Adventures Up Shit Creek: A Paediatric Surgeon’s tale-Dr Pingali Gopal

How does a sniper identify and shoot a paediatric surgeon in a crowd? Fling a clod of human faeces into the crowd, wait till the entire crowd flees in disgust and watch for the only person examining it deeply.

The obsession and fascination that stools hold for a paediatric surgeon is legendary, while too many of his compatriots from other, more glamorous fields of medicine, it evokes a feeling of revulsion and disgust.

One of the nurses, at a hospital in the UK where I worked ages ago while showing parents around the newborn intensive care unit (NICU), would confess that the only thing that alarmed her the most were the stool-obsessed surgeons!

 And why not? Many of the surgeries in small children relate to the bowels and the success of surgery would be a visibly non-distended abdomen and the information whether the child has passed stools.

The rest- clinical examination with tons of monitors and other investigations are superfluous and a sham almost. Nothing satisfies a paediatric surgeon more than the news that the child has passed stools in the post-operative period and there is no sight more pleasant than a good quantity of green or yellow-coloured stools staining the diapers.

The ecstasy of an art lover viewing the Mona Lisa for the first time is minuscule in comparison!

In a condition called biliary atresia, where the tubes delivering the bile from the liver to the gut are absent, the stools are ‘clay coloured’ to begin with. This obsession reaches a frightening peak (as our dear nurse used to narrate!) in the post-operative period.

Surgery involves creating new channels using the small intestine. And from the earliest post-operative period, every stool sample is examined minutely for colour. We tell parents to place each sample in the provided boxes or preserve each diaper for us to observe during our rounds.

It is a delight to see the face of a beaming paediatric surgeon as he observes a load of golden-yellow stool emitted by the post-operative biliary atresia child. Nothing else matters and nothing else counts; it is the zenith of human satisfaction.

It might appear disgusting, but stools play an important role in our lives. In a condition called intussusception, a typically healthy child suddenly starts crying in an episodic manner. The child’s screaming episodes progressively increase as the child draws up his legs. The biggest clue here is the passage of blood in stools; a typical ‘currant-red’ jelly stools. Yes, we have colourful descriptions!

Later investigations only confirm that the child’s bowels need early intervention in the form of a procedure or surgery to prevent gangrene of the bowels.

Families must know that the presence of visible blood in stools always needs investigation. The causes may vary cuts in the mucosa, growth, outpouchings of bowels, ulcers, and blood0vessel malformations.

The source of bleeding can be anywhere on the entire length of the gastrointestinal tract – from the food pipe to the back passage- and the cause may vary from a simple cut to something ominous like cancer. Investigating a child with blood in the stools can sometimes become extremely challenging-  such as identifying the cause and source of bleeding or in a rare instance, prevent doctors from multiple specialities from quarrelling and enthuse them to put their heads together.

From ordinary people to heads of state, the anal passage is used as a common epithet. In these days, with the onslaught of social media, people are truly hypersensitive to any form of ethnic, religious, linguistic, cultural, social, gender, or environmental connotations in their communication. Truly secular messages which do not cause any protests are rapidly shrinking.

But, we, paediatric surgeons flinch at this seemingly innocuous epithet. The anal opening is one of the most elegant gifts of God or evolution (for you non-believers!) to human beings. It is an intricate mechanism involving many muscles, nerves, the spinal cord and the brain is extremely complicated loops of feedback processes allowing us to evacuate and hold the faeces, almost at our will. It is a gift humankind fails to appreciate.

In a group of conditions called anorectal malformations, where the anus and rectum do not form properly, paediatric surgeons engage themselves, for almost a lifetime of care, for these unfortunate children. It involves two or more surgeries to make these children continent enough to have an acceptable social life. These children sometimes have only one chance for a proper surgery that calls for the best of precautions and handling.

And who else can do this job? (Sorry for the advertisement, could not resist this!!). Any abnormal configuration of the orifices should always come to the notice of the doctor because some of these conditions can appear later in life with constipation or with ‘ribbon-like’ stools (yes, we are descriptive!) due to a very narrow passage.

In the good old days of train travel, when co-passengers actually spoke to each other, one senior citizen told me, when I was a strapping medical student, that the truly happy man in the world is one who lives without any medicinal help, sleeps for seven-or-eight hours straight on hitting the bed and empties his bowels completely on waking up. Reflect on this and realize the Absolute Truth. Sleep and healthy passing of stools are indeed a reason for untold happiness, but both also reflect an entire way of living a healthy active life.

Constipation is a dreaded problem in childhood, more so these days as the modern fibre-poor diet replaces our traditional diet. In a condition called acquired constipation, a child gets progressively constipated. It is a huge trauma to all involved, as the screaming child holding the parents or the wall, to try and expel the faeces standing in a cross-legged position.

The sweating face can go red in the extreme effort to expel the faeces. Sometimes there might be blood-staining of the faeces and even soiling of the undergarments.

Passing stools without knowledge (known as encopresis) is almost always a sign of severe constipation. Ignored, this can even damage the kidneys and the bladder mechanism. Constipation in children, otherwise healthy before, always needs prompt evaluation and a long and sympathetic follow-up. The treatment program involves enemas, medications, dietary and lifestyle modifications. The results are gratifying if treated promptly. But many parents tend to ignore this important problem out of either embarrassment or improper advice from friends and relatives.

In a condition called Hirschsprung’s disease, where the nerves coordinating the smooth passage of stools are deficient or disturbed, the child again is severely constipated, but the presentation tends to be earlier and associated with abdominal distension and vomiting too. There is difficulty in even expelling flatus. This condition requires again two or more surgeries to cure. Some of the surgical innovations include single-stage surgeries for these traditional multiple-stage procedures.

A summary message to parents: do not ignore constipation in children. The causes and consequences can be serious, but the condition is curable with good and proper treatment. Personally, the laxative stock in my pharmacist’s shop flies off faster than the antibiotics and the pain-killers!

It is an amazing irony that something so intimately attached to the body becomes an object of extreme disgust once it leaves the body. But the humble stools carry many tales and some of us specialists listen to them carefully.

So, to the nose-wrinkling world out there, bowels and back-passages have a lot of importance and should have respect at par with the heart, lungs, brain, or the bones (Damn those specialists who run away with the gold!!).

Another epithet referring to a head filled with stools may apply to paediatric surgeons, but someone must do the job!