Imperforate anus

Case presentation

Under the guidance of:Dr. S.C.Lodha

Dr. B.K.Sharma

Imperforate anusIncludes agenesis and atresia of the rectum and

anus.Etiology: unknownIncidence: 1 in 4,500SEX: 60% male

Case StudyWe are presenting a case of a 18 month old

male child who came to us with imperforate anus and a functioning colostomy.

On diagnosis of imperforate anus, at birth, a relieving colostomy was performed at 2 days of age at SMS Hospital , Jaipur.

Case studyName: GauravAge: 18 monthsSex: MaleReligion: HinduSocial status: Low socio economic stausFather’s occupation: FarmerResident : Sawai MadhopurEducation: Parents are illiterate.

Chief ComplaintsInability to pass faeces.Absent anal opening.Functioning colostomy.

History of present illnessPatient could not pass meconium in the 1st

24hrs of the birth.He had vomiting and abdominal distention.An imperforate anus was found which was

immediately repaired by transverse colostomy.

Now the patient has come for the 2nd step management of imperforate anus with a functional colostomy.

There is no other associated congenital anomaly.

Past HistoryFailure to pass meconium within the 1st 24

hours of life.Absent anal opening.Abdominal distension.VomitingPresence of meconium in urine

(suggesting high anorectal malformation)Invertogram done after -- hrs showed

presence of gas above pc line which established high anorectal malformation.

Family historyPatient’s parents are from a low

socioeconomic and rural background.Farmer by profession from Sawai Madhopur.Patient’s mother is an illiterate woman with

poor knowledge of child care.The patient is the couple’s first child.Parents were not educated about the stoma

care.

Drug history: Not significantPersonal History : Vegetarian, well fed on

breast milk.Immunization history: The child is well

immunized according to the universal immunization chart.

Developmental history: Normal development according to the age and sex of the child.

General Physical ExaminationOn examination :-• Patient is conscious.• Well built, averagely nourished childVery irritableChild visibly paleP-108/minT- AfebrileRR-32/minWt approx 10 kg

General Physical ExaminationNo CyanosisNo oedema No facial puffiness No icterusNo clubbingHead to toe examination was uneventful.

LOCAL EXAMINATION• No orifice seen at the anal region • No redness• No discharge • No induration

Systemic ExaminationCVSo S1, S2 present o No murmur Respiratory systemo Air entry bilaterally equalo No wheezing, no crepitationsCNSo Consciouso Irritableo Frequent incessant crying.

Systemic ExaminationPer Abdomeno Soft.o Non tendero No distensiono No organomegalyo Functioning colostomy present in left hypochondriumo Mild redness and induration present around the colostomy

stoma.o Child’s parents are apparently oblivious to the irritation

caused to the child by poor stoma care. A simple rough cloth had been tightly tied around the stoma most of the day.

InvestigationsCBC,BT ,CTLFT,RFTUrine examinationCXR,ECGULTRASOUNDS.ElectrolytesB.Sugar (R)HIV/HBsAgBlood GroupingBarium study

2.Determine whether abnormality is high or low!!1)Invertogram:With a metal button or a coin strapped to the site of the

anus or a metal bougie inserted into the blind anal canal Infant is held upside down for 3-4 minutesThen radiograph in the inverted lateral position ( both the

greater trochanters should be on the same line)The gas in the rectum will rise to the top indicates the

distance between the site of the metal indicator and the blind end of the rectum >>> if the distance > 2.5 cm, the abnormality is high!!

If the rectum ends above the PC line (pubococcygeal line = from the symphysis pubis to the last vertebra), the abnormality is Low & vise versa or according to ischeal line (between ant.-sup. Iliac spines).

When to be done?• Although it is a useful method, sometimes vitiated by a plug

of meconium in the rectum causing an apparent gap far in excess of that actually present. So, it may be necessary to wait until the baby is 24 hrs old before rectal gas appears.

PC line

Metal button

gas in the rectum

It was a high type of imperforate anus for which transverse colostomy was performed

The treatment of imperforate anus requires immediate surgery to open a passage for faeces until corrective surgery takes place .

Immediate surgery depends on the type of malformation which can be corrected immediately or with primary colostomy and corrective surgery at a later date.

Associated anomaliesImperforate anus is associated with an increased

incidence of some other specific anomalies as well, together being called VACTERL ASSOCIATION.

• V- vertebral anomalies• A- anal atresia• C-cardiovascular anomalies• T- tracheoesophageal fistula• E- esophageal atresia• R- renal( kidney) and/or radial anomalies• L- limb defects.However no such anomalies are seen in this patient.

Associated anomaliesInvestigation Associated abnormality

Spinal ultrasound, Spinal x-ray "V" Vertebral Abnormality (butterfly vertebrae, hemi-vertebrae)

Cardiac ECHO "C" Cardiac, Heart Abnormality Cardiac ECHO (VSD, ASD, PDA)

Renal ultrasound, Voiding cysto-urethra-gram (VCUG)

"R" Renal, Kidney abnormality (solitary kidney, horse shoe kidney)

Physical examination "TE" tracheoesophogeal abnormality (TEF)

Physical examination, x-rays "L" Limb deformity

BARIUM STUDYProcedure• Barium is injected in the colostomy stoma

distally with the help of folley’s catheter.• A coin is placed on the child’s perineum and

images are taken.• Barium passes smoothly through the distal loop

as well as proximal loop with normal outlining of the descending and sigmoid colon.

• Obstruction in the rectum is 4.2 cm above the anal verge, indicating high type of ano rectal stenosis.

Barium study • A fistulous track is seen connecting sigmoid

colon with bladder and contrast filling the bladder.

• Immediately after the Barium examination, the child started passing pink urine due to passage of the dye in the bladder.

• As a result, Foley’s catheter was inserted and frequent flushing of the bladder by saline initiated to relieve the barium load of the bladder and prevent cystitis.

Impression:High type of ano rectal stenosis with colo

vesical fistula

Diagnosis• On the basis of the history, examination and

the barium study the final diagnosis is ANO RECTAL MALFORMATION.

• It is a high type of ano rectal stenosis with colo vesical fistula