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proliferation of ectoderm closes the caudalmost region of the anal canal. During the ninth week, this region recanalizes.
imperforate anus:
there is no anal opening. This defect occurs because of a lack of recanalization of the lower portion of the anal canal
The rectum may end in a blind pouch that does not connect with the colon. The rectum may have openings to the urethra, bladder, and base of the penis or scrotum in boys, or vagina in girls.
Symptoms
Anal opening very near the vagina opening in girls
Baby does not pass first stool within 24 - 48 hours after birth Missing or moved opening to the anus
Associated anomalies
V - Vertebral anomalies A - Anal atresia C - Cardiovascular anomalies T - Tracheoesophageal fistula E - Esophageal atresia R - Renal (Kidney) and/or radial anomalies L - Limb defects
Diagnosis
It is usually detected quickly as it is a very obvious defect. It is important to determine the presence of any associated defects during the newborn period in order to treat them early and avoid further sequelae. Sonography can be used to determine the type of imperforate anus. The decision to open a colostomy is usually taken within the first 24 hours of birth.
Investigations
1-Invertogram
2- Perineal U/S or MRI 3- X-ray 4- Colostogram
5-Abdominal U/S
Evaluation for other anomalies
Invertogram
High lesions are above the levator if the distance between level of the air and coin more than 2cm.
Intermediate lesions are characterized by the rectal pouch ending within the levator, Low lesions, the rectal pouch has completely traversed the levator musculature, the distance between level of the air and coin less than 2cm .
If required, the level of the rectal pouch can be delineated more definitively by ultrasonography or magnetic resonance imaging. Perineal ultrasonography may be useful in determining the distance between the rectal pouch and the anal skin.
Abdominal radiograph performed at day one of life, shows multiple air filled distended bowel loops suggestive of bowel obstruction.
Colostogram
Should be done under pressure to illustrate any fistula
Distal colostogram showing the colon ending in a long, narrow rectourethral fistula
Abdominal U/S
During the first 24 hrs. of life, All these patients need abdominal ultrasound evaluation To identify an obstructive uropathy especially in patients with;
Meconium/mucus present Low anomaly Fistula present High Anomaly No meconium Inversion radiology
High Anomaly
High Anomaly
Ectopic Anus
Inversion Radiology or needle aspiration of meconium and injection of contrast media High or Low
RectoVestibular fistula
Persistant cloaca
Rectourethral fistula
Bulbar
Prostatic
Rectal atresia
rectovesical
Vestibular fistula
Pena classification (Therapeutic classification) 1995 Males Perineal(cutaneous)fistula Rectourethral fistula Bulbar Prostatic females Perineal(cutaneous)fistula Vestibular fistula
Rectovesical fistula
I
Rectal atresia
Rectal atresia
Perineal (cutaneous) fistula Rectourethral fistula Prostatic Bulbar Rectovesical fistula Vestibular fistula Cloaca No fistula Anal stenosis
Surgical treatment :
-Initial pelvic colostomy. -Pull through operation. -Closure of colostomy. -Continence work up.
- Cut back in case of membrane. - Perineal anoplasty. - Regular post operative anal dilatation
Algorism of Management
Algorism of Management
Algorism of Management
Postoperative Management
Rectouetheral fistula Nutrition?? Dilatation ??
Thank You