Ano-recal Malformations

Introduction
 Ano-recal Malformations (ARMs) are developmental deformities of the anorectal canal.
 The term imperforate anus is used to describe all congenital abnormalities of the
anorectal canal or in location of the anus within the perineum.
Incidence
 That occurs in about 1 out of 5,000 infants.
 Approximately 40 percent of neonates with ARMs have associated congenital anomalies
like Down's syndrome, congenital heart disease, undescended testes, renal
abnormalities, esophageal atresia and neural tube defect.
Etiology
 The exact cause of these malformations is not known.
 It occurs due to arrest in embryonic development of the anus, lower rectum and
urogenital tract at the 8th week of embryonic life.
Classification of ARMs
1. Classification of ARMs can be done into three groups in the infants without a normal
anus.
 Anal stenosis: - The baby may pass ribbon-like stools with difficulty as the anal
opening is very small.
 Imperforate anus: - Infant fails to pass meconium. Greenish bulging membrane is
seen on examination. Bowel and sphincter return to normal after excision.
 Anal Agenesis: - It presents with only anal dimple. Usually fistulas are found to the
perineum or urethra in male and perineum or vulva in female. Intestinal obstruction
develops, if there is absence of any fistula
 Rectal Agenesis: -in that condition anal canal and anus is present but no connection
between the rectum and anal canal. It presents with fistula. In male baby, fistula
may communicate with posterior urethra and in female with upper vagina.
Associated major congenital malformations are common.
 Rectal atresia: - Absence of the rectum.

Anal Imperforate Anal Rectal

Stenosis anus Agenesis Agenesis

2. ARMs can be classified into two groups on the basis of levator ani muscle, which is the
main muscle of fecal control-
  Supralevator or high ano-rectal malformations- when rectum terminates above
the levator ani muscle, which is found as rectal atresia, rectoprostatic fistula and
rectovaginal fistula. About 30 percent of children with high ARMs or associated
genitourinary fistula achieve bowel continence.
 Translevator or low ano-rectal malformations- when rectum terminates below
the levator ani muscle e.g. in anocutaneous fistula and anovestibular fistula, about
90 percent of children with low ARMs achieve bowel continence.
Clinical manifestations
 Absence of anal opening
 Misplaced anal opening
 Anal opening very near the vaginal opening in the female
 No passage of first stool within 24 - 48 hours after birth
 Stool passed by way of vagina, base of penis or scrotum, or urethra
 Abdominal distention
Investigations
 Physical examination of the neonates is the most important diagnostic measure of ARMs.
 On inspection of perineal area there is absence of anal opening.
 No history of passing of meconium or stools.
 Per rectum examination- catheter cannot be passed into the rectum.
 Urinary fistula can be diagnosed by urine examination for presence of meconium.
 USG helps to locate the rectal pouch.
 X-ray with inverted infant (upside down position), i.e. invertogram or Wangensteen-Rice
X-ray is useful to locate rectal pouch which can be performed only after the infant is 24
hours of age.
Complications
 Intestinal obstruction
 Bowel incontinence or constipation
 Urinary tract infection,
 Fecal impaction,
 Colostomy related problems,
 Recurrence of fistula,
 Anal stenosis and
 Post-operative complications.
Management
 The reconstructive surgery is done to correct or repair the congenital malformations. It
depends upon the type of anomalies and sex of the infant.
 For the anal stenosis, manual dilation is done by the doctor. The repeated regular
dilatation is done in the hospital and showed to the parents to continue at home.
Surgical Management
 Reconstruction surgery is depends on the level at which rectum ends. Anoplasty,
temporary colostomy, and pull-through at a later stage are the surgical intervention.
 In case of low ARMs, the abdominal pull-through and rectal cutback anoplasty or Y-V
plasty is done for male infants and dilatation of fistula with definitive repair or perineal
anoplasty is performed for female infants.
 In case of high ARMs, initial colostomy is done in the neonatal period followed by
definitive reconstructive surgery as posterior sagittal ano-rectoplasty (PSARP) at the age
of 10 to 12 months or when the infant is having 7 to 9 kg body weight and the infant
has to grow and put on weight to be fit for the surgery. Colostomy closure is done after
10 to 12 weeks of successful definitive surgery.
Nursing Management
 Assessment of a newborn is done immediately after birth by inspection of anal opening
and passing a catheter into the rectum.
 The neonate must pass meconium within 24 hours after birth. Passage of meconium
from inappropriate orifice such as into vagina should be inspected that anorectal petancy
is absent the doctor should be informed.
Pre-operative Care
 After birth as soon as imperforate anus is noticed the oral feeds should be withheld.
 The gastric decompression should be done by nasogastric aspiration.
 Abdominal girth should be measured.
 Vital signs should be observed.
 Normal body temperature should be maintained.
Post-operative Care
 General post-anesthetic care should be given.
 In that period, prevention of skin breakdown around colostomy wound [stoma] and
prevention of infections are important measures. Observation of the colour and
circulation of the stoma and patency of lumen.
 Maintenance of fluid and electrolyte balance and routine post-operative care to be
provided after colostomy and definitive surgery.
 Emotional support for family coping and demonstration of colostomy care are essential
aspects of nursing management.
 Health education to be given about continuation of care at home, diet modification,
prevention of fecal impaction, bowel habit training and need for medical help.
Care of pull-through and anoplasty
 The area should be kept clean and dried by exposing to the air.
 The area can be protected by covering with sterile Vaseline gauze.
 Place the baby on side lying position with hips raised, it helps to prevent tension on the
sutures.
 The feeds started after peristalsis is heard.
 The urine output should be observed.
 The observation of the abdominal distention, bleeding or other disturbances should be
notified.
 The fluid and electrolyte and nutritional needs should be met by proper feeding or
monitoring intravenous fluids.
Advice and Guidance to the Parents
 Reassure the parents to accept the child.
 Care of colostomy should be explained and demonstrated to be carried out at home.
 Anal dilatation may be demonstrated to for regularly to be done at home to prevent
stricture.
 Explain about care of the child, its diet and future surgery.
 Toilet training may be taught at the later appropriate stage.