ANORECTAL MALFORMATION.ppt

7/24/2019 ANORECTAL MALFORMATION.ppt

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Presented ByAnu George

MSc Nsg(Peadiatrics) Student

Supervisor:Dr.(Mrs.) Raman Kaia

!ecturer


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Imperforate anusIncludes agenesis and atresiaof the rectum and anus

Etiology: unknownIncidence: 1 in 4,500

SEX: 0!male


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"#$: Em%ryologyThe cloaca&which is a common cham%er into the hindgut and allantois'

Separated into:

(ownward growth

of a septum

Fusion during the )rdmonth of intrauterine life

when there is imperfect fusion imperforate anus

The bladderpost-allantoic gut

)rectum(

Proctadeum

)epiplastic bud(


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Imperforate anus

Low abnormalities*ermination of %owel %elow

the pel+ic floor

Easy to (iagnoseSimple to #

utlook is good

1'-o+ered anus.'Ectopic anus

)'Stenosed anus

4'$em%ranous stenosis

High abnormalities*ermination of %owel a%o+e

the pel+ic floor

ften ha+e a fistula into theurinary tract with

deficient pel+ic floor

(ifficult to R

1'"norectal agenesis

.'#ectal atresia

)'-loaca


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1'-o+ered anus"nal canal co+ered %y a %ar of skinwith a

trackrunning forwards to the perinealraphe/ *his track is called ucket 2andle3

midline #aphe fistula/


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.'Ectopic anus

"nus situated anteriorly in , it opens in" perineum

in , it opens in# +ul+a&more commonly'+ul+al

ectopic anusor +agina&rare'


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)'Stenosed anusi/e/ microscopic anus

*here is a minute openingthat can %e seen if

eamined carefuly


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4'$em%ranous stenosis#are"nus is normally sited

co+ered with a thin mem%rane that%ulges with retained meconium


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-ould %e associated with:a fistulasconnection %etween the %lind rectalstump and the %ladder

or other pel+ic structures a%normally


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1'"norectal "genesis

#arelind rectal pouch lies 6ust a%o+e the pel+icfloor

In " anterior aspect attached tothe%ladder 7 often there is a recto+esical fistulaor rectourethral fistula&manifested %y passageof gas or meconium in the urine' or perinealfistula

In # fistula to the posterior forni

recto+esti%ular &or recto+aginal' low #89 Easy to correctost;op/ 9unction is good

high #89 (ifficult to correct

ost;op function is poor


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.'#ectal atresia#areAnal canalis normal %ut ends %lindlyat the le+el

of pel+ic floor 7 the rectumalso ends %lindlya%o+e the pel+ic floor without a fistulas opening/


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)'-loacaccurs only in #owel, urinary7 genital tractsall open into a

common wide ca+ity

-ommonly associated with otherde+elopmental a%normalities e/g/tracheoesophagial fistula


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"pproach2istory the systems in+ol+edEamination ((

In+estigation ($anagement


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2istory9ailure to pass meconiumwithin the 1st.4

hours of life/

atients with anterior ectopic anusmaypresent in childhood or in adulthood/ *hesepatients ha+e lifelong histories of constipation

and painful defecationand usually ha+ere


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Eamination

Inspectionalone is sufficient for management plan in 90%of patients/

Low=ucket handle defect

=>as?meconium from perineum

=erineal fistula if skin %ridge%etween +esti%ule and fistula/

="nterior ectopic anusi/e/ normal si@ed anussurrounded %y normal muscle/

=Arine free of meconium&B a+erage of .0 hrs for meconium to appear in urine'/

High=9lat %ottom

=Short sacrum

=Cittle muscle contraction=$econium per urethra

=#ecto+esti%ular fistula if within mucosalmargin of the +esti%ule/

=Sphincter located close to the scrotumor %ifid scrotum often associated

with a rostatic 9istula/=-loacae are often missed if urethralopening is not identified in female

with a recto;+aginal3 fistula/=9urthermore, cloacae often ha+e small

openings and may %e a cause ofreferral for am%iguous genitalia/

?


