Hirschsprung disease — branching viva

Opening — framing the problem

The examiner begins: a full-term male neonate has not passed meconium at 52 hours. He is feeding poorly and his abdomen is distended. What is your first thought? ^[1]

My first thought is that failure to pass meconium within 48 hours in a term neonate is abnormal, and the combination with distension and poor feeding points to a low intestinal obstruction. The diagnosis I must exclude is Hirschsprung disease, because missing it risks the child developing Hirschsprung-associated enterocolitis, which is the leading cause of death. I would assess and stabilise the child and arrange a suction rectal biopsy. ^{[1] [6]}