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Neonatal Rectal Perforation: Rare Complication of Congenital Anal Stenosis

Abdul Rauf Khan, Atif Saeed, Hamza Iltaf Malik, Adil Aslam,
Department of Paediatric Surgery
Cambridge University Hospitals NHS Foundation Trust
Addenbrooke’s Hospital, United Kingdom

 

Correspondence 

Mr Abdul Rauf Khan
Acting Consultant, Department of Paediatric Surgery, Box 267
Cambridge University Hospitals NHS Foundation Trust,
Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom
Tel: 01223256276 / Fax: 01223 596367
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

Abstract

Congenital anal stenosis, although quite common in neonates, can be easily missed with serious consequences for the child. Although classed as a minor anomaly, if neglected, becomes a major one requiring urgent surgical treatment. We present a case of rectal perforation secondary to anal stenosis in an apparently normal looking anus. A 2-day-old 3.5 kg male neonate presented with a 24-hour history of poor feeding and abdominal distension. Abdominal radiographs revealed pneumoperitoneum. At laparotomy, a full-thickness perforation of the anterior wall of rectum above the peritoneal reflection was found, which was repaired and anal dilatation with a sigmoid loop colostomy performed. Rectal biopsy was normal. The colostomy was reversed 6 weeks later. Subsequently, postoperative recovery was uneventful and bowel habit was normal. It is therefore recommended that neonates with signs of low intestinal obstruction should have per rectal examination even in the presence of normal looking anus and should be monitored closely.

key words: rectal perforation, congenital anal stenosis

 

 

Introduction

Gastrointestinal perforation in neonates continues to be a serious problem in paediatric surgical practice because of the high morbidity due to peritonitis and resulting sepsis. This case report of rectal perforation in a neonate secondary to anal stenosis discusses the associated diagnostic and management complexities in order to prevent future complications.

Case Report

A 2-day-old previously healthy neonate presented to a district hospital with a 1-day history of poor feeding, abdominal distension and vomiting. Antenatal scans had shown no fetal abnormality and maternal history was normal. He was delivered by caesarean section due to placenta previa at full term with the birth weight of 3.45 kilograms. His APGAR (Appearance, Pulse, Grimace, Activity, Respiration) scores were normal. He had passed a small amount of meconium soon after birth. Examination by a paediatrician was reported as normal. Breast feeds were started. His condition deteriorated within 24 hours as he developed abdominal distension, poor feeding and bilious vomiting. No stools were subsequently passed. Repeat physical examination showed haemodynamic instablility with signs of peritonitis. Abdominal x-ray ( fig. 1) showed free air in the peritoneal cavity. At that stage, he was transferred to our hospital, which is a tertiary care centre.

12 JPSS 8 1 2010-12 

Figure 1: Supine Abdominal x-ray showed free air in the peritoneal cavity (Football sign) 

Haemodynamic instability was present at arrival. Abdominal examination revealed diffuse abdominal tenderness with guarding and diminished bowel sounds in a distended abdomen. External examination of the anus was normal; however rectal examination was not possible due to a tight stenosis. A laparotomy was performed through a lower transverse incision which showed meconium and purulent material in the peritoneal cavity. There was a ragged 4-cm long perforation in the anterior wall of the rectum above the peritoneal reflection. The small bowel was distended but normal in its entirety. Rectal perforation was closed with a single layer of PDS sutures. The proximal sigmoid colon was exteriorized as a loop colostomy. Examination of anal canal showed an anal stenosis of size Fr 6, which was dilated up to Fr 12 with a Hegar dilator. The baby recovered uneventfully and was discharged after 5 days. A rectal biopsy was performed before colostomy closure. Rectal biopsy revealed normal ganglion cells. The colostomy was closed 6 weeks later. The anal canal was found normal at the time of the second operation. Subsequent bowel pattern is normal on 3 months clinic follow-up.

Discussion

Anorectal malformations are uncommon. Anorectal malformations occur in 1:5000 births with a slight preponderance in males [1, 2, 5]. In many cases there is a fistulous opening into the urinary tract in the male or the genital tract in the female [3]. There are many different sub-types of anorectal anomalies and these anomalies are also associated with other syndromes [1].

According to ‘Wingspread’ classification of anorectal malformations (1984), there are High, Intermediate and Low types of malformations depending on the relation of the bowel to the Levator ani muscle and the nature of any fistula are the key features of this classification [5]. Anal stenosis is a low malformation. Incidence of anal stenosis however is not usually described separately. Management of anal stenosis is dilatation usually. The usual management approach to a newborn with anorectal malformations is to wait for 24 hours as intraluminal pressure build up may force meconium unto the perineum in low malformations, or from the urethra in high malformations therefore facilitating diagnosis [3]. It also takes time for air to travel down the bowel to reach the distal end. Therefore radiographs within a few hours of birth may not be helpful. On the other hand, waiting longer than 24 hours risks bowel perforation by over distention.

It is rare to have rectal perforation with 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, as a stenosed anus will often allow meconium and the soft stool of the newborn to escape. Similarly a rectal thermometer can usually be easily introduced into the rectum in these cases. The technique of anal examination in a newborn is easy and it is therefore recommended that in infants with signs of poor feeding or abdominal distension, a rectal examination should be performed early to assess the patency of the anal canal by the neonatologist or paediatric surgeon. This manoeuvre is not only diagnostic but also therapeutic in cases of delayed passage of meconium. Early referral to a paediatric surgery centre is recommended particularly if the problem has been ongoing for 48 hours or longer as bowel perforation is imminent.

Congenital anal stenosis, although quite common in neonates, can be easily missed with serious consequences for the child. It is therefore recommended that neonates with signs of abdominal distension, poor feeding or delayed passage of meconium should have per rectal examination even in the presence of normal looking anus and should be monitored closely.

 

 

References 

  1. Shaul DB, Harrison EA: Classification of anorectal perforation – initial approach, diagnostic tests, and colostomy: Semin Pediatr Surg. 1997;6:187195
  2. Al-Qahtani A, El-Wassabi A, Al-Bassam A: Mercury-in-glass thermometer as a cause of neonatal rectal perforations: a report of three cases and review of the literature. Ann Saudi Med. 2001;21:59-61
  3. Kiely EM, Pena A: Anorectal Malformation, in O’Neill JA, Rowe MI, Gros- feld JL(eds): Pediatric Surgery. Mosby-Year Book, Inc. 1998, pp 1425-48
  4. Holschneider AM, Pfrommer W, Gerresheim B: Results in the treatment of anorectal malformations with special regard to the histology of the rectal pouch: Eur J Pediatr Surg. 1994;4:303-309
  5. Hutson John M, Woodward AA, Beasley SW: Chapter – Anorectal Anomalies, Page 65: Jones Clinical Paediatric Surgery Diagnosis and management, 5th Edition: Blackwell Publishing