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 Annals of Health Research
CC BY-NC Volume 6, Issue No 1: 51-58
March 2020
doi :10.30442/ahr.0601-06-66
ORIGINAL RESEARCH

Accuracy of Lateral Invertogram in diagnosing and

classifying anorectal malformations
Nwokoro CC*1, Ayoade BA1, Salami BA1, Fatungase OM2, Olatunji
AA3, Emmanuel EA2
1Department of Surgery, 2Department of Anaesthesia and Intensive Care, 3Department of Radiology, Olabisi
Onabanjo University/Olabisi Onabanjo University Teaching Hospital, Sagamu

*Correspondence: Dr CC Nwokoro, Department of Surgery, Olabisi Onabanjo University/ Olabisi Onabanjo

University Teaching Hospital, Sagamu. Email: [email protected];
ORCID - https://orcid.org/000-0002-5599-4247.

Abstract

Background: The initial management of a new born baby with anorectal malformation could be made only after
an accurate determination of the level of the anomaly.
Objective: To determine the accuracy of lateral invertogram in diagnosing and classifying anorectal anomalies.
Methods: This was a retrospective study carried out between January 2003 and December 2013. The accuracy,
sensitivity, and specificity of lateral invertogram in diagnosing and classifying anorectal malformations in the
cases studied were determined.
Results: A total of 62 children with anorectal malformations patients were seen during the study period. The age
range was 4 hours to 6 years. A total of 50 (80.6%) had lateral invertogram while only 39 films of lateral
invertogram were available for analysis. A total of 22 patients had high anomalies while 12 patients had low
anomalies. The accuracy of lateral invertogram in identifying anorectal anomaly was 100% and its ability to
differentiate between high and low anomalies was 76.5%. The Sensitivity in identifying high anomalies was 59%
while the specificity was 31.8%. The sensitivity in identifying low lying lesions was 66.5% while the specificity
was 50%.
Conclusion: The accuracy, sensitivity, and specificity of lateral invertogramin diagnosing and classifying
anorectal malformations were found to be satisfactory in the present study.

Keywords: Accuracy, Anorectal malformations, Imperforate anus, Lateral Invertogram, Neonatal intestinal
obstruction.

Introduction the doubtful cases, the internal anatomy could

be assessed using imaging techniques such as
The incidence of anorectal malformations is 1 the invertogram radiology, erect plain
in 5000 globally. They are more common in abdominal radiography, ultrasound
males than compared to females. The examination of the abdomen, pelvis, and
diagnosis is usually made shortly after birth spine, computed tomography (CT),
and clinical evidence of anorectal micturating cystourethrogram, distal
malformations could be found in 80-90% of colostogram, magnetic resonance imaging
cases while about 10-20% remains doubtful. In (MRI) and muscle stimulation under general
anaesthesia. [1-4]

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Lateral Invertogram_______________________________________________________

for the period between January 2003 and

Using the invertogram, the bowel-skin December 2013 at the Olabisi Onabanjo
distance can be estimated and based on the University Teaching Hospital, Sagamu.
findings, anorectal malformations could be
divided into high and low types, depending The hospital records of patients managed for
on whether the termination of the hindgut is anorectal malformations during the study
above or below the puborectalis sling. More period were retrieved from the Medical
than 1cm bowel-skin distance indicates a high Records Department. The invertograms were
anomaly while a bowel-skin distance of 1cm or done not less than 24 hours after birth; this
less indicates a low anomaly. [5] was to allow the baby’s swallowed air to reach
Though the lateral invertogram serves as an the most distal part of the rectum. Relevant
important modality of investigation, it could data such as age, sex, clinical and radiographic
be associated with aspiration pneumonitis or (lateral invertogram) findings were extracted
cerebral congestion; the latter may arise while from the hospital records. The anorectal
performing the procedure, as a result of malformation was classified as low-lying
positioning the baby in an inverted state. Also, when the distance between the distal gas
the invertogram could be limited by its shadow in the rectal pouch and a radiopaque
inability to accurately differentiate between marker at the perineum (anal dimple) is about
the high and low types of anomalies as 1cm or less. High anorectal malformations
reported by some authors. [5,6] were characterized by distances of more than
1cm. All the patients included in this study
The classification of anorectal malformations is had lateral invertograms as the diagnostic
important because it helps in planning and modality following clinical suspicion or
choosing the appropriate methods of identification of an anorectal anomaly.
treatment and also, provides a guide for
prognosis. The earlier methods of classification The gold standard against which the lateral
of the malformations such as the Wingspread invertogram was tested was intra-operative
classification and the international findings. The accuracy, sensitivity, and
classification did not standardize the specificity of lateral invertogram were
indications and choices of intervention; calculated using the following formulae:
however, Pena’s classification includes some a. True positives were actual positives
indications aimed at standardising the choices with anorectal malformations and
and types of treatment available to the those who had high or low
patients. [7, 8] malformations and were correctly
identified through the lateral
The objective of this study was to determine invertogram.
the accuracy, sensitivity, and specificity of b. True negatives were the actual
lateral invertogram in the diagnosis of negatives and were identified
anorectal malformations and to ascertain the accordingly. These were proportions
role the lateral invertogram plays in the without anorectal malformations,
classification and definitive treatment of those without high malformations
patients with anorectal malformations. who were accordingly identified and
those without low malformations who
were also accordingly identified.
Methods c. False positives were those who were
tested to have the condition but at
This was a retrospective study of the use of surgery, were found not to have
lateral invertogram in anorectal malformations anorectal malformations and cases

