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    Case Presentation On ARMs

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    Somyee Pachuau
    Anorectal malformations (ARMs) are birth defects where the anus and rectum do not develop properly. They can include a narrow anal passage, a membrane over the anal opening, or the rectum connecting to the urinary or reproductive systems through a fistula instead of the anus. ARMs are diagnosed at birth and require medical and surgical management. Prognosis depends on the complexity of the malformation and presence of other issues. Long-term follow up is important as social continence may not be achieved until older ages.

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    Case Presentation On ARMs

    Uploaded by

    Somyee Pachuau
    721 views39 pages
    Anorectal malformations (ARMs) are birth defects where the anus and rectum do not develop properly. They can include a narrow anal passage, a membrane over the anal opening, or the rectum connecting to the urinary or reproductive systems through a fistula instead of the anus. ARMs are diagnosed at birth and require medical and surgical management. Prognosis depends on the complexity of the malformation and presence of other issues. Long-term follow up is important as social continence may not be achieved until older ages.

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    Case Presentation on ARMs

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    Anorectal malformations (ARMs) are birth defects where the anus and rectum do not develop properly. They can include a narrow anal passage, a membrane over the anal opening, or the rectum connecting to the urinary or reproductive systems through a fistula instead of the anus. ARMs are diagnosed at birth and require medical and surgical management. Prognosis depends on the complexity of the malformation and presence of other issues. Long-term follow up is important as social continence may not be achieved until older ages.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    721 views39 pages

    Case Presentation On ARMs

    Uploaded by

    Somyee Pachuau
    Anorectal malformations (ARMs) are birth defects where the anus and rectum do not develop properly. They can include a narrow anal passage, a membrane over the anal opening, or the rectum connecting to the urinary or reproductive systems through a fistula instead of the anus. ARMs are diagnosed at birth and require medical and surgical management. Prognosis depends on the complexity of the malformation and presence of other issues. Long-term follow up is important as social continence may not be achieved until older ages.

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    CASE PRESENTATION

    ON
    ANORECTAL
    MALFORMATIONS
    (ARMs) Presented by :
    Malsawmtluangi
    Roll no.16
    3 r d year BSc(Nursing)
    DEFINITION
    ARMs(anorectal malformations) 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.

    Approximately 40% of neonates with ARMs have associated


    congenital anomalies like Down’s syndrome,congenital heart
    disease,undescended testis,renal abnormalities and esophageal atresia.
    RELATED ANATOMY AND PHYSIOLOGY
    The rectum and the anal canal are the terminal parts of the large
    bowel.

    The rectum : The rectum is located in the pelvis,begins at the level of


    the sacral promontory,and extends 12-18cm distally.It has 2 or 3
    curves within its lumen,created by submucosal folds called the valves
    of Houston.It is attached to a strong endopelvic fascia extending
    from the anterior surface of the sacral bone at about the level of
    S4.This area of attachment is known as Waldeyer ring.
    Contd...

    The anal canal : The anal canal is approximately 2.5 to 5 cm in


    length.It begins at the level of the levator ani muscle and opens to the
    anal verge.The anal canal is surrounded by the internal and external
    anal sphincter muscle.

    The rectum serves as a reservoir to fecal contents,and the anal canal


    regulates continence and defecation via synchronization of events.
    Contd...
    CLASSIFICATION OF ARMS
    A. Classification of ARMs can be done into three groups in the
    infants without the normal anus

    1.With a visible abnormal opening of the bowel :

    • Anal stenosis
    Contd...
    • Anoperineal fistula
    Contd...
    • Anovestibular fistula in female
    Contd...
    2.With an invisible but manifested opening of the bowel :

    • Rectovaginal fistula in female


    Contd...
    • Rectourethral fistula in male
    Contd...
    • Rectovesicular fistula
    Contd...
    3.No manifested opening of the bowel

    • Persistent anal membrane


    Contd...
    • Rectal atresia
    Contd...
    B. Anorectal malformations can also be
    classified into two groups on the basis of levator
    ani muscle,which is the main muscle of fecal
    control :
    Contd...
    • Supralevator or high anorectal malformations - When
    rectum terminates above the levator ani muscle which is
    found as rectal atresia,rectoprostatic fistula and
    rectovaginal fistula.

    • Translevator or low anorectal malformations - When the


    rectum terminates below the levator ani muscle e.g.in
    anocutaneous fistula and anovestibular fistula
    ETIOLOGY
    Most of the time, the cause for an anorectal malformation is
    unknown, but in rare cases, it appears to run in families.Boys
    are at a slightly higher risk for this abnormality than girls.

    Upto one third of babies who have genetic


    syndromes,chromosomal abnormalities or other congenital
    defects also have imperforate anus or other anorectal
    malformation.
    Contd...
    These genetic syndromes and other congenital
    problems include :

    • VACTERL association

    • Digestive system abnormalities

    • Urinary tract abnormalities

    • Abnormalities of the spine


    PATHOPHYSIOLOGY
    Genitourinary tract originates from the embryonic structure
    called CLOACA

    By the 7 th week of gestation membrane separates the rectum


    from anus
    Contd...
    If the membrane that seperates the rectum and anus is not
    absorbed

    Union of anus and rectum does not occur

    Resulting in anorectal anomaly


    SIGNS & SYMPTOMS
    Anorectal malformations are usually diagnosed immediately after
    birth by the person conducting the delivery or within hours by the
    caregivers.

