Handle with Care – “Bucket Handle” Imperforate Anus
A
15-day-old boy presented to the emergency department with a 2-day history of nonbilious vomiting, 1-day history of diarrhea, and poor feeding. He was born at term, passed meconium within the first 24 hours, and discharged home on day 4 of life. Examination revealed that he was jaundiced and irritable with a distended tense abdomen. He had a prominent midline skin bridge in the perineum (Figure 1) consistent with a “bucket-handle” imperforate anus. Abdominal radiography (Figure 2; available at www.jpeds.com) showed a prominently dilated sigmoid colon and the appearance of intramural air.
Inflammatory markers were raised, thus antibiotics were administered for treatment of presumed enterocolitis. Serial Hager dilators were used to divide the skin bridge and decompress the colon to prevent perforation. Anorectal malformations occur 1 in 5000 births.1 In a “bucket-handle” deformity, a ridge of tissue divides the anus into two orifices; this feature is important to recognize to identify the malformation.2 Serial Hager dilatations and anoplasty are therapeutic. Delayed diagnosis (identification >24 hours after birth) is common (20%)3 and is associated with complications, including sepsis and bowel perforation. This case highlights the importance of careful newborn examination to identify anorectal malformations and that the passage of meconium does not indicate normal anatomy. n
Kathleen Mary Gorman, MB BCh NUI, MRPCI, MRCPCH Department of General Pediatrics
Olugbenga Michael Aworanti, MBBS MRCSEd, MSc John Gillick, MB BCh U Dub, MD, FRCSI (paed surg) Department of Surgery
Louise Capra, MB BCh NUI, FRCPI Department of General Pediatrics Children’s University Hospital Dublin, Ireland
References
Figure 1. Midline skin ridge “bucket-handle” imperforate anus.
J Pediatr 2015;166:1090. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.12.071
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1. Levitt MA, Pena A. Anorectal malformations. Orphanet J Rare Dis 2007; 26:33-7. 2. Pena A, Levitt M. Anorectal malformations. In: Stringer M, Oldham K, Mouriquand PDF, eds. Pediatric surgery and urology: long term outcomes. Cambridge: Cambridge University Press; 2007. p. 401-15. 3. Fareen F, Coyle D, Aworanti OM, Gillick J. Delayed diagnosis of anorectal malformation - a persistent problem. Ir Med J 2013;106:238-40.
Vol. 166, No. 4 April 2015
Figure 2. Abdominal radiography showing a dilated sigmoid colon and features suggesting intramural gas.
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A
15-day-old boy presented to the emergency department with a 2-day history of nonbilious vomiting, 1-day history of diarrhea, and poor feeding. He was born at term, passed meconium within the first 24 hours, and discharged home on day 4 of life. Examination revealed that he was jaundiced and irritable with a distended tense abdomen. He had a prominent midline skin bridge in the perineum (Figure 1) consistent with a “bucket-handle” imperforate anus. Abdominal radiography (Figure 2; available at www.jpeds.com) showed a prominently dilated sigmoid colon and the appearance of intramural air.
Inflammatory markers were raised, thus antibiotics were administered for treatment of presumed enterocolitis. Serial Hager dilators were used to divide the skin bridge and decompress the colon to prevent perforation. Anorectal malformations occur 1 in 5000 births.1 In a “bucket-handle” deformity, a ridge of tissue divides the anus into two orifices; this feature is important to recognize to identify the malformation.2 Serial Hager dilatations and anoplasty are therapeutic. Delayed diagnosis (identification >24 hours after birth) is common (20%)3 and is associated with complications, including sepsis and bowel perforation. This case highlights the importance of careful newborn examination to identify anorectal malformations and that the passage of meconium does not indicate normal anatomy. n
Kathleen Mary Gorman, MB BCh NUI, MRPCI, MRCPCH Department of General Pediatrics
Olugbenga Michael Aworanti, MBBS MRCSEd, MSc John Gillick, MB BCh U Dub, MD, FRCSI (paed surg) Department of Surgery
Louise Capra, MB BCh NUI, FRCPI Department of General Pediatrics Children’s University Hospital Dublin, Ireland
References
Figure 1. Midline skin ridge “bucket-handle” imperforate anus.
J Pediatr 2015;166:1090. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.12.071
1090
1. Levitt MA, Pena A. Anorectal malformations. Orphanet J Rare Dis 2007; 26:33-7. 2. Pena A, Levitt M. Anorectal malformations. In: Stringer M, Oldham K, Mouriquand PDF, eds. Pediatric surgery and urology: long term outcomes. Cambridge: Cambridge University Press; 2007. p. 401-15. 3. Fareen F, Coyle D, Aworanti OM, Gillick J. Delayed diagnosis of anorectal malformation - a persistent problem. Ir Med J 2013;106:238-40.
Vol. 166, No. 4 April 2015
Figure 2. Abdominal radiography showing a dilated sigmoid colon and features suggesting intramural gas.
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