Child health nursing

1. Anorectal
Malformations
Ms. K. Lavanya
MSc(N)-CHN
Associate Professor

2. Definition:
• ARMs 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.

3. Incidence:
• Minor abnormalities of the anus and rectum occur in 1 of 500 living
newborns, while major abnormalities occur in 1 of 5000 living
infants.

4. Etiology:
 Idiopathic
 Mutation of Genes

5. Pathophysiology:

6. Classification:
• Classification of ARMs can be done into three groups in the infants without a normal anus.
1. With a visible abnormal opening of the bowel:
a. Anal stenosis
b. Anoperineal fistula
c. Anovestibular fistula in female
2. With an invisible but manifested opening of the bowel:
a. Rectovaginal fistula in female
b. Rectourethral fistula in male
c. Rectovesicular fistula
3. No manifested opening of the bowel:
a. Persistent anal membrane
b. Rectal atresia

7. CONTD…..
• Anorectal malformations can be classified into two groups on the basis of levator ani muscle, which is the
main muscle of fecal control:
1. Supralevator or high anorectal malformations:
• When rectum terminates above the levator ani muscle, which is found as rectal atresia, rectoprostatic fistula
and rectovaginal fistula. About 30% of children with high ARMs or associated genitourinary fistula achieve
bowel continence.
2. Translevator or low anorectal malformations:
• When rectum terminates below the levator animuscle, e.g., in anocutaneous fistula and Anovestibular fistula.
About 90% of children with low ARMs achieve bowel incontinence.

8. Clinical Manifestations:
 Absence of stool. There is no passage of stool within a day or two of
birth.
 Passing of stools in other openings. The infant may pass stools
through another opening like the urethra in boys or vagina in girls.
 Swollen belly. The newborn could not pass out stools, resulting in a
swollen belly.
 Absence of anal opening. The opening of the anus is missing or not in
its usual place; in girls, this may be near the vagina.

9. The specific features for specific anomalies
• Imperforate Anal Membrane:
Infant fail to pass meconium. Greenish bulging membrane seen on examination.
• Anal Stenosis:
It accounts for 10% of all ARMs. The baby may pass ribbon like stools with difficulty
as the anal opening is very small.
• Anal Agenesis:
It presents with only anal dimple. Intestinal Obstruction may develop.

10. • Rectal Agenesis:
It accounts 75% of all ARMs. It presents with fistula & can observe in male baby.
• Rectoperineal fistula:
It is found in small orifice in the perineum. In male baby it is found close to the scrotum and
in female in the vulva.
• Rectovaginal Fistula:
It presents with a communication between rectum and vagina and stool passed through the
vagina.

11. Diagnostic Evaluation:
 HC
 PE
 Laboratory Studies- CBC, Blood Typing & Screening
 Sacral Radiography
 Abdominal USG
 X-ray with inverted infant (upside down position), i.e., invertogram or wangensteen
Rice X-ray is useful to locate rectal pouch
 Urine examination
 Spinal ultrasonography or MRI
 Lateral pelvic radiography at 24 hours.
 Micturating cystourethrogram- to detect urinary abnormalities

12. Management:
Medical Management:
 Nothing per mouth
 Neonatal colostomy.
 Primary neonatal pull-through without colostomy.
 Diet.
 Activity.
 Laxatives
 Antibiotic Prophylaxis

13. Surgical Management:
 Posterior sagittal pull-through with a colostomy.
 Colostomy closure.

14. Nursing Management:
Nursing Assessment
• Assessment of an infant with imperforate anus include the following:
 History.
 Physical exam.

15. Nursing Considerations:
Nursing Diagnosis
• Based on the assessment data the major nursing diagnoses are:
 Fluid volume deficit related to excessive loss through vomiting.
 Impaired skin integrity related to the colostomy.
 Risk for infection related to surgical procedures.

16. Nursing Considerations:
• Nursing Interventions
• Nursing interventions for a child with imperforate anus are:
•
 Avoid infection.
 Protect skin integrity.
 Restore balanced fluid volume.

17. Complications:
 UTI
 Intestinal Obstruction
 Fecal impaction
 Colostomy related problems
 Recurrence of fistula
 Anal stenosis
 Postoperative complications

18. Bibiliography:
 Wong’s. (2005), Essentials of Pediatric nursing, 7th Edition, Elsevier Publications, New Delhi. Page no:
883- 885.
 Parul Datta. (2007), Pediatric Nursing, 4th Edition, Jaypee publications, New Delhi. Page No: 271-273.
 Dorothy R. Marlow (2008), Textbook of Pediatric Nursing, 6th Edition, Elsevier publications, New Delhi.
Page No: 457-459.
 Rimple sharma(2017), Essentials of Pediatric Nursing, 2nd Edition, Jaypee publications, New Delhi.
Page No: 313-317
Websites:
• https://nurseslabs.com/imperforate-anus/
• https://www.slideshare.net/VipinChandran21/anorectal-malformation-110975114