WESLEYAN UNIVERSITY-PHILIPPINES

AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING

I. Case Scenario
A 9 years old, previously healthy boy presented with sudden onset of colicky abdominal
pain of 4 h duration. The pain was mainly infra-umbilical. Associated with this he had gross
abdominal distension and 2 episodes of non-bilious vomiting. Parents reported that the child had
bowel movements daily before he joined school since when bowel movement became every 2–
3 days. The child had similar attack a month before presentation to our hospital and rectal tube
deflation was done at a nearby hospital. Otherwise there was no other complaints. His growth and
development is similar compared to his peers. He was not on any medications. There was no family
history of similar illnesses.
On physical examination except for tachycardia other vital signs were all in normal range.
All anthropometric measurements were in normal range. He was in pain while holding his
abdomen. He had gross abdominal distension. There was no direct or rebound tenderness.
Abdomen was hyper tympanic to percussion. Bowel sounds were increased. There was no
organomegally or palpable masses on deep palpation. Per-rectum examination showed empty
rectum. No stool or blood on examining finger. A Plain abdominal radiographs showed single
hugely dilated bowel loops in the left lower quadrant with single air fluid level (Fig. 1). Abdominal
ultrasound was unremarkable except for gas filled abdomen. Complete blood count and organ
function test was done and all were in normal range.
We put the patient in knee-chest position and gently introduced fully lubricated rectal tube
into the rectum and slowed advanced upward. Gush of air and scanty stool came out. The abdomen
became soft and the cramp subsided. We left the tube in the rectum for 24 h. We took full thickness
rectal biopsy the next day. It showed aganglionated rectum with absent ganglion cell in both
submucosal and muscles layers. We also obtained diagnostic barium enema and it showed
redundant sigmoid with no radiologic evidence of Hirschsprung’s disease (Fig. 2).

Figure 1. PA plain abdominal x-ray showing Figure 2. PA barium enema study showing dilated
single air fluid level with coffee bean ap and redundant sigmoid colon without radiologic evidence of
Hirschsprung’s disease

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

II. Patient’s Profile and History

A. BIOGRAPHICAL DATA
Patient’s Profile
Name: Patient X
Age: 9 years old
Sex: Male
Date of Birth: July 21, 2013
Address: Cabanatuan City
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Attending Physician: Dr. X
Chief Complaint: Abdominal pain of 4 h duration, abdominal distension, 2 episodes
of non-bilious vomiting, bowel movement became every 2–3 days
Admitting Diagnosis: Aganglionated rectum with absent ganglion cell in both
submucosal and muscles layers
Final Diagnosis: Hirschsprung Disease

Patient’s History
Past Medical History: Had similar attack a month before presentation to our hospital and
rectal tube deflation was done
Family History: None
Allergies: No known allergies
Surgical: Not Stated
Medications: None
Vitals: Blood Pressure 120/80, Pulse Rate 112, Respiratory rate 18,
Temperature 37 degree Celsius
Injuries and Accident: Not Stated

