Anorectal Malformation

1. Anorectal Malformation
Dr Ninad S Patil
MBBS,MD Pediatrics
Department of Pediatrics
NKP Salve & LMH ,Nagpur

2. It is developmental deformities of the lower end of
alimentary canal i.e. anorectal canal

4. Incidence
• Minor anomalies seen in one in 500 live birth
• Major anomalies seen in one in 5000 live birth
• More in male than female

5. Etiology
• Exact cause not known
• It occurs due to the arrest in the embryonic development of the anus,
lower rectum and anogenital tract at around 8th week of intrauterine
life
• Up to 40 % cases associated other anomalies , Downs syndrome
• Well known other anomalies –VACTERL
V-vertebral A- anorectal C-cardiac
TE-TEF R-renal L-limb deformity

6. CLASSIFICATION
• Classified based upon the whether the malformation is above or
below puborectalis muscle ( investigation based)
• Low (60%) type-mc
• High (40%) type

7. Low malformation
• Continence is maintained in 90 % of cases
• Easy – diagnose
- treat
• Good prognosis
• They include
- covered anus
- ectopic anus
- anal stenosis

8. High malformation
• It include
 anorectal agenesis
 rectal atresia
 cloaca

10. Approach
• History
• Examination
• Investigation
• management

11. History
• Non-passage of meconium in 24 hours of life
• Meconium stained urine color
• Child/adult with mild variety of ectopic anal opening –
constipation/excess straining

12. Examination
• Absent anal opening
• Bulge (membrane) over anal opening area
• Ectopic anal opening
• Abdominal distension
• Look for other associated anomalies

13. Investigation
• Differentiate high Vs Low lying malformation - X ray
abdomen
• Look for other associated anomalies – USG/MRI/karyotyping
etc

14. X ray abdomen
1) invertogram
 hold baby – inverted position baby, 3-4 min
 Metal button/ coin placed over buttock (normal anatomical site)
 lateral x ray taken
• Look for distance between the coin shadow and bowel gas shadow
If distance is more than 2.5 cm k/a high type anomaly
• Less comfortable ,now days not preferred technique

15. 2) Prone cross table lateral view
- easy , more accurate and preferrable comparatively
- keep baby in prone position
- place coin
- lateral x ray

16. Management
Low lying anomaly
1) Covered anus – Skin/membrane
track opening by scissors, f/b routine dilatation of opening for 3
months
1) Ectopic anal opening – midline operation and f/b routine dilatation
2) Stenosed anus– regular dilatation

17. High lying anomaly
• 1st temporary colostomy for 3 months f/b
• Definitive repair- PSARP(Posterior sagittal anorectoplasty) i.e. pull
through procedure , f/b daily dilatation
Complications-
• incontinence
• re-stenosis

18. Nursing management
• Assisting in identification of anorectal malformation-
new born not passed meconium in 24 hours of life OR abnormal
location of anal opening (ectopic)
• Pre-operative care
- withheld feed once diagnosis is made
- start IV fluid/parenteral nutrition to meet babies calories intake
- NG tube placement and abdominal decompression
- monitor abdominal girth
- bladder preparation
- family counselling and psychological preparation for surgery

19. Post operative care
• Administration of IV antibiotics and Fluids
• Iv analgesic to minimize the pain
• Continue nasogastric suctioning
• Start feed once gut sound appears
• Stoma site care(high anomaly)
• Local site care to prevent infection ( low anomaly Sx/ high anomaly
with definitive care)
• Patient education about local wound site care and regular dilatation

20. THANK YOU