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Anu George
MSc Nsg(Peadiatrics) Student
Supervisor:
Dr.(Mrs.) Raman Kalia
Lecturer
Imperforate anus
Includes agenesis and atresia of the rectum and anus
Etiology: unknown
Incidence: 1 in 4,500
SEX: 60% male
ARM: Embryology
The cloaca
Separated into:
The bladder
post-allantoic gut
(rectum)
Downward growth
of a septum
Proctadeum
(epiplastic bud)
imperforate anus
Imperforate anus
Low abnormalities
High abnormalities
Easy to Diagnose
Simple to R
Outlook is good
1)Covered anus
2)Ectopic anus
3)Stenosed anus
4)Membranous stenosis
1)Anorectal agenesis
2)Rectal atresia
3)Cloaca
1)Covered anus
Anal canal covered by a bar of skin with a
track running forwards to the perineal
raphe. This track is called Bucket Handle
midline Raphe fistula.
2)Ectopic anus
or vagina
(more commonly)>>
(rare)
vulval
3)Stenosed anus
i.e. microscopic anus
There is a minute opening that can be seen if
examined carefuly
4)Membranous stenosis
Rare
Anus is
normally sited
covered with a thin membrane that
bulges with retained meconium
1)Anorectal Agenesis
Rare
Blind rectal pouch lies just above the pelvic
floor
In
anterior aspect attached to the
bladder & often there is a rectovesical fistula
or rectourethral fistula (manifested by passage
of gas or meconium in the urine) or perineal
fistula
In
fistula to the posterior fornix >>
rectovestibular (or rectovaginal)
low RVF Easy to correct
Post-op. Function is good
high RVF
Difficult to correct
Post-op function is poor
2)Rectal atresia
Rare
Anal canal is normal but ends blindly at the level
3)Cloaca
Occurs only in
Bowel, urinary & genital tracts all open into a
Approach
History >>> the systems involved
Examination >>> DDx
Investigation >>> Dx
Management
History
Failure to pass meconium within the 1st 24
hours of life.
Examination
Inspection
alone is sufficient for management plan in 90% of patients.
?
Low
High
Flat bottom
Short sacrum
Little muscle contraction
Meconium per urethra
Rectovestibular fistula if within mucosal
margin of the vestibule.
Sphincter located close to the scrotum
or bifid scrotum often associated
with a Prostatic Fistula.
Cloacae are often missed if urethral
opening is not identified in female
with a recto-vaginal fistula.
Furthermore, cloacae often have small
openings and may be a cause of
referral for ambiguous genitalia.
Investigation
Very Important to:
group of anomalies
V
Vertebral body segmentation defect
A
Anal atresia
C
Cardiovascular (PDA, VSD)
TE Tracheo esophagial fistula
R
unilateral Renal agenesis
L
Limb anomaly (radial ray hypoplasia)
Associated abnormality
Investigation
Cardiac ECHO
"R" Renal, Kidney abnormality )solitary Renal ultrasound, Voiding cystokidney, horse shoe kidney(
urethra-gram )VCUG(
"TE" tracheoesophogeal abnormality
)TEF(
Physical examination
Metal button
PC line
gas in the rectum
2)Urine culture:
Presence of meconium
Presence of proteus or pseudomonas usually signifies that a fistula is present
3)US:
To evaluate the lesion type
4)MRI:
If we suspected complex malformation
5)Micturating cystourethrogram:
By injecting a dye in the urethra
(PSARP)
Pull-through Operation
Lower bowel is mobilized
New passage is created through the
PSARP
Incision in PSARP
Prognosis
In high % of cases, imperforate anus is associated
with other congenital abnormalities especially of
the urinary organs & nearly 50% of deaths in
cases of imperforate anus are due to other
malformations
Nursing Management
Identification of ARM at birth and prompt
management/ Referral
Prepare for colostomy
Demonstrate to the parents the care of
colostomy
Ensure competent home care and regular follow
up
Preparation for surgery
Post-Op Nursing Management
Nursing Management
(contd)
Post-Op
Immediate post-op care
Prevent Infection and promote healing: Care of
In a Summary
1 opening >>> Cloaca
2 openings >>> anorectal agenesis with
rectovaginal fistula
3 openings >>> ectopic anus, stenosed anus,
membranous anus, rectal atresia or even
normal anus!!!
The most important investigation is the
invertogram
It is very important to rule out other
anomalies
The best & the newest operation is PSARP
Bibliography
1. Marlow D.R and Redding B.A. Textbook of
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