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In+estigationVery Important to:

1/ Eclude other anomaliesDD

./(etermine whether a%normality is highor lowDD


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1/ Eclude other "nomaliesDDD"nal atresia may occur as a part of the VAT!"L

groupof anomaliesV Verte%ral %ody segmentation defect

A Anal atresia ardio+ascular &(", 8S('T! Tracheo esophagial fistula" unilateral "enal agenesis

L Lim% anomaly &radial ray hypoplasia'

So, +ery careful eamination of the %a%y must %e madeto eclude these anomalies


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Eclude other "nomaliesDDD

&contd'Associated abnormality Investigation

"V" Vertebral Abnormality )butterflyvertebrae, hemi-vertebrae(

pinal ultrasound, pinal !-ray

"" ardiac, #eart Abnormalityardiac $#% )V&, A&, P&A(

ardiac $#%

"R" Renal, 'idney abnormality )solitaryidney, horse shoe idney(

Renal ultrasound, Voiding cysto-urethra-gram )V*(

"T$" tracheoesophogeal abnormality)T$+(

Physical e!amination

"" imb deformity Physical e!amination, !-rays

. ( h h % l


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./(etermine whether a%normality ishighor lowDD

#$Inertogram:with a metal buttonor a coinstrapped to the site of the anus or

a metal bougieinserted into the %lind anal canalInfant is held upside downfor );4 minutes*hen radiograph in the in+erted lateral position & %oth the

greater trochanters should %e on the same line'*he gas in the rectum will rise to the top indicates the distance%etween the site of the metal indicator and the %lind end of therectum &&& if the distance ./5 cm, the a%normality is highDD

if the rectum ends a%o+e the - line &pu%ococcygeal line F fromthe symphysis pu%is to the last +erte%ra', the a%normality is Cow

7 +ise +ersa or according to ischeal line &%etween ant/;sup/ Iliacspines'/Ghen to %e doneH"lthough it is a useful method, sometimes +itiated %y a plug of

meconium in the rectum causing an apparent gap far in ecess ofthat actually present/ So, it may %e necessary to wait until the

%a%y is .4 hrs old%efore rectal gas appears


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' line

(etal button

gas in the rectum


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)$*rine culture:resence of meconium

resence of proteusor pseu+omonasusually signifies that a fistulais present

,$*-:*o e+aluate the lesion type

.$("I:If we suspected comple malformation

/$(icturating cystourethrogram:y in6ecting a dye in the urethra


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Treatment of Low abnormalities:

#$oere+ anus:

*he track should %e opened %y scissors

9ollowed %y routine dilatationof the anus

)$!ctopic anus:

lastic cut;%ack3operation

,$-tenose+ anus:#egular dilatation


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Treatment of High Abnormalities:

8ery difficult pro%lem 7 each case must %e consideredon its merits*he possi%ilities are:Twostage operation:1ststage laparotomy

(i+ision of rectourethral fistula *rans+erse colostomy.ndstage rectal pull;through3 operation1nestage operation:

laparotomy (i+ision of fistula pull;through3 operation(i+ision of fistula 7 rectal pull;down3 operation

through the perinum& now rarely used'


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Treatment of High abnormalities

2cont+3$*he new techni


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ull;through peration

Cower %owel is mo%ili@edBew passage is created through thepel+ic floor %y passing a pair of cur+edforceps7 through it, keeping close tothe urethra, to the site of the futureanus/

*his is dilated %y 2egars dilatorsothat the %owel can %e pulled down andits mucosa stitched to the skinof the

newly formed anus/(aily dilatationwill %e re


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'-A"'*he S"# dissection is along the midline pro+idinge4cellent e4posurewith minimal trauma toneres an+ musculature5

It inoles:= Stimulation of musclesto demonstrate the midline

and sphincter

= osterior sagittal incision; length depends onse+erity of a%normality and re


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osition for S"#


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Incision in S"#


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osterior sagittal repair of a recto+esti%ular

fistula/


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rognosisIn high %of cases, imperforate anus is associatedwith other congenital a%normalities especially ofthe urinary organs 7 nearly /0%of deaths incases of imperforate anus are due to othermalformations


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Bursing $anagementIdentification of "#$ at %irth and promptmanagement? #eferral

repare for colostomy(emonstrate to the parents the care ofcolostomy

Ensure competent home care and regular follow

upreparation for surgeryost;p Bursing $anagement


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Bursing $anagement&contd''ost1pImmediate post;op care

re+ent Infection and promote healing: -are ofthe suture line, anti%ioticsButritionSystematic (ilation

re+ention of constipationowel training-are of colostomy


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In a Summary# opening -loaca) openings anorectal agenesis with

recto+aginal fistula, openings ectopic anus, stenosed anus,

mem%ranous anus, rectal atresia or e+ennormal anusDDD

*he most important in+estigation is the

in+ertogramIt is +ery important to rule out other

anomalies*he %est 7 the newest operation is S"#


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i%liography1/ $arlow (/# and #edding /"/ *et%ook of

edatric Bursing/ th

Edition/ p: /./(onna C Gong/ Essentials of ediatricBursing/ 5thEdition/ p: J45;J4K

)/Lliegman and et al&.00K'M Belson *et%ook of

ediatricsM 1Jth editionM pages: 1)5;)N/


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THA6781*THA6781*

ANORECTAL MALFORMATION.ppt

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