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

III. Anatomy and Physiology

The digestive system is made up of the
gastrointestinal tract—also called the GI tract
or digestive tract—and the liver, pancreas, and
gallbladder. The GI tract is a series of hollow
organs joined in a long, twisting tube from the
mouth to the anus. The hollow organs that
make up the GI tract are the mouth, esophagus,
stomach, small intestine, large intestine, and
anus. The liver, pancreas, and gallbladder are
the solid organs of the digestive system.
As food moves through your GI tract,
your digestive organs break the food into
smaller parts using:
motion, such as chewing, squeezing, and
mixing
digestive juices, such as stomach acid, bile,
and enzymes
Mouth. The digestive process starts in your mouth when you chew. Your salivary glands make
saliva, a digestive juice, which moistens food so it moves more easily through your esophagus into
your stomach. Saliva also has an enzyme that begins to break down starches in your food.
Esophagus. After you swallow, peristalsis pushes the food down your esophagus into your
stomach.
Stomach. Glands in your stomach lining make stomach acid and enzymes that break down food.
Muscles of your stomach mix the food with these digestive juices.
Pancreas. Your pancreas makes a digestive juice that has enzymes that break down carbohydrates,
fats, and proteins. The pancreas delivers the digestive juice to the small intestine through small
tubes called ducts.
Liver. Your liver makes a digestive juice called bile that helps digest fats and some vitamins. Bile
ducts carry bile from your liver to your gallbladder for storage, or to the small intestine for use.
Gallbladder. Your gallbladder stores bile between meals. When you eat, your gallbladder
squeezes bile through the bile ducts into your small intestine.
Small intestine. Your small intestine makes digestive juice, which mixes with bile and pancreatic
juice to complete the breakdown of proteins, carbohydrates, and fats. Bacteria in your small

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

intestine make some of the enzymes you need to digest carbohydrates. Your small intestine moves
water from your bloodstream into your GI tract to help break down food. Your small intestine also
absorbs water with other nutrients.
Large intestine. In your large intestine, more water moves from your GI tract into your
bloodstream. Bacteria in your large intestine help break down remaining nutrients and make
vitamin K. Waste products of digestion, including parts of food that are still too large, become
stool.

IV. Overview of the Disease

a. Definition
Hirschsprung's disease is a condition that affects the large intestine (colon) and causes
problems with passing stool. The condition is present at birth (congenital) as a result of missing
nerve cells in the muscles of the baby's colon. Without these nerve cells stimulating gut muscles
to help move contents through the colon, the contents can back up and cause blockages in the
bowel.

b. Etiology
During fetal development, nerve cells typically grow from the top of the small intestine
through the large intestine to the anus. In children with Hirschsprung disease, these nerve cells
stop growing in the large intestine before reaching the anus. Doctors aren’t sure why this happens.
The disease is generally sporadic, although incidence of familial disease has been increasing;
multiple loci appear to be involved, including chromosomes 13q22, 21q22, and 10q; mutations in
the Ret proto-oncogene have been associated with multiple endocrine neoplasias (MEN) 2A or
MEN 2B and familial Hirschsprung disease; other genes associated with Hirschsprung disease
include the glial cell-derived neurotrophic factor gene, the endothelin-B receptor gene, and the
endothelin-3 gene.
Hirschsprung disease is strongly associated with Down syndrome; 5-15% of patients with
Hirschsprung disease also have trisomy 21; other associations include Waardenburg syndrome,
congenital deafness, malrotation, gastric diverticulum, and intestinal atresia.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

c. Risk Factors
Factors that may increase the risk of Hirschsprung's disease include:
Having a sibling who has Hirschsprung's disease. Hirschsprung's disease can be inherited.
If you have one child who has the condition, future biological siblings could be at risk.
Being male. Hirschsprung's disease is more common in males.
Having other inherited conditions. Hirschsprung's disease is associated with certain
inherited conditions, such as Down syndrome and other abnormalities present at birth, such as
congenital heart disease.

d. Clinical Manifestations

Children with Hirschsprung disease who don’t have signs and symptoms of intestinal
obstruction at birth may not be diagnosed and treated until they are older. Common symptoms in
older infants and children include

 chronic constipation that doesn’t get

better after treatment with
oral laxatives—laxatives that are taken
by mouth
 Abdominal pain and swelling
 Brown or green vomit
 malnutrition or failure to thrive,
meaning that an infant or child weighs
less or is gaining less weight than
expected for his or her age

In older infants and children, symptoms of Hirschsprung disease, such as constipation, may
be similar to symptoms of other conditions. Therefore, doctors may not suspect
and diagnose Hirschsprung disease right away.

