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LETTER TO THE EDITOR Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 2  |  Page : 264-266
Palm kernels impaction in anorectal malformation: An unusual presentation in an 8-year-old boy

Paediatric Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria

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Date of Web Publication14-Oct-2011

How to cite this article:
Osifo OD, Akpanudoh EI, Osagie OT. Palm kernels impaction in anorectal malformation: An unusual presentation in an 8-year-old boy. Afr J Paediatr Surg 2011;8:264-6

How to cite this URL:
Osifo OD, Akpanudoh EI, Osagie OT. Palm kernels impaction in anorectal malformation: An unusual presentation in an 8-year-old boy. Afr J Paediatr Surg [serial online] 2011 [cited 2020 Feb 18];8:264-6. Available from:

Anorectal malformation, which may be the low, intermediate or high types is a common cause of intestinal obstruction in the newborn. [1],[2],[3],[4] The often associated multiple congenital malformations and high risk of sepsis result in poor outcome especially in developing countries. [1],[2] A better understanding of the pathophysiology of the lesion, early presentation, prompt diagnosis, appropriate and timed surgical management have resulted in excellent outcomes for affected children. [3] In regions where awareness and resources are poor, late presentation and different inappropriate management, which influenced outcome, have been reported. [1],[2],[4],[5],[6] However, late childhood presentation of anorectal malformation after management from birth using traditional medications and presentation with intestinal obstruction following foreign body impaction in the anorectum is unusual and scant in the literatures. [1],[2]

The case of an 8-year-old boy with a low anorectal malformation who was managed from birth with traditional medications but presented with intestinal obstruction following palm kernels impaction in the anorectum is presented. The aim is to increase public awareness and stress the need for thorough perineal examination of newborn by birth attendants before being discharged home after birth.

An 8-year-old boy was admitted through the Paediatric Emergency Department of our institution with a complaint of inability to pass stool for two weeks. This was associated with colicky abdominal pain and distension, but no vomiting. He had difficulty passing meconium at birth, which was relieved on the fourth day of life by an anal incision made by a quack rural health worker. This was performed with unsterilized instruments, without the use of anaesthesia, analgesic and antibiotic. His condition improved but he subsequently developed recurrent episodes of constipation lasting between 7 and 10 days, which alternated with passage of copious watery stools. These failed to respond to the traditional medications procured by his parents even when he was made to ingest native concoction containing ten fresh palm fruits a few days prior to presentation.

Examination revealed a small for age boy who was restless and dehydrated. The abdomen was grossly distended with multiple visible peristalses and hyperactive bowels sounds. The perianal region was smeared with watery foul smelling faecal material with a covered anus, a classical bucket handle deformity and a small lateral perforation through which watery faeces emitted was demonstrated [Figure 1]. He was resuscitated with crystalloids, placed on broad spectrum antibiotics, and had anoplasty performed on the second day on admission. Digital rectal examination under general anaesthesia revealed anorectum filled with ten palm kernels, which were manually evacuated with accompanying explosive passage of flatus and watery faeces [Figure 2]. He was discharged to follow-up at the surgical outpatient clinic on the seventh postoperative day following an uneventful post-operative course and satisfactory anal dilatation.
Figure 1: Intra-operative photograph showing covered anus, a bucket handle deformity displayed with a retractor and a lateral perforation through which watery faeces emitted

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Figure 2: Intra-operative manual disimpaction and evacuation of ten palm kernels from the anorecutm

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This case illustrates the poor healthcare status still prevalent in many developing countries as also reported by others. [1],[2],[4],[5],[6] Anorectal malformation has been reported as the commonest cause of neonatal intestinal obstruction in this subregion. [1],[2],[4] Other authors [7],[8] reported late diagnosis to be commoner with low anomaly especially in those with associated fistulous communication, which corresponded with findings in this case. The incidence of delayed presentation and late diagnosis has been found to be significantly higher in developing than developed countries as exemplified by index case. [1],[2],[7],[8] The low socioeconomic status, ignorance and cultural

beliefs of the people were reported as contributory factors. [1],[2] This boy was delivered in rural setting where there was poor awareness and lack of properly trained personnel. Therefore, shortage of qualified manpower and inadequate perineal examination at birth resulted in late diagnosis.

