anal stenosis
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This is a case of a 7-month old female from Apas, Lahug, admitted for constipation
Prenatal: unremarkable Natal history: unremarkable Postnatal history: unremarkable Immunization: Immunization: BCG x
1 dose, DTP x 2 doses, OPV x 3 doses, Hepatitis B x 2 doses, Pneumococcal x 3, Flu x 1
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Hospitalizations: none Heredofamilial diseases:
hypertension
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Chief Complaint: constipationHPI: Two weeks PTA: patient has been
having decreased frequency in bowel movement with minimal amount of solid stools which was yellow-orange in color, with no associated fever or vomiting
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No consult was done, mother opted to observe patient and began adding mashed papaya during feeding and two teaspoons of castor oil twice a day.
A week PTA, no improvement was noted prompting mother to bring the patient for consult at the ER of this institution, prescribed with laxative and lactose-free milk formula.
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Two days prior to admission, patient was noted to have decreased appetite, irritable and with episodes of straining that prompted consult with pediatrician.
Xray of the abdomen: non-specific and non-obstructive bowel gas pattern and fecal stasis in the ascending and transverse colonic segments
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Patient was then referred to a gastroenterologist who advised them admission.
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Physical Examination Vital Signs: BP=90/60 mmHg HR= 100 bpm
RR=38 cpm T= 37C Wt= 7.7 kg (P-50) Ht= 70 cm (P-90)
Skin: brown, no lesions, warm with good turgor
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HEENT: anicteric sclerae, pinkish palpebral conjunctivae, non-erythematous ear canals with intact tympanic membranes, no nasal secretions, dry lips, moist tongue, no lesions seen in buccal mucosa, non-erythematous and unenlarged tonsils
Chest and Lungs: equal chest expansion, clear breath sounds
Cardiovascular system: distinct heart sounds, regular rate and rhythm, no murmurs
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Abdomen: globular, tympanitic, not distended, hypoactive bowel sounds
GUT: grossly female, no discharges Rectal Exam: skin tag at 12 o’clock
position, admits tip of 5th digit, no stool on examining finger
Extremities: full strong pulses, CRT < 2 seconds
CNS: GCS 11 (E4V3M4) Mental status: alert
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Cranial Nerves: I and II: not assessed III, IV, VI: pupils equally reactive, full
EOM V: (+) corneal reflex VII: no facial asymmetry VIII: not assessed IX & X: (+) gag reflex, able to
swallow
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XI: not assessed XII: tongue at midline on protrusion Sensory: light touch, pain and
temperature intact Motor: spontaneous movements
noted in bilateral upper and lower extremities
Reflexes: +2 in both upper and lower extremities
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Fundoscopy: not done Meningeal signs: none Primitive Reflex: (+) grasp and
rooting reflexes Admitting Impression: R/I Ileus vs
Large Bowel Obstruction
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Course in the Wards: On admission, venoclysis was started
and diagnostics done include CBC which revealed leukocytosis (24.4). CRP, serum creatinine (0.4 mg/dl), serum potassium (3.9 meq/L), SGPT (26 mg/dl) and bleeding parameters were all within normal values.
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Wbc Hb Hct Plt Neu Lym Mon Eos BasCBC 24.4 12.6 38.4 561 39.7 51.7 4.5 3.9 0.2
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Patient was given castor oil 10 ml every 6 hours as bowel preparation for colonoscopy the following day. Patient was able to move her bowel consisting of non-bloody, non-mucoid, yellow-green soft stools.
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On 1st hospital day, patient underwent colonoscopy. Skin tags at 12 o’clock position was noted, and a tight stenotic anal opening with limitation was noted during rectal exam and on insertion of the scope.
At 35 cm from the anal verge, pinpoint lesions were seen and biopsy specimen were taken. IV Cefuroxime (AD= 64.9 mkD) was started post-colonoscopy.
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On 2nd hospital day, repeat CBC was done which showed a decrease in leukocyte count (16.7 from 24.4). No rectal bleeding and no recurrence of constipation were noted.
CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas
4/26 24.4 12.6 38.4 561 39.7 51.7 4.5 3.9 0.2
4/28 16.7 12.1 36.5 393 37.1 51.9 3.8 6.4 0.8
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On 3rd hospital day, another repeat CBC was done revealing further decrease in leukocyte count (12.9 from 16.7). Patient regained her appetite, was no longer irritable and had no episodes of straining on bowel movement. CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas
4/26 24.4 12.6 38.4 561 39.7 51.7 4.5 3.9 0.2
4/28 16.7 12.1 36.5 393 37.1 51.9 3.8 6.4 0.8
4/29 12.9 12 36 398 30.1 54.3 4 11.2 0.4
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Patient was discharged improved on the 4th hospital day.
Final Diagnosis: Colitis Probably Infectious,
Rectosigmoid Area Anal StenosisBiopsy: Chronic Non-Specific Colitis
with Erosions
Anal Stenosis
Anal Stenosis/Atresia-the absence, closure, or constriction
of the rectum or anus -usually diagnosed shortly after
delivery ; often associated with a group of defects called the VACTERL syndrome (vertebral, anal, cardiac, trachea, esophageal, renal, and limb abnormalities)
Anal Stenosis
-can also be associated with chromosomal abnormalities, particularly trisomy 21
Demographic and Risk Factors-race/ethnicity: higher among
Europeans and South Asians-maternal age: advanced maternal age
associated with increased risk of chromosomal abnormalities
Anal Stenosis
Demographic and Risk Factors (continued)
- Infant sex: more common among males
Increased risk with prematurity, lower birth weight,
Maternal diabetes: may increase risk First trimester maternal exposure to
lorazepam does increase the risk for anal atresia
Anal Stenosis
Prevalence: - United States: ranges between 1.04
and 7.89 per 10,000 live births Common Presenting Symptoms: 1. Constipation 2. Fecal Incontinence 3. Abdominal distention 4. Rectal Bleeding
Anal Stenosis
Diagnosis Physical Examination: - presence of an obstructive skin
Anal Stenosis
Anal Stenosis
The anus can look perfectly normal and yet be severely stenosed.
The normal passage of meconium and stools is not a reliable guide to the state of the anus
A stenosed anus will often allow meconium and soft stool of the newborn to escape; a rectal thermometer can also be accomodated
Anal Stenosis
Rectal Examination: -note the size of the anus -suppleness or rigidity of the canal
Imaging:1. Barium enema2. CT Scan3. MRI4. Ultrasound
Anal Stenosis
Anal Stenosis
Treatment:1. Surgical- with the use of anorectal
dilators2. Supportive- high fiber diet and
laxatives
Anal Stenosis