In rare cases, Hirschsprung isn’t diagnosed and treated until adulthood. Adults with
Hirschsprung disease typically have a history of abdominal swelling and chronic constipation that
doesn’t get better after taking oral laxatives.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

e. Types of Hirschsprung's disease

The major types of Hirschsprung disease are

 short-segment Hirschsprung disease, in which nerve cells are missing from

the rectum and sometimes the lower part of the colon, called the sigmoid colon.
 long-segment Hirschsprung disease, in which nerve cells are missing from the rectum
and a longer part of the colon than in short-segment Hirschsprung disease, but nerve
cells are present in at least part of the colon.
 total colonic Hirschsprung disease, in which nerve cells are missing from the rectum
and the entire colon, but are present in the end of the small intestine.
 small intestinal Hirschsprung disease, in which nerve cells are missing from the
rectum, colon, and the end of the small intestine, but are present in the rest of the small
intestine.
 total intestinal Hirschsprung disease, in which nerve cells are missing from the
rectum, colon, and all, or nearly all, of the small intestine.

f. Complications
Hirschsprung-associated enterocolitis
The most common complication of Hirschsprung disease is Hirschsprung-associated
enterocolitis, a condition in which the intestines become inflamed. This complication may occur
before or after a child has surgery to treat Hirschsprung disease.
Symptoms of Hirschsprung-associated enterocolitis may include
 swelling of the abdomen
 fever
 diarrhea
 vomiting
 lack of energy
 rectal bleeding
 shock

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

Other complications
Other possible complications of Hirschsprung disease include
 soiling, or when a child has accidental bowel movements in their underwear
 megacolon, or severe constipation and swelling of the intestine
 malnutrition, or when a child doesn’t get enough vitamins, minerals, and other nutrients
to grow and be healthy
 perforation, or a hole in the wall of the intestine, which is more common in newborns
than in older children

g. Diagnostic Procedures
Biopsy: During a rectal biopsy, your provider removes a small piece of rectal tissue. Your
provider examines the tissue under a microscope to check for nerve cells. In infants, providers use
a suction device to remove the tissue. This procedure isn’t painful and doesn’t require anesthesia.
X-ray: Abdominal X-rays can show a bowel blockage.
Anorectal manometry: An anorectal manometry uses external pressure sensors and an
internal balloon device. It gauges how well your child’s rectum and anus get rid of poop. Your
child may be sedated during this test.
Barium enema X-ray: While your child is under sedation, a provider inserts a catheter
(thin tube) into your child’s anus. The catheter fills the intestine with barium, a safe, white liquid.
A technician takes X-rays as the barium travels through the intestine. A barium enema X-ray is a
type of lower gastrointestinal (GI) exam. It shows bowel obstructions and narrowed intestines.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

V. Pathophysiology

HIRSCHSPRUNG DISEASE

Predisposing factors
Common in male
Genetics
Family History

Intestines
(Sigmoid
Colon)

Serosa Smooth Muscles Submuscosa Mucosa Lumen

Plexus
DISRUPTED
Genes needed for
migration and
development of
Auerbach’s Plexus Meissner’s Plexus
nerve fibers
(Myenteric Plexus) (Submucous Plexus)

No Peristalsis
Causes smooth Helps control blood RET EDNRB
muscle to relax flow, absorption
Loss of appetite
and secretion
Mutation of Gene that
Constipation this gene is codes
linked to proteins that
Down connect the
Abdominal
syndrome ganglions to
distention
the digestive
RET gene are tract
Megacolon the most
common known
genetic cause of
Hirschsprung
disease

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

VI. Management
a. Medical Management
Initial therapy. If a child with Hirschsprung disease has symptoms and signs of a high-
grade intestinal obstruction, initial therapy should include intravenous hydration, withholding of
enteral intake, and intestinal and gastric decompression.
Decompression. Decompression can be accomplished through placement of a nasogastric
tube and either digital rectal examination or normal saline rectal irrigations 3-4 times daily.
Diet. A special diet is not required; however, preoperatively and in the early postoperative
period, infants on a nonconstipated regimen, such as breast milk, are more easily managed.
Antibiotics. Administer broad-spectrum antibiotics to patients with enterocolitis.

