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: constipationHPI: 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 non-obstructive bowel gas pattern and fecal stasis in the ascending and transverse colonic segments

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Patient was then referred to a gastroenterologist who advised them admission.

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Physical Examination Vital Signs: BP=90/60 mmHg HR= 100 bpm

RR=38 cpm T= 37C Wt= 7.7 kg (P-50) Ht= 70 cm (P-90)

Skin: brown, no lesions, warm with good turgor

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HEENT: anicteric sclerae, 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 Ileus vs

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 Plt Neu Lym Mon Eos BasCBC 24.4 12.6 38.4 561 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, non-mucoid, 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 3.9 0.2

4/28 16.7 12.1 36.5 393 37.1 51.9 3.8 6.4 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 38.4 561 39.7 51.7 4.5 3.9 0.2

4/28 16.7 12.1 36.5 393 37.1 51.9 3.8 6.4 0.8

4/29 12.9 12 36 398 30.1 54.3 4 11.2 0.4

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Patient was discharged improved on the 4th hospital day.

 Final Diagnosis: Colitis Probably Infectious,

Rectosigmoid Area Anal StenosisBiopsy: 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 Physical Examination: - presence of an obstructive skin

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: -note the size of the anus -suppleness or rigidity of the canal

Imaging:1. Barium enema2. CT Scan3. MRI4. Ultrasound

Anal Stenosis

Anal Stenosis

Treatment:1. Surgical- with the use of anorectal

dilators2. Supportive- high fiber diet and

laxatives

Anal Stenosis