Clinical Features

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The most common symptom is refractory constipation, either primarily or persistent after successful reconstructive surgery for a known ARM. Rectal ectasia predisposes to ampullary overloading and constipation. Patients usually present after 6 months of age, the most common period being around 1-3 years.

Paradoxical diarrhea occurs when peristalsis relentlessly pushes the column of feces against the pu-borectalis sling and levator diaphragm. These muscles fatigue, relax, and temporarily lose the important sphincter functions that control the entrance to the rectoanal canal. Soft feces are then massaged by peristalsis over the fecal masses to escape constantly from the anus (known as a "hold-back dyschesia cycle" or "pseudoincontinence"), in spite of good surgery [21,23].

The clinical significance of the anomaly is two fold. First, following PSARP, the ectatic rectum may become a passive reservoir for feces, which accumulates and impacts; second, the large bulk of the walls of the intact wide rectum may impair the reconstruction of the sphincter muscles at the time of the PSARP, thus lessening the ultimate degree of continence. Paradoxical diarrhea and incontinence resulting from anatomically defective sphincters may be differentiated by rectal examination. Digital palpation of the

Defecogram

Fig. 12.3 A Contrast study delineating the posterior rectal shelf. B Persistence of the shelf on a defecogram

Fig. 12.4 Distal colostogram suggestive of rectal ectasia. This patient had an anorectal malformation with a long fistula opening in the bulbar urethra strongly contracting sphincters of the anal canal or satisfactory pressure profiles in the anal canal indicates that the leakage is more likely to be paradoxical. The proximal ectatic bowel remains large and dilated even after a defunctioning colostomy.

In a study including adults who were diagnosed with rectal ectasia, it was noticed that all of the patients were symptomatic since childhood, with the most common symptom being soiling and impaction [25].

On per rectal examination, ballooning of the posterior rectal shelf may be found, in which the finger in the rectum can be brought very close to the perineum with very little intervening tissue. Typically, the child presents with chronic constipation, straining at stool, and only able to pass small amounts of hard fecal matter by rubbing the bottom against the floor/toilet seat.

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Constipation Prescription

Constipation Prescription

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