Imperforate Anus / Malone Procedure Versus Bowel Management
Question: My son was born with a high imperforate anus. He had the Malone Procedure ... is there any way to get the water through him more quickly to avoid cramping?
My son had the Malone Procedure done in 1997. He was born with a high imperforate anus and had no bowel management previous to the Malone. He is six years old and is very active.
The procedure has provided him with a wonderful quality of life. The irrigation is done with 1,000 milliliters of saline water and one pediatric Fleet" enema, which normally takes 20 minutes, and then he sits on the toilet for an hour until he is cleaned out.
The problem is that sometimes the 1,000 milliliters with enema does not come out for hours, and he has horrible stomach cramps and throws up.
Last week we had to go to the emergency room after the water did not come out for 36 hours, and his pain was unbearable. It did make its way through, finally. He had x-rays and barium enemas to see if there was a blockage or any other problems. There were none.
We tried regulating his diet with bran and other laxative foods, but this made this situation worse. Our doctors say they have no idea why this is happening as everything looks fine.
Is there any advice you can give us to help us to get the water through him quickly? We find if we do it faster than 20 minutes it just creates more cramping and does not solve the problem. We have tried adding mineral oil enemas with the regular enemas and I do not see a big improvement.
Answer: The Malone procedure only provides a different route for administration of the enema. Your main problem seems to be bowel management.
The Malone procedure only provides a different route for administration of the enema. Your main problem seems to be bowel management. When we implement the bowel management program, we do it over a period of one week by trial and error, seeing the patient and taking x-ray films every day.
If you give an enema through the Malone orifice and the rectosigmoid is impacted (which may or may not be the case of your son), it is expected that the patient will have cramps and will not be able to evacuate.
It is important first to remove the impaction in the colon, since the bowel management should start with a clean colon. The enema should only remove the amount of stool that has been produced for 24 hours.
We cannot answer your question because we do not have enough information. When we implement the bowel management program, we see the patient everyday and also take an abdominal film, which we consider indispensable to interpret correctly the symptoms of the patient.
The x-ray film will tell us if you are giving an enema to a child with a fecal impaction. In such case, we will indicate a program of disimpaction prior to the implementation of the bowel management program.
On the other hand, the abdominal film may show an empty colon; in such case, we must consider the possibility of the enema producing an irritation of the colon.
Our specific suggestion is to go through the entire bowel management all over again, to try to figure out the best way to keep your son clean, without inflicting pain.
Contact the Colorectal Center at Cincinnati Children's
For more information or to request an appointment for the Colorectal Center at Cincinnati Children's Hospital Medical Center, please contact us.
