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Anal Stenosis
Anal Stenosis
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This is a case of a 7-month old female from
Apas, Lahug, admitted for constipation Prenatal: unremarkable Natal history: unremarkable Postnatal history: unremarkable Immunization: Immunization: BCG x 1 dose, DTP x 2 doses, OPV x 3 doses, Hepatitis B x 2 doses, Pneumococcal x 3, Flu x 1
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Hospitalizations: none Heredofamilial diseases: hypertension
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Chief Complaint: constipation
HPI: Two weeks PTA: patient has been having decreased frequency in bowel movement with minimal amount of solid stools which was yellow-orange in color, with no associated fever or vomiting
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No consult was done, mother opted to
observe patient and began adding mashed papaya during feeding and two teaspoons of castor oil twice a day. A week PTA, no improvement was noted prompting mother to bring the patient for consult at the ER of this institution, prescribed with laxative and lactose-free milk formula.
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Two days prior to admission, patient was
noted to have decreased appetite, irritable and with episodes of straining that prompted consult with pediatrician. Xray of the abdomen: non-specific and nonobstructive bowel gas pattern and fecal stasis in the ascending and transverse colonic segments
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Patient was then referred to a
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Physical Examination Vital Signs:
HR= 100 bpm RR=38 cpm T= 37rC Wt= 7.7 kg (P-50) Ht= 70 cm (P-90) Skin: brown, no lesions, warm with good turgor
BP=90/60 mmHg
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HEENT: anictericsclerae, pinkish palpebral
conjunctivae, non-erythematous ear canals with intact tympanic membranes, no nasal secretions, dry lips, moist tongue, no lesions seen in buccal mucosa, non-erythematous and unenlarged tonsils Chest and Lungs: equal chest expansion, clear breath sounds Cardiovascular system: distinct heart sounds, regular rate and rhythm, no murmurs
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Abdomen: globular, tympanitic, not distended,
hypoactive bowel sounds GUT: grossly female, no discharges Rectal Exam: skin tag at 12 o clock position, admits tip of 5th digit, no stool on examining finger Extremities: full strong pulses, CRT < 2 seconds CNS: GCS 11 (E4V3M4) Mental status: alert
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Cranial Nerves: I and II: not assessed III, IV, VI: pupils equally reactive, full EOM V: (+) corneal reflex VII: no facial asymmetry VIII: not assessed IX & X: (+) gag reflex, able to swallow
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XI: not assessed XII: tongue at midline on protrusion Sensory: light touch, pain and temperature
intact Motor: spontaneous movements noted in bilateral upper and lower extremities Reflexes: +2 in both upper and lower extremities
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Fundoscopy: not done Meningeal signs: none Primitive Reflex: (+) grasp and rooting
reflexes
Admitting Impression: R/I Ileusvs Large
Bowel Obstruction
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Course in the Wards: On admission, venoclysis was started and
diagnostics done include CBC which revealed leukocytosis (24.4). CRP, serum creatinine (0.4 mg/dl), serum potassium (3.9 meq/L), SGPT (26 mg/dl) and bleeding parameters were all within normal values.
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Wbc Hb Hct CBC 24.4 12.6 38.4 Plt Neu Lym Mon Eos Bas 561 39.7 51.7 4.5 3.9 0.2
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Patient was given castor oil 10 ml every 6
hours as bowel preparation for colonoscopy the following day. Patient was able to move her bowel consisting of non-bloody, nonmucoid, yellow-green soft stools.
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On 1st hospital day, patient underwent
colonoscopy. Skin tags at 12 o clock position was noted, and a tight stenotic anal opening with limitation was noted during rectal exam and on insertion of the scope. At 35 cm from the anal verge, pinpoint lesions were seen and biopsy specimen were taken. IV Cefuroxime (AD= 64.9 mkD) was started post-colonoscopy.
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On 2nd hospital day, repeat CBC was done
which showed a decrease in leukocyte count (16.7 from 24.4). No rectal bleeding and no recurrence of constipation were noted.
CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas
4/26 24.4 12.6 38.4 561 39.7 51.7 4.5 4/28 16.7 12.1 36.5 393 37.1 51.9 3.8
3.9 6.4
0.2 0.8
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On 3rd hospital day, another repeat CBC was
done revealing further decrease in leukocyte count (12.9 from 16.7). Patient regained her appetite, was no longer irritable and had no episodes of straining on bowel movement.
CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas
4/26 24.4 12.6 38.4 4/28 16.7 12.1 36.5 4/29 12.9 12 36
4.5 3.8 4
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Patient was discharged improved on the 4th
hospital day. Final Diagnosis: Colitis Probably Infectious, Rectosigmoid Area Anal Stenosis Biopsy: Chronic Non-Specific Colitis with Erosions
Anal Stenosis
Anal Stenosis/Atresia
-the absence, closure, or constriction of the rectum or anus -usually diagnosed shortly after delivery ; often associated with a group of defects called the VACTERL syndrome (vertebral, anal, cardiac, trachea, esophageal, renal, and limb abnormalities)
Anal Stenosis
-can also be associated with chromosomal abnormalities, particularly trisomy 21 Demographic and Risk Factors -race/ethnicity: higher among Europeans and South Asians -maternal age: advanced maternal age associated with increased risk of chromosomal abnormalities
Anal Stenosis
Demographic and Risk Factors (continued)
- Infant sex: more common among males - Increased risk with prematurity, lower birth weight, - Maternal diabetes: may increase risk - First trimester maternal exposure to lorazepam does increase the risk for anal atresia
Anal Stenosis
Prevalence:
- United States: ranges between 1.04 and 7.89 per 10,000 live births Common Presenting Symptoms: 1. Constipation 2. Fecal Incontinence 3. Abdominal distention 4. Rectal Bleeding
Anal Stenosis
Diagnosis
Anal Stenosis
Anal Stenosis
The anus can look perfectly normal and yet
be severely stenosed. The normal passage of meconium and stools is not a reliable guide to the state of the anus A stenosed anus will often allow meconium and soft stool of the newborn to escape; a rectal thermometer can also be accomodated
Anal Stenosis
Rectal Examination:
Anal Stenosis
Anal Stenosis
Treatment:
1. Surgical- with the use of anorectal dilators 2. Supportive- high fiber diet and laxatives
Anal Stenosis