ANORECTAL

MALFORMATIONS
 DEFINITION

Anorectal malformations are developmental

deformities of the lower end of the
alimentary tract i.e. the anorectal canal.
 INCIDENCE

Minor abnormalities of the anus and rectum

occur in 1 in 500 living newborns while
major abnormalities occur in 1 in 5000
living infants.
 CAUSE

The exact cause of these malformations is

not known. It occurs due to the arrest in the
embryonic development of the anus, lower
rectum and urogenital tract at the 8th week
of embryonic life.
 CAUSE CONTD…

The membrane that separates the

endodermal hindgut from the ectodermal
anal dimple perforates and a continuous
canal is formed, the outlet of which is the
anus.
 CAUSE CONTD…

If the membrane separating the rectum

from the anus is not absorbed, and if the
union does not take place, an anorectal
anomaly results.
 CAUSE CONTD…

Approximately 40% of the neonates with

anorectal malformations have associated
anomalies like Down’s syndrome,
congenital heart disease, undescended
testes, renal abnormalities, esophageal
atresia and neural tube defect.
 TYPES
ACCORDING TO THE VISIBILITY OF
THE ANUS:
a) With a visible abnormal opening of
the bowel
1)Anal stenosis: It accounts for 10% of all
ARMs. A stricture is at the anus or at levels 1
to 4 cm above the anus, or extends the entire
length of the anus.
ANAL STENOSIS
 TYPES CONTD…
2) Ano-perineal fistula
 TYPES CONTD…
3) Ano-vestibular fistula in female.
 TYPES CONTD…
b) With an invisible but manifested opening
of the bowel:
1) Rectovaginal fistula in female
 TYPES CONTD…
2) Recto urethral fistula in male
 TYPES CONTD….
3) Rectovesicular fistula
 TYPES CONTD…
c) No manifested opening of the bowel
1) Persistent anal membrane or imperforate
anus: Here there is an imperforate anal
membrane that produces obstruction
behind which the meconium is seen.
IMPERFORATE ANUS
 TYPES CONTD…
2) Rectal atresia
 TYPES CONTD…
a) On the basis of levator ani muscle
1) Supralevator or high ano-rectal
malformation: When rectum terminates
above the levator ani muscle, which is found
as rectal atresia, rectoprostatic fistula and
rectovaginal fistula.
 TYPES CONTD…
2) Translevator or low ano-rectal malformation
: When rectum terminates below the levator
ani muscle found in ano-cutaneous fistula
and anovestibular fistula.
 ANAL AGENESIS
There is an imperforate anus, possibly seen
as a dimple. The rectal pouch ends blindly
some distance above the anus or forms a
fistula with other organs leading to
– Rectovaginal fistula- low and high (female)
– Rectoperineal fistula (male and female)
– Rectovesical fistula (male)
– Rectourethral fistula (male)
– Rectoprostatic fistula (male)
ANAL AGENESIS CONTD…
RECTOVAGINAL LOW FISTULA
 RECTAL ATRESIA
There is a normal anus and anal pouch.
The rectal pouch ends blindly in the hollow
of the sacrum. The anus might form a
fistula with other parts leading to
– Ano vestibular fistula (female)
– Ano perineal fistula (male and female)
– Ano cutaneous fistula (male and female)
 CLOACAL EXSTROPHY
It is a rare, severe defect in which there is
externalization of the bladder and bowel through
the abdominal wall. Often the genetalia are
indefinite, and the chromosome studies are
necessary to determine the child’s sex. These
children are mostly females
CLINICAL MANIFESTATIONS

– Absence of meconium

– No anal opening
– Unable to insert a gloved finger or a rectal
thermometer into the rectum

– Abdominal distention
CLINICAL MANIFESTATIONS
– History of difficult defecation, abdominal distention
and ribbon like stools in an older child in case of anal
stenosis.

– Greenish bulging membrane behind anus in case of

imperforate anal membrane

– Intestinal obstruction if no fistulas

– Passage of meconium through vagina, perineal orifice
or with urine in case of fistula
 DIAGNOSTIC TESTS

Physical examination by passing the gloved

little finger through the anus and by
observing the passage through which
meconium was passed.

Ultrasounds scan to locate the rectal pouch.

 DIAGNOSTIC TESTS contd…

X-ray with inverted infant called as

invertogram or Wangensteen-Rice X-ray
when the infant is 24 hrs of age.

Urine examination for presence of

meconium and epithelial debris.
 DIAGNOSTIC TESTS contd…

Micturating cystourethrogram (MCU) to

detect urinary abnormalities.

