GUT INTEGRITY

A popular joke goes:

All the organs of the body were having a meeting, trying to decide who was the one in charge...

"I should be in charge," said the brain, "Because I run all the body's systems, so without me nothing would happen."

"I should be in charge," said the blood, "Because I circulate oxygen all over so without me you'd waste away."

"I should be in charge," said the stomach," Because I process food and give all of you energy."

"I should be in charge," said the legs, "because I carry the body wherever it needs to go."

"I should be in charge," said the eyes, "Because I allow the body to see where it goes."

"I should be in charge," said the rectum, "Because I’m responsible for waste removal."

All the other body parts laughed at the rectum and insulted him. So, in a huff, he shut down tight. Within a few days, the brain had a terrible headache, the stomach was bloated, the legs got wobbly, the eyes got watery, and the blood was toxic. They all decided that the rectum should be the boss.

The analogy couldn’t be more correct. When babies are born yelling, breathing and all pink, the next thing everybody looks out for over the next few days is when they will pass stool. The first green, gummy and sticky stool is not only an assurance to the mother that baby’s functions are intact but also extremely reassuring to the doctor that the digestive tract is well formed and the involuntary muscle activity of the gut is intact.

It is easy to take for granted the function of eating and drinking without belabouring the thought of what could go wrong. Many people worry when they are unable to eat. They should worry when the transit is incomplete and the tail end of things fails.

Hirshsprung disease is one that catches the attention of many doctors that attend to babies. From the paediatrician who receives the newborn, to the paediatric surgeon who is the ultimate specialist in dealing with it. In the development of the digestive tract, as the system develops, the nerves that ensure the peristaltic movements of food along the tract develop alongside. The nerves grow along the tract from the food-pipe heading down to the anal opening.

In the event this downward progress of the nervous system terminates along the way, the part beyond the termination remains without a driver of the peristalsis process. This means that the gut remains narrow and does not relax to allow stool to move along it. The earliest sign to show then will be difficulty in passing stool. In those babies who do manage to pass stool, it will be stringy.

Over time, this chronic constipation will interfere with the baby’s feeding and hence the normal growth and development. This is what little Ndani* came to us with. She was a few months old, having been delivered at a district hospital and gone home with a certificate of good health. Thankfully her grandmother was experienced enough to raise alarm about the fact that Ndani did not pass stool well. After several visits to the hospital, she was eventually referred to our teaching hospital.

This is not a condition a baby can live with and must be addressed. Treatment is not easy. It requires highly skilled doctors to perform surgery. There may be need for a colostomy (when part of the intestine is brought out onto the skin surface and fixed there for a period, to divert from the anal opening). As much as I love working with children, seeing the little baby with a colostomy made me take the instant decision that I would never be a paediatric surgeon. There is no amount of counselling that can prepare a young mother for the experience of having a baby with a colostomy.

Nandi’s mother lost over 10 kilograms in the harrowing ordeal that followed the treatment of her child. She was grateful to be so far from home so she did not have to explain to visitors who would otherwise visit her in the wards, about her daughter’s condition. Nandi’s father visited every weekend but the young man would hold his daughter delicately, lost in thought. It was extremely difficult to comprehend why his little one had to go through so much.

Even when the repair is completed and the colostomy is reversed, and she was lucky to be in the care of the most competent and empathetic surgical and anesthesia team I know, she still required to learn how to control her anal sphincter to achieve continence. She will always have a permanent reminder on her abdomen of the surgery and the colostomy. She may be too young to remember the actual experience but it is not going to be easy for her in future, attempting to explain her scars. It is unlikely she will be able to understand her own condition fully for a long time.

I think about Nandi often and wonder how she is doing. She’s a teenager now, at the most sensitive phase of her life. I hope life has been kind to her and she is surrounded by people who are supportive and will ensure she grows up with a strong positive image of herself. She is the only female child I have ever seen with the disease as Hirschsprung is more common in boys than girls, at a ratio of 4:1.

Nandi taught me never to take any body organ for granted. The rectum may be viewed as a conduit for waste management by the body, but just like a blocked drainpipe can cause enormous grief, this nondescript part of our system can cause grief to a whole community. So yes, sometimes, the least impressive body parts can quietly remind us who is boss!