The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
With Dr. Jason Fisher & Dr. Mark Levitt · hosted by Dr. Rod Gerardo · Colorectal Channel
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
VACTERL association screening includes plain abdominal X-ray for vertebral abnormalities including hemivertebrae
Cardiac evaluation for anorectal malformation includes both physical exam and echocardiogram
Esophageal atresia screening requires NG tube passage
Renal evaluation requires kidney ultrasound
True sacral ratio measurements should wait until the child is 3 months of age
Radiologists evaluating anorectal malformation patients should examine the presacral space with spinal ultrasound
Presacral masses are rare in typical imperforate anus but found almost half the time in anal stenosis or rectal atresia defects
Patients with anal stenosis or rectal atresia and presacral mass will require MRI
Cross-table lateral radiograph is obtained at approximately 24 hours of life to visualize the rectal gas column position
The 24-hour waiting period allows the baby to declare whether they need colostomy or might benefit from primary repair
Cross-table lateral is performed with the baby prone and a bump under the buttocks to position the buttock as the highest point where air will rise
A marker should be placed at the expected anal location on cross-table lateral to enable distance measurements
A sacral ratio greater than 0.7 connotes very good prognosis for bowel control
Well-formed buttocks and visible sphincter mechanism location on physical exam contribute to good prognosis
The danger of primary posterior sagittal approach without knowing rectal location is finding midline white structures like urethra, bladder neck, or bladder instead of rectum
Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically
Colostomy carries its own complications both from the initial procedure and from subsequent closure
Performing anoplasty without identifying and addressing a fistula can result in the child urinating through the anus postoperatively
During primary posterior sagittal anorectoplasty, the posterior rectal wall should be opened and the anterior wall inspected to rule out fistula
In low rectal lesions, inspecting and dissecting a small portion of the anterior rectal wall will usually rule out fistula
Low bulbar fistulas are located very close to the rectum, requiring careful plane dissection
Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra
95% of Down syndrome patients with anorectal malformation have no fistula, but 5% do have fistulas
Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite the low fistula rate