O.C.R.

O.C.M.
 This is a case of a 7-month old female from    

Apas, Lahug, admitted for constipation Prenatal: unremarkable Natal history: unremarkable Postnatal history: unremarkable Immunization: Immunization: BCG x 1 dose, DTP x 2 doses, OPV x 3 doses, Hepatitis B x 2 doses, Pneumococcal x 3, Flu x 1

O.C.M.
 Hospitalizations: none  Heredofamilial diseases: hypertension

O.C.M.
 Chief Complaint: constipation

HPI:  Two weeks PTA: patient has been having decreased frequency in bowel movement with minimal amount of solid stools which was yellow-orange in color, with no associated fever or vomiting

O.C.M.
 No consult was done, mother opted to

observe patient and began adding mashed papaya during feeding and two teaspoons of castor oil twice a day.  A week PTA, no improvement was noted prompting mother to bring the patient for consult at the ER of this institution, prescribed with laxative and lactose-free milk formula.

O.C.M.
 Two days prior to admission, patient was

noted to have decreased appetite, irritable and with episodes of straining that prompted consult with pediatrician.  Xray of the abdomen: non-specific and nonobstructive bowel gas pattern and fecal stasis in the ascending and transverse colonic segments

O.C.M.
 Patient was then referred to a

gastroenterologist who advised them admission.

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 Physical Examination  Vital Signs:

HR= 100 bpm RR=38 cpm T= 37rC Wt= 7.7 kg (P-50) Ht= 70 cm (P-90) Skin: brown, no lesions, warm with good turgor

 BP=90/60 mmHg

O.C.M.
 HEENT: anictericsclerae, pinkish palpebral

conjunctivae, non-erythematous ear canals with intact tympanic membranes, no nasal secretions, dry lips, moist tongue, no lesions seen in buccal mucosa, non-erythematous and unenlarged tonsils  Chest and Lungs: equal chest expansion, clear breath sounds  Cardiovascular system: distinct heart sounds, regular rate and rhythm, no murmurs

O.C.M.
 Abdomen: globular, tympanitic, not distended,  

  

hypoactive bowel sounds GUT: grossly female, no discharges Rectal Exam: skin tag at 12 o clock position, admits tip of 5th digit, no stool on examining finger Extremities: full strong pulses, CRT < 2 seconds CNS: GCS 11 (E4V3M4) Mental status: alert

O.C.M.
 Cranial Nerves:  I and II: not assessed  III, IV, VI: pupils equally reactive, full EOM  V: (+) corneal reflex  VII: no facial asymmetry  VIII: not assessed  IX & X: (+) gag reflex, able to swallow

O.C.M.
 XI: not assessed  XII: tongue at midline on protrusion  Sensory: light touch, pain and temperature

intact  Motor: spontaneous movements noted in bilateral upper and lower extremities  Reflexes: +2 in both upper and lower extremities

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 Fundoscopy: not done  Meningeal signs: none  Primitive Reflex: (+) grasp and rooting

reflexes
 Admitting Impression: R/I Ileusvs Large

Bowel Obstruction

O.C.M.
 Course in the Wards:  On admission, venoclysis was started and

diagnostics done include CBC which revealed leukocytosis (24.4). CRP, serum creatinine (0.4 mg/dl), serum potassium (3.9 meq/L), SGPT (26 mg/dl) and bleeding parameters were all within normal values.

O.C.M.
Wbc Hb Hct CBC 24.4 12.6 38.4 Plt Neu Lym Mon Eos Bas 561 39.7 51.7 4.5 3.9 0.2

O.C.M.
 Patient was given castor oil 10 ml every 6

hours as bowel preparation for colonoscopy the following day. Patient was able to move her bowel consisting of non-bloody, nonmucoid, yellow-green soft stools.

O.C.M.
 On 1st hospital day, patient underwent

colonoscopy. Skin tags at 12 o clock position was noted, and a tight stenotic anal opening with limitation was noted during rectal exam and on insertion of the scope.  At 35 cm from the anal verge, pinpoint lesions were seen and biopsy specimen were taken. IV Cefuroxime (AD= 64.9 mkD) was started post-colonoscopy.

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O.C.M.
 On 2nd hospital day, repeat CBC was done

which showed a decrease in leukocyte count (16.7 from 24.4). No rectal bleeding and no recurrence of constipation were noted.
CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas

4/26 24.4 12.6 38.4 561 39.7 51.7 4.5 4/28 16.7 12.1 36.5 393 37.1 51.9 3.8

3.9 6.4

0.2 0.8

O.C.M.
 On 3rd hospital day, another repeat CBC was

done revealing further decrease in leukocyte count (12.9 from 16.7). Patient regained her appetite, was no longer irritable and had no episodes of straining on bowel movement.
CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas

4/26 24.4 12.6 38.4 4/28 16.7 12.1 36.5 4/29 12.9 12 36

561 393 398

39.7 51.7 37.1 51.9 30.1 54.3

4.5 3.8 4

3.9 6.4 11.2

0.2 0.8 0.4

O.C.M.
 Patient was discharged improved on the 4th

hospital day. Final Diagnosis:  Colitis Probably Infectious, Rectosigmoid Area  Anal Stenosis Biopsy: Chronic Non-Specific Colitis with Erosions

Anal Stenosis
 Anal Stenosis/Atresia

-the absence, closure, or constriction of the rectum or anus -usually diagnosed shortly after delivery ; often associated with a group of defects called the VACTERL syndrome (vertebral, anal, cardiac, trachea, esophageal, renal, and limb abnormalities)

Anal Stenosis
-can also be associated with chromosomal abnormalities, particularly trisomy 21  Demographic and Risk Factors -race/ethnicity: higher among Europeans and South Asians -maternal age: advanced maternal age associated with increased risk of chromosomal abnormalities

Anal Stenosis
 Demographic and Risk Factors (continued)

- Infant sex: more common among males - Increased risk with prematurity, lower birth weight, - Maternal diabetes: may increase risk - First trimester maternal exposure to lorazepam does increase the risk for anal atresia

Anal Stenosis
 Prevalence:

- United States: ranges between 1.04 and 7.89 per 10,000 live births  Common Presenting Symptoms: 1. Constipation 2. Fecal Incontinence 3. Abdominal distention 4. Rectal Bleeding

Anal Stenosis
 Diagnosis

Physical Examination: - presence of an obstructive skin

Anal Stenosis

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 A stenosed anus will often allow meconium and soft stool of the newborn to escape; a rectal thermometer can also be accomodated

Anal Stenosis
 Rectal Examination:

-note the size of the anus -suppleness or rigidity of the canal

 Imaging: 1. Barium enema 2. CT Scan 3. MRI 4. Ultrasound

Anal Stenosis

Anal Stenosis
 Treatment:

1. Surgical- with the use of anorectal dilators 2. Supportive- high fiber diet and laxatives

Anal Stenosis