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Imperforate Anus

Case Presentation and Discussion on Imperforate Anus

Marlou O. Padua, MD

General Data: M. I., 3 day old, male

Chief Complaint: Absent anal opening

History of Present Illness:

Born to a 22 y.o. G1P1 via NSD at home assisted by a ‘hilot’

24^th HOL (-) passage of meconium

(-) urine output

(+) vomiting

noted absent anal opening

brought to Ospital ng Muntinlupa

- OGT

- Invertogram done

- Ampicillin, Gentamycin

78^th HOL transferred to OMMC

Maternal History: unremarkable

Physical Examination:

Gen. Survey: asleep, comfortable

Vital Signs: CR: 118/min RR: 34/min T:37.1 ^oC

HEENT: normocephalic, patent non-bulging ant. & posterior fontanelles, pink palpebral conjunctivae, anicteric sclerae, supple neck, OGT inserted

Chest/Lungs: symmetrical chest expansion, no retractions, clear breath sounds

CVS: adynamic precordium, normal rate, regular rhythm, no murmur

Abdomen: globular, dry umbilical stump, hypoactive bowel sounds, soft

Genitalia: undescended testes R

Perineum: (-) fistula, (+) midline groove, (+) prominent anal dimple

Invertogram:

Salient Features:

• Newborn, male

• (-) anal opening

• (-) perineal fistula

• Invertogram result

Clinical Diagnosis:

Primary Clinical Diagnosis	Imperforate Anus, High Lying	90% Certainty
Secondary Clinical Diagnosis	Imperforate Anus, Low Lying	10% Certainty

Algorithm:

Paraclinical Diagnostic Procedure:

Is there a need for a further paraclinical diagnostic procedure?

No, since the degree of certainty for my primary diagnosis is already 90%.

Paraclinical Diagnostic Options:

	Benefit	Risk	Cost	Availability
Invertogram	will differentiate low from high lying imperforate anus	exposure to radiation	Php 300	✔
Cross-table Lateral, Prone position with Pelvis elevated	will differentiate low from high lying imperforate anus	exposure to radiation	Php 300	✔

Pre-Treatment Diagnosis:

Primary Clinical Diagnosis	Imperforate Anus, High Lying	90% Certainty
Secondary Clinical Diagnosis	Imperforate Anus, Low Lying	10% Certainty

Goals of Treatment:

• Decompress the bowel obstruction by diverting the flow thru a colostomy.

• Create a temporary outlet of feces while prior to anoplasty

• Provides protection during the healing of subsequent total repair (anoplasty).

Treatment Options:

	Benefit	Risk	Cost	Availability
Sigmoid Colostomy	provide decompression relatively short segment of defunctonalized distal colon easier mechanical cleansing of distal colon prior to definitive repair	wound infection necrosis colostomy	Php 4,000	✔
Transverse Colostomy	provide decompression	unformed stool leading to mashing of skin	Php 4,000	✔
Minimal PSARP	provide decompression one stage procedure	damage to nerve seminal vesicles and prostate	Php 4,000	✔

Plan of Operation:

Diverting Sigmoid Colostomy

Pre-operative Preparation:

• Informed consent obtained

- Explain the diagnosis and proposed treatment

- Explain the need to perform colostomy

• Provide psychosocial support to allay fear and anxiety of parents

- Questions regarding survival, prognosis and life with a colostomy

• Preoperative Preparation

- Hydration : D10 0.3 NaCl 60cc X 6h

- Thermoregulation

- Antiobiotics

Ampicillin 125mg TIV q12

Gentamycin 12mg TIV OD

- Decompression

- OGT inserted

• Screening for other health problems

- CXR

Intra-operative Management:

• Position of patient - Supine

• Incision

• Sigmoid Colostomy

1. 2.

3. 4.

• Meconium evacuated

• Serosal tear repaired

• Hemostasis check

• Correct count

Intra-operative Findings:

• Well formed midline groove with prominent anal dimple with no bulge. No fistula noted on the perineal area.

• On doing LLQ transverse incision, sigmoid noted to be dilated (5cm widest diameter) containing meconium with serosal tear

Post-operative Diagnosis: Imperforate Anus, High Lying

Post-operative Care:

• Maintain on NPO/OGT

• IVF continued

• Ampicillin and Gentamycin continued, Metronidazole 18mg TIV q12 started

• Thermoregulation

• 1st POD- (+) colostomy output

• 2nd POD - started breast feeding

• 3rd POD - transferred to Pedia Ward for nutritional build-up

Follow-up Plan:

• Daily follow up of colostomy for signs of infection

• Other wok-ups - Ultrasound of KUB, 2D Echo

• Parents advised colostomy care and scheduled definitive management after 8 weeks

Outcome:

• Resolution of the obstruction due to imperforate anus

• Live patient

• No complications

• Satisfied patient

• No medico-legal suit

Discussion:

Types of Anorectal Malformation

• Classification of Anorectal Malformation in Male

	Malformation	Colostomy Required
Male	Cutaneous Fistula	No
	Rectourethral Fistula Bulbar Prostatic	Yes Yes
	Rectovesical Fistula	Yes
	Anorectal Agenesis w/o Fistula	Yes
	Rectal Atresia	Yes