CASE PRESENTATION

ON
ANORECTAL
MALFORMATIONS
(ARMs) Presented by :
Malsawmtluangi
Roll no.16
3 r d year BSc(Nursing)
 DEFINITION
ARMs(anorectal malformations) are developmental deformities of
the lower end of the alimentary tract , i.e. 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.

Approximately 40% of neonates with ARMs have associated

congenital anomalies like Down’s syndrome,congenital heart
disease,undescended testis,renal abnormalities and esophageal atresia.
 RELATED ANATOMY AND PHYSIOLOGY
The rectum and the anal canal are the terminal parts of the large
bowel.

The rectum : The rectum is located in the pelvis,begins at the level of

the sacral promontory,and extends 12-18cm distally.It has 2 or 3
curves within its lumen,created by submucosal folds called the valves
of Houston.It is attached to a strong endopelvic fascia extending
from the anterior surface of the sacral bone at about the level of
S4.This area of attachment is known as Waldeyer ring.
 Contd...

The anal canal : The anal canal is approximately 2.5 to 5 cm in

length.It begins at the level of the levator ani muscle and opens to the
anal verge.The anal canal is surrounded by the internal and external
anal sphincter muscle.

The rectum serves as a reservoir to fecal contents,and the anal canal

regulates continence and defecation via synchronization of events.
Contd...
 CLASSIFICATION OF ARMS
A. Classification of ARMs can be done into three groups in the
infants without the normal anus

1.With a visible abnormal opening of the bowel :

• Anal stenosis
 Contd...
• Anoperineal fistula
 Contd...
• Anovestibular fistula in female
 Contd...
2.With an invisible but manifested opening of the bowel :

• Rectovaginal fistula in female

 Contd...
• Rectourethral fistula in male
 Contd...
• Rectovesicular fistula
 Contd...
3.No manifested opening of the bowel

• Persistent anal membrane

 Contd...
• Rectal atresia
 Contd...
B. Anorectal malformations can also be
classified into two groups on the basis of levator
ani muscle,which is the main muscle of fecal
control :
 Contd...
• Supralevator or high anorectal malformations - When
rectum terminates above the levator ani muscle which is
found as rectal atresia,rectoprostatic fistula and
rectovaginal fistula.

• Translevator or low anorectal malformations - When the

rectum terminates below the levator ani muscle e.g.in
anocutaneous fistula and anovestibular fistula
 ETIOLOGY
Most of the time, the cause for an anorectal malformation is
unknown, but in rare cases, it appears to run in families.Boys
are at a slightly higher risk for this abnormality than girls.

Upto one third of babies who have genetic

syndromes,chromosomal abnormalities or other congenital
defects also have imperforate anus or other anorectal
malformation.
 Contd...
These genetic syndromes and other congenital
problems include :

• VACTERL association

• Digestive system abnormalities

• Urinary tract abnormalities

• Abnormalities of the spine

 PATHOPHYSIOLOGY
Genitourinary tract originates from the embryonic structure
called CLOACA

By the 7 th week of gestation membrane separates the rectum

from anus
 Contd...
If the membrane that seperates the rectum and anus is not
absorbed

Union of anus and rectum does not occur

Resulting in anorectal anomaly

 SIGNS & SYMPTOMS
Anorectal malformations are usually diagnosed immediately after
birth by the person conducting the delivery or within hours by the
caregivers.

Some of the important features are:

• Abnormally formed or no anal opening

• Absence of meconium or stool

• Passing of stool through the fistula

• Swollen belly
 INVESTIGATIONS
Physical examination of the neonates is the most important
diagnostic measures of ARMs.The diagnosis of an anorectal
malformations is based on the physical finding of an absent
anal opening.

Some of the diagnostic measures are:

• Ultrasonography(USG)

• X -ray
 Contd...
• Urine examination

• Micturating cystourethrogram

Other diagnostic examination that may be performed

include pelvic MRI,radiography and fluroscopic
examination of pelvic anatomic contents
 MANAGEMENT
Medical Management

1. IV fluids : IV fluids are administered unless it is

contraindicated to maintain glucose and fluids and
electrolyte balance.

2. Antibiotic prophylaxis: Antibiotics such as

ampicillin,gentamycin and clindamycin are given to the
children during the perioperative period.
 Contd...
3. Laxatives: Common laxatives such as senna
products,milk of magnesia and propylene glycol
solutions are given

4. Diet: Foods such as banana,rice,apple sauce and

toast should be avoided.Instead high fiber and
laxatives foods should be encouraged
 Contd...
Surgical 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.
 Contd...
In case of low ARMs : Surgery that can be perform is
rectal cutback anoplasty or Y-V plasty.

In case of high ARMs : Surgery that can be done is

colostomy surgery followed by definitive
reconstructive surgery as posterior saggital
anorectoplasty(PSARP)
 COMPLICATION
Intraoperative complications

• For males : Injury to the urinary

structure,including the urethra,seminal
vesicles,and vas deferens

• For females : Injury to the vagina

 Contd...
Post-operative complications
• Superficial and deep wound infection

• Dehiscence of the anastomosis

• Prolapse of the anoplasty or stricture of the anoplasty

• Recurrent fistula between the urinary system in males

or gynaecologic system in females
 NURSING MANAGEMENT
Nursing Assessment
Assessment of an infant with imperforate anus or anorectal
malformations include the following:

• Full patient and family history should be collected to

enable the delivery of high quality care
 Contd...
• Physical examination should be performed to
identify newborn with imperforate anus

• Inspection of perineal areas should be done for

abnormalities
 Contd...
Nursing Diagnosis

Preoperative :

1) Impaired bowel elimination related to bowel malformation from

childbirth

2) Fluid volume deficit related to excessive loss through vomiting and

nil per oral

3) Risk for infection (UTI) related to passage of meconium through

urethra
 Contd...
Post-operative :

1) Pain related to surgical procedures or post-operative surgical

incision

2) Impaired skin integrity related to colostomy or surgical

procedures

3) Imbalanced nutrition less than body requirements related to

nil per oral
 HEALTH EDUCATION
• Instruct the relatives that long-term follow-up is
essential for children with complex malformations

• Inform the relatives about the delayed toilet

training and that complete continence is seldom
achieved at the usual age of 2-3 years
 Contd...
• Instruct the relatives about bowel habit traning , bowel
management irrigation programs , etc to help the child
improve bowel function and social continence

• Inform the relatives about diet that can help the child pass
stool more easily

• Teach the relatives about the importance of maintaining

hygiene at home
 PROGNOSIS
Prognosis of ARMs depends upon type of anomalies,presence
of associated malformations,operative skill,presence of
neuromuscular fecal control and general health of the
infant.Patient with less complex malformations have
excellent outcomes while patient with very complex
malformations have poor outcomes.
 SUMMARY
Anorectal malformations are birth defects in which the anus
and rectum does not develop properly.Anorectal
malformations include several different abnormalities
including:

• Anal passage may be narrow

• A membrane may be present over the anal opening

 Contd...

• The rectum may not connect to the anus

• The rectum may connect to a part of the

urinary tract or the reproductive system
through an anal passage called a fistula
 CONCLUSION
Anorectal malformations are among the more frequent
congenital anomalies encountered in pediatric surgery,with
an estimated incidence ranging between 1 in 2000 and 1 in
5000 live births.All patients born with anorectal
malformations can be kept clean of stool and dry of
wine,either because they achieve bowel control or because
they are subjected to a bowel management program
THANK YOU