b. Surgical Management
Pull-through procedure

Pictures showing trans-anal Soave’s endo-rectal pull through

During a pull-through procedure, a surgeon removes the part of the large intestine that is
missing nerve cells. The surgeon then connects the healthy part of the large intestine to the anus.
Surgeons may perform the pull-through procedure as either laparoscopic or open surgery.
During laparoscopic surgery, surgeons make small cuts in the abdomen and insert a laparoscope
and tools to perform the operation. For open surgery, surgeons make a larger cut to open the
abdomen. In some cases, surgeons may perform the pull-through procedure by inserting tools
through the anus instead of making cuts in the abdomen.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

The three common pull-through procedures for Hirschsprung disease. In the Swenson
procedure, a radial full-thickness resection is begun in the aganglionic rectum just proximal to
the dentate line, and the aganglionic segment and transition zone are pulled through the anus and
resected. The transected end of ganglionic bowel proximal to the aganglionic segment is sutured
end to end to the terminal rectum. In the Soave procedure, the initial radial incision is made
through the mucosa, and the dissection is extended proximally in the submucosal plane for several
centimeters before dividing the muscularis propria. As a consequence, the muscularis propria of
the distal rectum is retained as a “cuff” (c), through which the ganglionic bowel is drawn inferiorly
and attached just above the dentate line. In the Duhamel procedure, the pullthrough is performed
along the posterior aspect of the aganglionic rectum, and ganglionic bowel is attached in a side-
to-side manner to the posterior rectum. The anterior rectum remains as an aganglionic pouch.

Ostomy surgery
Doctors may recommend that children have ostomy surgery before having a pull-through
procedure, in some cases. For example, children may need ostomy surgery if they have
complications, such as severe Hirschsprung-associated enterocolitis, megacolon, or perforation.
Ostomy surgery allows a child’s health to improve and intestine to heal before pull-through
surgery. A child may also need ostomy surgery if the entire large intestine is affected by
Hirschsprung disease.
During ostomy surgery, surgeons create a stoma on a child’s abdomen and connect the
stoma to the large or small intestine. After ostomy surgery, waste will leave the child’s body
through the stoma.
The stoma is usually temporary. In most cases, surgeons can later close the stoma and
connect the healthy part of the intestine to the anus. Waste will move through the intestines, and
stool will pass through the anus again.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

c. Nursing Management
Nursing Management
Pre-Operative Care
 Assessement of complete history
 Nurse taught about giving isotonic enema, suppositories and stool softeners
 Low residue diet must be given to the child
 Monitor vital signs and abdominal girth of child
 Keep the child in semi-fowlers position
 Withhold oral feeds & Nasogastric aspiration done on the night before the surgery.
Post-Operative Care
 Monitor vital signs, observe abdominal bleeding
 Place the child in comfortable position according to the physician order
 Child is NPO, so administered IV fluids as ordered
 Monitor bowel sounds
 Colostomy is done which includes the following:
 Observe for stoma for its color (reddish-pink color)
 Observe for bleeding, purulent drainage, edema
 Provide bland diet
 Apply zinc oxide ointment on skin around stoma.
 Frequently empty the collecting bag
 Keep the colostomy clean and dry
 Educate parents about colostomy care
 Encourage and support the family during this stressful times

d. Discharge Planning

Laxatives (only as directed by your child's doctor). If your child doesn't respond to or can't
tolerate increased fiber, water or physical activity, certain laxatives — medications to encourage
bowel movements — might help relieve constipation. Ask the doctor whether you should give
your child laxatives, how often you should do so, and about the risks and benefits.

Increase fluids. Encourage your child to drink more water. If a portion or all of your child's colon
was removed, your child may have trouble absorbing enough water. Drinking more water can help
your child stay hydrated, which may help ease constipation.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

Encourage physical activity. Daily aerobic activity helps promote regular bowel movements.