    Some of the important features are:

    • Abnormally formed or no anal opening

    • Absence of meconium or stool

    • Passing of stool through the fistula

    • Swollen belly
    INVESTIGATIONS
    Physical examination of the neonates is the most important
    diagnostic measures of ARMs.The diagnosis of an anorectal
    malformations is based on the physical finding of an absent
    anal opening.

    Some of the diagnostic measures are:

    • Ultrasonography(USG)

    • X -ray
    Contd...
    • Urine examination

    • Micturating cystourethrogram

    Other diagnostic examination that may be performed


    include pelvic MRI,radiography and fluroscopic
    examination of pelvic anatomic contents
    MANAGEMENT
    Medical Management

    1. IV fluids : IV fluids are administered unless it is


    contraindicated to maintain glucose and fluids and
    electrolyte balance.

    2. Antibiotic prophylaxis: Antibiotics such as


    ampicillin,gentamycin and clindamycin are given to the
    children during the perioperative period.
    Contd...
    3. Laxatives: Common laxatives such as senna
    products,milk of magnesia and propylene glycol
    solutions are given

    4. Diet: Foods such as banana,rice,apple sauce and


    toast should be avoided.Instead high fiber and
    laxatives foods should be encouraged
    Contd...
    Surgical Management

    The reconstructive surgery is done to correct or


    repair the congenital malformations.It depends
    upon the type of anomalies and sex of the
    infant.
    Contd...
    In case of low ARMs : Surgery that can be perform is
    rectal cutback anoplasty or Y-V plasty.

    In case of high ARMs : Surgery that can be done is


    colostomy surgery followed by definitive
    reconstructive surgery as posterior saggital
    anorectoplasty(PSARP)
    COMPLICATION
    Intraoperative complications

    • For males : Injury to the urinary


    structure,including the urethra,seminal
    vesicles,and vas deferens

    • For females : Injury to the vagina


    Contd...
    Post-operative complications
    • Superficial and deep wound infection

    • Dehiscence of the anastomosis

    • Prolapse of the anoplasty or stricture of the anoplasty

    • Recurrent fistula between the urinary system in males


    or gynaecologic system in females
    NURSING MANAGEMENT
    Nursing Assessment
    Assessment of an infant with imperforate anus or anorectal
    malformations include the following:

    • Full patient and family history should be collected to


    enable the delivery of high quality care
    Contd...
    • Physical examination should be performed to
    identify newborn with imperforate anus

    • Inspection of perineal areas should be done for


    abnormalities
    Contd...
    Nursing Diagnosis

    Preoperative :

    1) Impaired bowel elimination related to bowel malformation from


    childbirth

    2) Fluid volume deficit related to excessive loss through vomiting and


    nil per oral

    3) Risk for infection (UTI) related to passage of meconium through


    urethra
    Contd...
    Post-operative :

    1) Pain related to surgical procedures or post-operative surgical


    incision

    2) Impaired skin integrity related to colostomy or surgical


    procedures

    3) Imbalanced nutrition less than body requirements related to


    nil per oral
    HEALTH EDUCATION
    • Instruct the relatives that long-term follow-up is
    essential for children with complex malformations

    • Inform the relatives about the delayed toilet


    training and that complete continence is seldom
    achieved at the usual age of 2-3 years
    Contd...
    • Instruct the relatives about bowel habit traning , bowel
    management irrigation programs , etc to help the child
    improve bowel function and social continence

    • Inform the relatives about diet that can help the child pass
    stool more easily

    • Teach the relatives about the importance of maintaining


    hygiene at home
    PROGNOSIS
    Prognosis of ARMs depends upon type of anomalies,presence
    of associated malformations,operative skill,presence of
    neuromuscular fecal control and general health of the
    infant.Patient with less complex malformations have
    excellent outcomes while patient with very complex
    malformations have poor outcomes.
    SUMMARY
    Anorectal malformations are birth defects in which the anus
    and rectum does not develop properly.Anorectal
    malformations include several different abnormalities
    including:

    • Anal passage may be narrow

    • A membrane may be present over the anal opening


    Contd...

    • The rectum may not connect to the anus

    • The rectum may connect to a part of the


    urinary tract or the reproductive system
    through an anal passage called a fistula
    CONCLUSION
    Anorectal malformations are among the more frequent
    congenital anomalies encountered in pediatric surgery,with
    an estimated incidence ranging between 1 in 2000 and 1 in
    5000 live births.All patients born with anorectal
    malformations can be kept clean of stool and dry of
    wine,either because they achieve bowel control or because
    they are subjected to a bowel management program
    THANK YOU

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