“poop fail” a case discussion
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Ryan Em C. Dalman MD MBA - 070070. “Poop fail” A Case Discussion. Objectives. Present a case of Imperforate Anus Discuss the pathophysiology and management of Imperforate Anus. Case Presentation. Patient History. General Data. - PowerPoint PPT PresentationTRANSCRIPT
“Poop fail” A Case Discussion
Ryan Em C. Dalman MD MBA - 070070
Objectives
Present a case of Imperforate Anus Discuss the pathophysiology and
management of Imperforate Anus
Case PresentationPatient History
General Data
Live preterm baby boy, born via primary CS for non-reassuring-fetal-heart-rate pattern and IUGR, at 35 weeks AOG, born on January 25, 2011
Maternal and Birth History 30 year-old G3P1 (0121) Pre-ecclampsia Maternal PMH: unremarkable
History of Present Pregnancy 1st trimester
Premature contractions—admitted for 1 week, given duphaston
2nd trimester UTI by urinalysis 3x, given 7 days unrecalled
antibiotics for each week ~30weeks AOG, BP 150/100, started on methyldopa
250mg BID BP at home was uncontrolled
3 days PTA, (+) headache, methyldopa increased to 500mg q6h, but was persistent and was admitted
Family History
unremarkable
Case PresentationPhysical Exam
General Infant Size
BW 1040g BL 35 cm HC 28 cm AC 21 cm AS 9,9 MT 35 weeks, AGA
General PE Active, good cry Fontanels - flat Pupils - brisk Muscle tone -
normal Strength of
extremities- normal Extremities – no
deformities Chest expansion-
normal
Breath sounds clear and equal
Abdomen - soft Anus - imperforate Spine – intact Color - pink Cord - dry Skin - clear Pulses - strong CRT <3 sec Edema - none
Case PresentationCase Discussion
Admitting Impression
Imperforate anus
Differential Daignosis
None There is no differential diagnosis for
an imperforate anus
Imperforate Anus
Abnormal termination of the anorectum
Ranges from anal stenosis to persistence of cloaca
Most common defect Imperforate anus with a fistula between
the distal colon and urethra in boys or the vestibule of the vagina in girls
Imperforate Anus
Associated anomalies: VACTER-L Vertebral Anal Cardiac Tracheal Esophageal Renal Limb
Imperforate Anus
Male defects: Perineal Fistula – rectum opens in the
perineum Rectourethral bulbar fistula – rectum
communicates with the lower posterior portion of the urethra called bulbar
Imperforate Anus
Female defects: Perineal Fistula – rectum opens in the
perineum Vestibular fistula – rectum opens through
an abnormally narrow orifice located in the vestibule of the genitalia immediately outside the hymen
Imperforate Anus
Female defects: Rectovaginal Fistula – fistula between
rectum and vagina
Imperforate Anus
Pathophysiology Embryogenesis of malformations still
unclear Rectum and anus develop from hindgut
or cloacal cavity when lateral ingrowth of the mesenchyme forms the urorectal septum in the midline.
Bladder&urethra septum rectum&anal canal
Cloacal duct – small communications bet. these 2▪ Should close by 7th week of gestation
Imperforate Anus
Pathophysiology Ventral urogenital external opening
forms first; dorsal anal membrane opens later
Anal development▪ Fusion of the anal tubercles and an external
invagination (proctoderm) which deepens toward the rectum but separated from it by an anal membrane▪ Anal membrane should desintegrate by 8th
week
Imperforate Anus
There are known risk factors that predispose a person to have a child with imperforate anus
A genetic linkage is sometimes present
Diagnostics/ workup
CBC, blood typing and screening Presence of meconium in the urine
(males) Filtering with a gauze pad Urinalysis ▪ If a patient has perineal fistulas, vestibular
fistula, or a single patent orifice, UA is unot indicated
Diagnostics/ workup
Invertogram Cross table lateral on prone position
Diagnostics/ workup
Prone cross table buttocks with elevation
Diagnostics/ workup
Abdominal Ultrasound Visualized liver, gallbladder, kidneys Obscured pancreas probably due to
overlying bowel gas Undefined gallbladder Bilateral hyrocoele, both testicles within
scrotal sac Minimal ascites No frank congenital problems on solid
organs
Management
Medical NPO, IV hydration Treat other life-threatening co-
morbidities first If urinary fistula is suspected, give
broad-spectrum antibiotics
Management
Invertogram < 1cm: Immediate Anoplasty > 1cm: colostomy, then definitive
surgery after a few months Males with meconium in urine:
colostomy, then definitive surgery after a few months
Epidemiology
1 newborn per 5000 live births (US)
Prognosis
All patients with anorectal malformations with no significant life-threatening co-morbidities should survive Prognosis best determined by the
probability of primary fecal incontinence