Serve high-fiber foods. If your child eats solid foods, include high-fiber foods. Offer whole
grains, fruits and vegetables and limit white bread and other low-fiber foods. Because a sudden
increase in high-fiber foods can worsen constipation at first, add high-fiber foods to your child's
diet slowly. If your child isn't eating solid foods yet, ask the doctor about formulas that might help
relieve constipation. Some infants might need a feeding tube for a while.

VII. Nursing Care Plan

a. Pre-operatively
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Fear Short term Independent: Short term
“Natatakot related to goal: Encourage the To lessen hospital goal:
ako impending After 2 patient pre- trauma for a child. After 2 hours
maoperhan” surgery hours of operatively. of nursing
as verbalized nursing intervention,
by the intervention, Explain procedures Fear is lessened by the patient
patient. the patient and care as information and was able to
will delivered. Repeat knowledge. verbalize the
Objective: verbalize explanations readiness for
V/S taken as the frequently as the upcoming
follows: readiness needed. surgery.
BP: 120/80 for the
T: 37.0 upcoming Acknowledge Knowing feelings Long term
P: 112 surgery. feelings of are normal can allay goal:
R: 22 normalcy feelings anxiety that client is After series of
Long term in this situation. losing control. nursing
goal: intervention,
After series Provide comfort For the patient’s the patient
of nursing and safety safety. was able to
intervention, precautions. report that
the patient anxiety is
will report Encourage deep Helps promote reduced to
that anxiety breathing exercises relaxation. manageable
is reduced as needed. level.
to
manageable
level. Collaborative:
Discuss the To provide
importance of the knowledge to
impending parents.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

procedure to the
parents.
To make a safe
Collaborate with environment for a
the family for child.
comfort measures
of the child.

b. Post-operatively
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Constipati Short term Independent: Short term
“Hindi on related goal: Do vital signs and For baseline data and goal:
matae ang to After 8 provide safety safety. After 8
anak ko 3 decreased hours, the measures. hours, the
days na” as bowel patient will patient was
verbalized motility. verbalize Auscultate bowel Monitor progress of able to
by the understand sounds. bowel movements verbalize
mother. ing about through bowel sounds. understandi
the ng about the
Objective: interventio Recommend Decrease gastric intervention
V/S taken a ns with avoiding gas- distress and abdominal s with
s follows: regards to forming foods distension. regards to
BP: 120/80 relieving such as nuts, peas relieving
T: 37.0 constipatio and spicy foods. constipation
P: 87 n. .
R: 18
Dependent: Long term
Long term Administer stool Facilitates defecation goal:
goal: softener or when constipation is After 3
After 3 laxatives if present. months, the
months, ordered. patient was
the patient able to
will experience
experience regular
regular bowel
bowel Collaborative: movements.
movement Consult with Fiber resist enzymatic
s. dietician to digestion and absorbs
provide well liquids in its passage
balanced diet high along the intestinal tract
in fiber and bulk. and there by produces
bulk, which acts as
a stimulant for
defecation.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

Collaborate with To make a safe

the family for environment for a
comfort measures child.
of the child.

VIII. Drug Studies

a. Bisacodyl
Name of Generic Dosage Action / Shape & Color or Nursing
Medication name Contraindication / the Medication Implications /
(Brand Side Effects Card to be Used Nursing
name) Reponsibilities
Dulcolax Bisacodyl 6-12yo: Action: Follow the 12

