10-Year-Old Male Presents with Severe Left-sided Abdominal Pain and Discharge from Anus

Lisa VanHouwelingen, M.D., M.P.H., F.R.C.S.C.
McMaster Children's Hospital, Hamilton, Ontario, Canada

  • Ten-year-old male presents to the ED with severe left sided abdominal pain and discharge from the anus.
  • He is febrile and tachycardic. He is admitted and ultimately diagnosed with Shigella colitis with overflow diarrhea into the efferent limb of his loop transverse colostomy. Also, he was a Syrian refugee who immigrated to Canada. No prior medical records available.
  • Per the medical and surgical history from the family he was born full term and spend several weeks in the NICU.
  • He passed stool within 24 h of life.
  • Anus never looked normal and he was discharged home with plan for family to perform dilations after birth.
  • At age 2, he had his first laparotomy and surgery on “the bladder”.
  • At age 3.5, he had second laparotomy and creation of a colostomy.
  • At age 4, he had a third laparotomy and revision of the colostomy—presumably loop transverse colostomy.
  • At age 8, he had laparotomy, pull-through, and PSARP complicated by perineal wound infection and significant scarring.
  • At age 8.5 he had appendicitis with open appendectomy.
  • On exam, he had multiple abdominal scars.
  • On perineal exam, he had severely scarred anus with multiple incisions surrounding the anus. He had a hypotonic anal sphincter that passed a size 6 Hegar. His sacral ratio was 0.58. He had a lower GI study through the anus that showed irregular margins of the rectum and colon to the level of the colostomy and he had a posterior rectocele.
  • CT abdomen and pelvis showed a presacral thin walled mass.
  • He had a transverse colon preserved and normal cecum.
  • MRI pelvis and spine showed a thickened rectum/sigmoid and thin walled presacral cyst not communicating with the spinal canal thought to represent dermoid.
  • EUA was performed using the Pena stimulator that showed no movement.
  • Anoplasty was performed by opening the shelf anteriorly and could then pass a Hegar 15.
  • Resection of the presacral mass with the tip of the coccyx was performed through a posterior approach.
  • Pathology confirmed an epidermoid cyst.
  • Contrast study was performed through the colostomy. The left colon and rectum are patent without stenosis, anterior to the rectal wall there was a small contrast extravasation and posterior rectal wall rectocele was identified.
  • He had an anorectal manometry study, because the patient would like his stoma closed.
  • Manometry showed hypotensive anal sphincter and no proper continence mechanism.


  • It is important for all the members of the family to have AP and lateral x-rays of the sacrum. If any of them have hemisacrum, MRI should be obtained.
  • Patient will mostly likely be fecally incontinent. A neomalone can be created at the same time as the colostomy closure. The neomalone should not be used for 1 mo following surgery. After the colostomy is closed, bowel management will need to be implemented to keep the patient clean.

Patient Case Discussion

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