Dr Arun aggarwal gastreontologist explain all about ANMS

1. Dr Arun Aggarwal Gastroenterologist.
ANMS Case

2.  7 year old male with h/o chronic
constipation and encopresis
 Never had formed stools in life, always
leaking
 On regular diet
 No organic cause of constipation
CASE I

3.  Physical examination: normal
 Rectal: full of stools
 Multiple admissions in past for clean
out.

4.  CBC, BMP: normal
 Abdominal X ray: fecal loading
 Barium enema: no transition zone, reduntant
colon
 Anorectal manometry: average resting
pressure 69-86, RAIR present at 30 cc, max
squeeze pressure at 116/9 mmHg
 Rectal biopsy: ganglion cells present
 Colonic transit study: slow transit
Previous Investigations

5.  Enemas
 Suppositories
 Miralax
 Stimulant laxatives
 Golytely
Previous medicines

6. Referred from outside hospital for
further evaluation before possible
colectomy…..

7.  Plan was made for colonic manometry
 Colonic catheter placed with colonoscopy
 Colonoscopy: dilated colon

8. Baseline colonic manometry showed
good activity in colon

9. Increase in colonic activity after meals

10. Colonic manometry after Bisacodyl
administration

11. Colonic manometry after Bisacodyl administration
showing High Amplitude propagated contractions

12. Colonic manometry after Bisacodyl administration
showing High Amplitude propagated contractions

13.  RESULT: normal colonic manometry
 PLAN: cecostomy for antegrade
enemas; avoid colectomy.

14.  7 year old male with chronic constipation
and encopresis.
 No other significant past medical history.
 No organic cause of constipation.
 Physical examination: normal
CASE II

15.  CBC, BMP, Ca, TFT, celiac profile: normal
 Anorectal manometry and suction
biopsy: normal
 MRI: normal lumbosacral spine,
constipation
 Barium enema: normal

16.  Previous medications:
 Miralax
 Exlax
 Enemas
 Suppositories
 Clean out in the ER

17.  colonic manometry followed by
cecostomy was done in 10/09.
 Started on antegrade enemas.
 Continued to have stool retention and
encopresis

18. Admitted for repeated colonic
manometry to decide for further
management…..

19. Baseline colonic manometry

20. Motility with meal

21. Motility after bisacodyl

22. Colonic manometry showing HAPC in proximal
colon, none in distal colon

23. Colonic manometry showing HAPC in
proximal colon, none in distal colon

24.  RESULT: normal proximal colonic manometry,
no motility in distal colon.
 PLAN: distal colectomy.
Result