Ward Bed #
Patient X

3-29-2023
Bisacodyl 5mg once
5mg once Laxative a day per orem rights in
8am
a day PO administering
before Contraindication: Jaimie La Peña medication.
WUP SN 23 CI
breakfast In intestinal 3-29-23 signature
obstruction and in Inform the
case of any patient and
undiagnosed acute guardian about
or persistent the possible
abdominal side effects.
symptoms
Educate client
Side Effects: and guardian
Stomach/abdominal to promote
pain or cramping, understanding
nausea, diarrhea, or and
weakness compliance.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

b. Ampicillin
Name of Generic Dosage Action / Shape & Color Nursing
Medication name Contraindication / or the Implications /
(Brand Side Effects Medication Nursing
name) Card to be Used Reponsibilities
Principen Ampicillin 50mg/kg Action: Follow the 12

Ward Bed #
Patient X

3-29-2023
IV q6 Antibiotic Ampicillin 50mg/kg
every 6 hours intravenously
rights in
12mn-6am-12nn-6pm
administering
Contraindication: Jaimie La Peña
medication.
Patients who have WUP SN 23 CI
3-29-23 signature
allergy to this Inform the
medication patient and
guardian about
Side Effects: the possible
Nausea, vomiting, side effects.
diarrhea, and mild
rashes Educate client
and guardian to
promote
understanding
and
compliance.

Monitor patient
for
hypersensitivity
reaction
especially if
drug is taken
previously.

Do not use
anti-diarrhea
medication if
symptoms
occur because
this can only
worsen the side
effects.

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 WESLEYAN UNIVERSITY-PHILIPPINES
AN AUTONOMOUS METHODIST UNIVERSITY
COLLEGE OF NURSING

References
Belleza, M., & R.N. (2018, June 29). Hirschsprung Disease (Aganglionic Megacolon) Nursing
Care Management. Nurseslabs. https://nurseslabs.com/hirschsprung-disease-aganglionic-
megacolon/

Bisacodyl - Mechanism, Indication, Contraindications, Dosing, Adverse Effect, Interaction, Renal

Dose, Hepatic Dose | Drug Index | Pediatric Oncall. (n.d.). Www.pediatriconcall.com.
Retrieved March 29, 2023, from https://www.pediatriconcall.com/drugs/bisacodyl/333

Definition & Facts for Hirschsprung Disease | NIDDK. (n.d.). National Institute of Diabetes and
Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-
diseases/hirschsprung-disease/definition-facts

Gosaye, A. W., Nane, T. S., & Negussie, T. M. (2021). A case report of Hirschsprung’s disease
presenting as sigmoid volvulus and literature review, Tikur Anbessa Specialized Hospital,
Addis Ababa, Ethiopia. BMC Surgery, 21(1). https://doi.org/10.1186/s12893-020-00938-x

Hirschsprung Disease Nursing Management. (2019, April 27). RNpedia.

https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes/hirschsprung-
disease-nursing-management/

MedlinePlus. (2018). Ampicillin: MedlinePlus Drug Information. Medlineplus.gov.

https://medlineplus.gov/druginfo/meds/a685002.html

R.N, G. W. B. (2018, June 12). Fear – Nursing Diagnosis & Care Plan. Nurseslabs.
https://nurseslabs.com/fear/#:~:text=Fear%20Nursing%20Care%20Plans.%20Fear%20is%
20a%20distressing

Smith, C., Ambartsumyan, L., & Kapur, R. P. (2019). Surgery, Surgical Pathology, and
Postoperative Management of Patients With Hirschsprung Disease. Pediatric and
Developmental Pathology, 23(1), 23–39. https://doi.org/10.1177/1093526619889436

\Wayne, G. (2016, August 8). Constipation – Nursing Diagnosis & Care Plan. Nurseslabs.
https://nurseslabs.com/constipation/

Your Digestive System & How it Works - NIDDK. (n.d.). National Institute of Diabetes and
Digestive and Kidney Diseases. Retrieved March 29, 2023, from
https://www.niddk.nih.gov/health-information/digestive-diseases/digestive-system-how-it-
works?fbclid=IwAR2MFeeg-
4MWG84sDL_u5tn5NMGrRj3Jj5YKalqAlky1om6TQ7qFHT3DkNs

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