Hirschsprung’s Disease

 Also known as Congenital Aganglionic Megacolon.

 It is the congenital absence of or arrested
development of parasympathetic ganglion
cells in the intestinal wall, usually in the
distal colon.
 Symptoms are related to chronic
intestinal obstruction and usually appear
shortly after birth but may not be
recognized until later in childhood or
(rarely) in adulthood.
 The lack of colorectal innervation
inhibits peristalsis, and the affected portion
of intestine becomes spastic and contracted.
The internal rectal sphincter fails to relax,
which prevents evacuation of fecal material
and gas and causes severe abdominal
distention and constipation.
 The most common site affected is the rectosigmoid colon (short segment disease), and the
less common is the upper descending colon and possibly the transverse colon are affected
(long segment disease).
Assessment:
1. In the neonate:
 No meconium passed
 Vomiting – bile stained or fecal
 Abdominal distention
 Constipation – occurs in all patients
 Overflow-type diarrhea
 Anorexia, poor feeding
 Temporary relief of symptoms with enema
2. Older child (symptoms not prominent at birth):
 History of constipation at birth
 Distention of the abdomen – progressive enlarging
 Thin abdominal wall with observable peristaltic activity
 Constipation – no fecal soiling, relieved temporarily with enema
 Stool appears ribbon like, fluid like, or in pellet form
 Failure to grow – loss of subcutaneous fat; appears malnourished; perhaps has stunted
growth
 Anemia
Diagnostic Evaluation:
1. Rectal examination demonstrate absence of fecal material in the long segment disease; in
short segment disease, rectal impaction may be present and, when the finger is removed, it
may cause a rush of stool as the obstruction is temporary relieved.
2. X-rays shows severe gaseous distention of the bowel, with absence of gas in the rectum.
3. Radiopaque markers, when ingested, measure intestinal transit time. Children with short
segment disease retain the markers in the rectum for long periods.
4. Barium enema shows narrowed intestine proximal to anus and dilated intestine proximal
to narrow segment.
5. Rectal biopsy may be done to demonstrate absent or reduced number of ganglion nerve
cells, and confirm diagnosis.
6. Anorectal manometry may be done to record the reflex response to anal sphincter,
requires cooperation of the child.
7. Ultrasonogram may be done to demonstrate dilated colon.
Therapeutic Interventions:
1. Enema or colonic irrigation with physiologic saline solution.
2. Older child whose symptoms are chronic but not severe may be treated with isotonic
enemas, stool softeners, and a low residue diet.
Surgical Interventions:
1. Initially, a colostomy or ileostomy is performed to decompress intestine, divert fecal
stream, and rest the normal bowel.
2. Definitive surgery is done to remove the non-functioning bowel segment with various
pull-through procedures (abdominoperineal, endorectal, or rectorectal).
Nursing Interventions:
Preoperative
1. Assist in emptying the bowel by giving repeated enemas and colonic irrigations.
2. If abdominal distention is not relieved by enemas, discomfort is significant, and rectal
tube insertion fails to give relief, consult doctor for a nasogastric (NG) tube.
3. Offer pacifier for infant to suck if on parenteral fluids.
4. Encourage parents to hold and rock the infant.
5. Maintain position of comfort with head elevated. Offer soothing stimulation (eg. music,
touch, play therapy).
6. Offer small frequent feedings. Low residue diet will aid in keeping the stool soft.
7. Administer parenteral nutrition if feeding causes additional discomfort because of
distention and nausea.
8. For older child, provide demonstration and written and verbal instruction to family for
saline enema administration and use of stool softeners.
Postoperative
1. Change wound dressing using sterile technique.
2. Prevent wound contamination from diaper.
3. Prevent perianal and anal excoriation by thorough cleaning and use of ointments after the
infant soils (postoperative stools can number 7 to 10 per day).
4. Use careful handwashing technique.
5. Report any wound redness, swelling or drainage, evisceration, or dehiscence
immediately.
6. Suction oral secretions frequently to prevent infection of the tracheobronchial tree and
lungs.
7. In older child, encourage frequent coughing and deep breathing to maintain respiratory
status.
8. Allow the infant to cry for a short period to prevent atelectasis.
9. Change position of infant frequently to increase circulation and allow for aeration of all
lung areas.
10. Maintain patency of NG tube immediately postoperatively.
11. Maintain NPO status until bowel sounds return and the bowel is ready for feedings as
determined by the physician.
12. Provide frequent oral hygiene while on NPO status.
13. Administer fluids to maintain hydration and replace lost electrolytes. Begin oral feedings
as ordered.
14. Support the parents when teaching them to care for their child’s colostomy. Reassure
parents that colostomy will not cause delay in the child’s normal development.
15. Involve the entire family in teaching colostomy care to enhance acceptance of body
change of the child