Intravenous pyelogram to rule out

vesicourethral reflux.
 MANAGEMENT

The reconstructive surgery is done to

correct or repair the congenital
malformations. It depends upon the type of
anomaly and sex of the infant.
 MANAGEMENT CONTD…
In case of low ARMs, where there is less
than 1.5cm distance between the anal
dimple and the rectal pouch, rectal cutback
anoplasty or Y-V plasty is done for male
infants and dilation of fistula with definitive
repair or perineal anoplasty is performed
for female infants.
 MANAGEMENT CONTD…
In case of high ARMs, where there is more than 1.5cm
distance between the anal dimple and the rectal pouch,
initial colostomy is done in the neonatal period followed by
definitive reconstructive surgery as posterior sagittal ano-
rectoplasty at the age of 10 to 12 months or when the
infant is having 7 to 9 kg body weight. Colostomy closure is
done after 10 to 12 weeks of successful definitive surgery.
 MANAGEMENT CONTD…

In case of imperforate anal membrane, the

membrane is perforated with a blunt
instrument. Repeated dilatation might be
necessary to prevent scar formation.
 MANAGEMENT CONTD…
In case of anal stenosis, dilatation is done every 4-6
months.

In case of fistulas, the colon can be brought down

through the anal dimple by an abdominoperineal
procedure. The anus is positioned in the area of
external sphincter and the fistula is removed.
 PREOPERATIVE CARE:
– Gastric suction may be done

– Withhold oral feedings

– Start parenteral hydration

– Measurement of abdominal girth

– Intake output chart

– Consent from parents

– Pre-medications
 POST OPERATIVE CARE

Scrupulous perineal care

Change perineal dressings whenever soiled

Apply protective ointments such as zinc oxides to
decrease skin irritation.

Position baby in a side-lying or a supine position

with the legs suspended at a 90° angle to the trunk
to prevent pressure on perineal sutures
POST OPERATIVE CARE contd…

Intravenous feedings till the wound heals or

until peristalsis appear.

Prevention of constipation by exclusive

breastfeeding and proper weaning with
stool softeners or fibers.

Bowel habit training

POST OPERATIVE CARE contd…
Daily enemas until control are achieved if
necessary.

Do not use diaper in case of anoplasty

Colostomy care by changing the collection device
and meticulous skin care.

Family support, discharge planning and home

care
 COMPLICATIONS
Urinary tract infection

Intestinal obstruction

Fecal impaction

Colostomy related problems

Recurrence of fistula

Anal stenosis

Poor bowel control

Constipation
 PROGNOSIS
– About 30% of children with high ARMs or
associated genitor urinary fistula achieve bowel
continence.

– About 90% of children with low ARMs achieve

bowel continence.
 NURSING CARE
Preoperative : Impaired bowel elimination related to bowel
malformation as evidenced by lack of patency or
passage of stool through a different opening.
Goal: The child will pass meconium and will not have abdominal distention

Interventions:

If there is a fistula, keep the perineum clean until surgery.

Follow pre-operative orders.

Do gastric decompression with NG tube.

Start IV line.

Follow strict nil per oral.

 Nursing care contd…
2) Fluid volume deficit related to nil per oral
Goal: The child will maintain normal fluid balance

Interventions:

– Maintain intake output chart

– Administer IV fluids as ordered.

– Do gastric decompression.
 Nursing care contd…
3) Risk for infection (UTI) related to passage of meconium through
urethra.

Goal: The child will have no risk for infection.

Interventions:

If there is a fistula, keep the perineum clean until surgery.

Follow pre-operative orders.

Start IV line.

Administer plenty of IV fluids as ordered.

Send urine for examination.

 Nursing care contd…
Postoperative:
1) Pain related to surgery
Goal: The child will have less pain
Interventions:
Keep the sutured site clean.
Do not spread the legs or place in prone position to avoid
strain on the sutures.
Keep the legs suspended at 90°angle to the trunk.
Prevent constipation by restarting breastfeeding when
peristalsis appears.
 Nursing care contd…
2)Impaired skin integrity related to surgery
Goal: The wound heals faster.
Interventions:
Keep the sutured site clean.
Do not spread the legs or place in prone position to avoid strain on the
sutures.
Keep the legs suspended at 90°angle to the trunk.
Prevent constipation by restarting breastfeeding when peristalsis appears.
Apply zinc oxide ointment to prevent skin irritation.
Change dressing often.
Do not use diaper.
A heat lamp may be used to facilitate healing.
 Nursing care contd…
3)Risk for infection related to surgical incision in the least
clean area.
Goal: The child will have no risk for infection Interventions:
Keep the sutured site clean.
Change dressing often.
Do not use diaper.
Change colostomy bag soon as it is soiled.
Administer antibiotics if prescribed.
Keep the site dry.
 Nursing care contd..
4)Impaired nutrition less than body requirement related to
nil per oral.
Goal: The child will take adequate feeds.
Interventions:
Maintain intake output chart
Administer IV fluids as ordered.
Do gastric decompression immediately after sugery.
Start breastfeeding when peristalsis begins.
Monitor abdominal girth.
Give laxative if child is on cow’s milk.
Increase fiber content during weaning.
 Nursing care contd…
Risk for complication (constipation, fecal
impaction) related to interference with
neurological control of defecation.

Impaired family process related to diagnosis of a

congenital condition

Anxiety related to surgery and hospitalization.

Knowledge deficit regarding post operative care

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