The treatment he received before presentation, nonetheless, relieved his absolute intestinal obstruction with a resultant alternating constipation and spurious diarrhoea, which he coped with until presentation. The ingested palm fruits in native concoction were intended to dilate the anorectum as explained to the parents by the traditional healthcare provider. The palm kernels, however got impacted in the anorectum with a resultant absolute intestinal obstruction for which he sought medical attention. Historical management of anorectal malformation as reported in the literatures [1],[2],[9] included anal perforation as done in this case. They were, however, associated with poor outcomes due especially to the risk of sepsis, incontinence, recurrent constipation and failure to thrive until in recent decades when breakthrough in the management of the lesion was recorded. [1],[2],[10]

Although policy makers in third world countries place emphasis on enlightening the public on the prevention of communicable diseases and early detection of breast cancer, not much attention has been paid to congenital non-communicable diseases. [1],[2] Consequently, many children with congenital anorectal lesions are subjected to extensive perineal cuts, tattoos of their abdomen and ingestion of native concoctions with its associated hazards as seen in index case. Low anorectal anomaly is a potentially correctable defect with good prognosis. The treatment is rewarding and the infrequently associated multiple congenital malformations usually give excellent outcome as recorded in this patient. [1],[2],[3],[7],[8]

In conclusion, poor awareness and unavailable personnel resulted in unusual presentation of an 8-year-old boy with a low anorectal malformation who was managed from birth with traditional medications until he presented with intestinal obstruction following palm kernels impaction in the anorectum. We advocate more public enlightenment campaigns on anorectal malformations and thorough perineal examination of babies by birth attendants before they are discharged home after birth.

   References Top

1.Adejuyigbe O, Abubakar AM, Sowande OA, Olayinka OS, Uba AF. Experience with anorectal malformations in Ile-Ife, Nigeria. Pediatr Surg Int 2004;20:855-8.  Back to cited text no. 1
2.Uba AF, Chirdan LB, Ardill W, Edino ST. Anorectal anomaly: A review of 82 cases seen at JUTH, Nigeria. Niger Postgrad Med J 2006;13:61-5.  Back to cited text no. 2
3.Haider N, Fisher R. Mortality and morbidity associated with late diagnosis of anorectal malformation in children. Surgeon 2007;5:327-30.  Back to cited text no. 3
4.Osifo OD, Okolo JC. Neonatal intestinal obstruction in Benin, Nigeria. Afr J Paediatr Surg 2009;6:98-101.  Back to cited text no. 4
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5.Archibong AE, Ndoma-Egba R, Asindi AA. Intestinal obstruction in Southeastern Nigerian children. East Afr Med J 1994;71:286-9.  Back to cited text no. 5
6.Ogundoyin OO, Afolabi AO, Ogunlana DI, Lawal TA, Yifieyeh AC. Pattern and outcome of childhood intestinal obstruction at a Tertiary Hospital in Nigeria. Afr Health Sci 2009;9:170-3.  Back to cited text no. 6
7.Lindley RM, Shawis RN, Roberts JP. Delays in the diagnosis of anorectal malformations are common and significantly increase serious early complications. Acta Pediatr 2006;95:364-8.  Back to cited text no. 7
8.Kim HL, Gow KW, Penner JG, Blair GK, Murphy JJ, Webber EM. Presentation of low anorectal malformations beyond the neonatal period. Pediatrics 2000;105:E68.  Back to cited text no. 8
9.Heinen FL. The surgical treatment of low anal defects and vestibular fistulas. Semin Pediatr Surg 1997;6:204-16.  Back to cited text no. 9
10.Daher P, Daher R, Riachy E, Zeidan S. Do low-type anorectal malformations have a better prognosis than the intermediate and high types? A preliminary report using the Krickenbeck score. Eur J Pediatr Surg 2007;17:340-3.  Back to cited text no. 10

Correspondence Address:
Osarumwense David Osifo
Paediatric Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0189-6725.86087

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