEDIATRIC SURGERY
MMCH

2. Particulars of the
patient
Name : Kowshik alom
Age : 2 years
Sex: Male
Religion : Islam
Address : Barhatta , netrokona
Date of admission : 24/11/2022
Date of examination : 24/11/2022

3. Presenting
complaints
1. Chronic constipation since birth.
2. Gradual abdominal distention and
occasional vomiting for same
duration .

4. History of present
illness
According to statement of informant
mother , presenting complaint started
since birth . The child did not pass
meconium up to 3 days after birth and then
passed meconium with the assistance of
suppositories . Since then child defecates
infrequently at 3-4 days interval with the
help of suppositories , laxatives and
sometimes spontaneously . Mother also
complaints of gradual abdominal
distention since then which was
accelerated in last 2 months.

5. Contd….
There are also complaints of occasional
non bilious projectile vomiting . For these
complaints he was taken to local doctors
and took antiemetic and laxatives in last 2
years for several times . There are no
history of fever , diarrhea , blood
mixed stool or perineal soiling . As of no
improvement of the condition the parents
admitted their child in department of
pediatric surgery of mymensingh medical
college hospital.

6. History of past
illness
No history of past illness.

7. Birth history
Antenatal history : uneventful but the
mother was not on regular checkup and
was not on anti thyroid drugs .
Natal history : He was delivered by NVD
at term at home .
Post natal history : uneventful except
delayed passage of meconium

8. Feeding history : The child was on exclusive
breast feeding and now on family diet .
Developmental history : His milestone of
development are normal .
Immunization history : Immunized as per
EPI schedule
Treatment history : Treated by laxatives and
suppositories .

9. Family history
The baby was 3rd issue of non
consanguineous parents . Parents and
other siblings are good health . No
family history of same type of illness .

10. Socioeconomic
history
Belongs to lower class family .

11. General
examination
Appearance : well alert
Anemia : mild
Jaundice : absent
Edema : absent
Cyanosis : absent
Clubbing : absent
Koilonychia : absent
Lymph node : No accessible lymph node are found
Temperature : normal
Pulse 100 beat /min
Res rate : 24B/MIN

12. Systemic
examination (GIT)
Mouth and oral cavity : healthy
Abdomen :
Inspection : Abdomen was distended ,
umbilicus centrally placed and inverted , no
visible peristalsis , no engorged vein or
scar mark . Hernial orifice were intact .
Palpation : Abdomen was soft and non
tender, no organomegaly , fecoloma or
ascities were present

13. Systemic
examination (
contd.)
Percussion : Tympanic , shifting dullness
absent
Auscultation : Bowel sound present .
Perineal examination : No perineal soiling ,
anus is normally placed , no excoriation or
fissure is noted .
D/R/E : Rectal grip can be felt on inserted
finger and index finger is snugly fitted to
the rectum . Rectum was empty . After
withdrawal of finger a gush of flatus and
feces comes out .

14. Other systemic
examination
Reveals no abnormality .

15. Salient feature Kowshik alom , a 2 years old boy hailing
from barhatta ,netrokona , got admitted with
the complaints of chronic constipation
since birth , gradual abdominal distention
and occasional vomiting for same duration .
The child did not pass meconium up to 3
days after birth and then passed meconium
with the assistance of suppositories . Since
then the child defecates infrequently at 3-4
days interval with the help of suppositories
, laxatives and sometimes spontaneously .

16. Contd.... Patients also complaints of gradual
abdominal distention since then which was
accelerated in last 2 month . There are also
complaints of occasional non projectile
bilious vomiting . For these complaints he
was taken to local physician and took
antiemetic , laxatives and suppositories in
last 2 years for several times . There are no
history of fever , diarrhea , blood mixed
stool or perineal soiling . His general survey
is essentially normal except mild anemia.

17. Contd..... Abdomen is distended , umbilicus is
centrally placed no visible peristalsis ,
organomegaly fecaloma or ascites .bowel
sound is present . There is no perineal
soiling , anus is normally placed . No
excoriation or fissure is noted , index finger
is snugly fitted to the rectum . Rectum was
empty . After withdrawal of finger a gush of
flatus and feces comes out . Other systemic
examination reveals normal .

18. Provisional
diagnosis
Hirschsprung disease

19. Differential
diagnosis
Habitual constipation
Hypothyroidism

20. Investigation
CBC with Blood grouping
s. createnine
s. electrolytes
T3,T4,TSH
Barium enema x-ray in both A/P And
L/V

21. Barium enema
x ray

22. Treatment:
Initial
management
NPO TFO
N-G SUCCTION
I/V FLUID
BROAD SPECTRUM ANTIBIOTICS
RECTAL IRRIGATION

23. Surgical Transverse colostomy with labelling
biopsy

24. Follow up
On 2nd post operative day baby was die
most probably due to aspiration
followed by cardiorespiratory failure

25. Thank you