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's disease is a congenital disorder characterized by the absence of intrinsic ganglion cells in the myenteric plexuses of the hindgut. The majority of patients present during infancy or childhood with constipation, intestinal obstruction, or megacolon [1]. Standard treatment includes single-or multi-stage pull-through surgery [2]. We have previously reported per-rectal endoscopic myotomy (PREM) for adult Hirschsprung's disease [3]. The rationale of this is to disrupt the spastic bowel segments, like those in achalasia or pylorospasm are disrupted by peroral endoscopic myotomy (POEM) or pyloromyotomy (G-POEM) [4, 5]. This report describes the technique and outcome of PREM in a pediatric patient with Hirschsprung's disease. An 8-year-old boy had had refractory constipation since the neonatal period that was partially relieved by high-dose laxatives. Barium enema demonstrated a spastic rectum and dilated sigmoid colon, which were classical of Hirschsprung's disease (▶ Fig. 1). Colonoscopy showed a spastic non-distensible empty rectum and dilated sigmoid colon with stool residue. Deep mucosal biopsies demonstrated ganglion cells at 8 cm but these were absent distally (▶ Fig. 2). Manometry demonstrated absent rectoanal inhibitory reflex (RAIR). Given our previous experience, we obtained consent for PREM from the patient's parents. PREM was performed ▶ Fig. 1 Barium enema in an 8-year-old boy showing the characteristic signs of Hirschsprung's disease.

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The formation of germtubes by twelve clinical isolates of C. albicans was studied in human serum containing per millilitre 10(3) to 10(9) organisms as: Staphylococcus pyegene, Escherichia coli, Klebsiella pneumoniae, Lactobacillus acidophilus and Proteus vulgaris. All the five bacteria inhibited formation of germtubes by C. albicans at all concentrations and the percent germtube formed diminished with increasing concentration of the bacteria. Lactobacillus acidophilus inhibited the formation of germtubes maximally followed by Staphylococcus pyogene, Escherichia coli and Klebsiella pneumoniae. Proteus vulgaris in the concentrations of 10(3) to 10(7) bacteria per millilitre produced only insignificant inhibition of formation of germtubes by C. albicans. Since germtubes of C. albicans are invasive, it is suggested that inhibition of "blastospore-germtube transformation" may be significantly responsible for prevention of infection by C. albicans by coexisting bacterial flora.