Severe Postoperative Chronic Constipation Related to Anorectal Malformation Managed with Osteopathic Manipulative Treatment

Participants

• Number: 1
• Description: a 3,400-g infant born by vaginal delivery at 40 gestational weeks with a postnatal diagnosis of anorectal malformation (imperforate anus with peritoneal rectal fistula). 6-mm pyelic ectasia of the left renal pelvis without ureter, kidney and bladder involvement. Negative cardiological, neurological, and orthopedic tests.

At 5 days of life the infant underwent anorectoplasty without complications during surgery. 6 months after surgery the infant was stable with an increase in daily caloric intake. However, he started to take laxative drugs (macrogol) and enemas as a consequence of the insurgence of severe constipation. Despite the increase in laxative drugs, the infant struggled to evacuate, suffering frequently of abdominal pain, aerophagia and frequent urination. 18 months after surgery, the infant was admitted to hospital for intestinal obstruction due to a faecaloma. After the resolution of the obstruction he started to receive a senna-based laxative every day.

21 months after surgery the infant started soiling and experiencing intense abdominal pain that made him less active during the day.

24 months after surgery, the infant was taken to an osteopath, who, through the assessment of the musculoskeletal status and of the pelvic region relieved some somatic dysfunctions especially on the pelvic floor and in the sacroiliac region.

Interventions and evaluations

• 4 OMT sessions of 45-minute each once a month.
• OMT with indirect manual techniques: ligamentous tension balancing at the sacroiliac level, balance and hold treatment of the sacrococcygeal ligaments and counterstrain at the pelvic level, balance treatment between the subdiaphragmatic region and the pelvic floor together with a craniosacral therapy.
• During the OMT, the pediatrician would check and adjust the laxative drug therapy.

Results

After the first session, the child began to manage to evacuate intermittently, with the help of enemas and senna.

After the third session, the frequency of evacuation increased durably, in conjunction with a reduction in intense colic abdominal pain and the interruption of laxative treatment administered by the pediatrician. Only enemas were still used when needed. In addition, the fecal incontinence stopped with feces assuming a healthier form according to the Bristol Stool Chart (change from type 6 to type 3).

After the fourth session, the evacuation became completely autonomous. Given the positive results, the child maintained 2 sessions of OMT per year in order to balance any tensions related to the surgical scar.

At the date of writing the article, the child evacuates autonomously without the need for laxatives or enemas, and does not manifest either constipation or incontinence.

Discussion

Constipation is often a side effect of surgery used to resolve anorectal malformations, independently of their severity, and can easily prevent the proper development of intestinal muscle/sphincter control, as well as increase the risk of morbidity. Therefore, when constipation occurs after such surgeries, it is essential to act as soon as possible.

In the case of anorectal malformations, there is an important fascial alteration (eg, altered tissue thickness) linked to a mismatch between the activity of the autonomic nervous system and bowel peristalsis, all most likely due to an incorrect maturation of the myofascial and nervous structures of the anorectal areas.

L’OMT, grazie alla sua capacità di agire sulle tensioni fasciali e sul sistema nervoso autonomico, ha favorito la risoluzione della stipsi qui descritta. In effetti, nel bambino trattato sono state riscontrate disparità nella distribuzione del carico miofasciale a livello del pavimento pelvico e disfunzioni somatiche a livello delle aree cervicali alte e presacrali, collegate a livello nervoso con il sistema parasimpatico e l’evacuazione.