Annals of Health Research. Volume 6, Issue No 1, 2020_______________________52

Nwokoro CC, et al________________________________________________________

pre-operatively classified as high and quality and excluded from further analysis.
low malformations, but with reverse The remaining 34 radiographic films showed
findings at surgery. 22 children with high anomalies and 12
children with low anomalies.
d. False negatives were those which
tested negative pre-operatively but Further findings from the 34 radiographic
were found to have the anorectal films showed an accuracy of 100% while its
malformations at the surgery. These ability to differentiate between high and low
refer to the presence of anorectal anomalies was 76.5%. The Sensitivity of lateral
malformations with high or low invertogram in identifying high anomalies
malformations which were correctly was 59% while the specificity was 31.8%. The
identified at surgery but missed pre- sensitivity of the lateral invertogram for
operatively. identifying low lying lesions was 66.5% while
the specificity was 50%.
Accuracy = (True positive + True
negative)/(True positive+True negative+False Figures 1 to 4 show the clinical and
positive+False negative) radiographic (lateral invertogram)
manifestations of anorectal malformations in
Sensitivity = (True the newborn.
positive)/(True positive+False positive)

Specificity = (True
Discussion
negative)/(True negative +False positive)

Anorectal anomalies represent a wide

The data obtained were analysed using SPSS
spectrum of congenital malformations of the
version 22 and the results presented as
lower gastrointestinal tract (the rectum and
frequencies and proportions.
anal canal) and may be extended to
Ethical considerations malformations and abnormal connections with
Ethical approval for this study was obtained the genitourinary tract. It may occur alone or
from the Health Research Ethics Committee in association with other life-threatening
(HREC) of the Olabisi Onabanjo University congenital anomalies involving the heart,
Teaching Hospital, Sagamu. vertebra and the musculoskeletal system (the
VACTERAL syndrome). The outward
appearance of the anorectum and perineum
may not give a true picture of the complexity
Results
of anomalies affecting the anorectal region,
neurovascular tissue, spinal cord, vertebra,
A total of 62 children aged 4 hours to 6 years
and the genitourinary system. [9,10]
with anorectal malformations were seen
during the study period. The subjects
The diagnosis of anorectal malformation is
comprised 41 males and 21 females, giving a
made in 80% of cases through physical
male-to-female ratio of approximately 2:1.
examination. However, in about 20% of cases,
Fifty children (80.6%) children had lateral
radiological studies would be required for the
invertogram while 12 (19.4%) did not have
confirmation of the diagnosis. Radiological
lateral invertogram and were not included in
studies also contribute immensely towards
the data analysis.
classifying the malformations and planning for
the ultimate care of these patients. The
Thirty-nine radiographic films of lateral
traditional radiological approach involves the
invertogram were retrieved, 5 were of poor

Annals of Health Research. Volume 6, Issue No 1, 2020_______________________53

Lateral Invertogram_______________________________________________________

use of an invertogram to determine the level of malformations would be safely repaired from
the distal rectal pouch; the information the perineum or whether a colostomy would
obtained from the invertogram report is useful be needed. [11,12]
in determining whether the anorectal

Figure 1: Lateral invertogram showing low-lying anomalies

Figure 2: Lateral invertogram showing the high type of anorectal anomalies

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Nwokoro CC, et al________________________________________________________

Figure 3: Gross appearances of the perineum of newborns with anorectal malformations

Figure 4: Anorectal malformation manifesting with neonatal intestinal obstruction

Annals of Health Research. Volume 6, Issue No 1, 2020_______________________55

Lateral Invertogram_______________________________________________________

In our experience, the first investigative least 24 hours after birth. The baby is carefully
approach is the lateral invertogram and it has held upside down for at least 3 minutes during
remained invaluable in the diagnosis and the procedure. Invertogram has been
classification of anorectal malformations in our considered to be the most important early
centre. It is very sensitive and specific in diagnostic modality in identifying and
confirming the diagnosis and classifying classifying newborns with anorectal
anorectal anomalies. The results in the present malformations. [15,16]
study are similar to the findings of Akansha [13]
and Horsirimanont [14] and their co-workers. Despite the usefulness of the lateral
Other investigations employed in the invertogram in the initial assessment and
management of the cases included abdominal categorization of patients with anorectal
and perineal ultrasonography, plain malformations, it is associated with limitations
abdominal radiography, chest radiography, such as difficulty in achieving optimum
and echocardiography as adjuncts to the position, the inability of air to reach the end of
lateral invertogram when indicated. None of the bowel due to impacted meconium,
the children in the present series had continuous crying during the procedure which
abdominal computerized tomography and leads to deceptive obliteration of lower
magnetic resonance imaging for clinical rectum, significant hypoxia due to inverted
evaluation. [13, 14] position in babies with the imperforate anus
and intestinal obstruction, upward
In the study by Akansha and co-workers, [13] displacement of the rectum due to the effect of
33% of their patients with anorectal gravity and escape of air through a fistulous
malformations were diagnosed with lateral tract which causes less distension of the blind-
invertogram while 20% were diagnosed with ending rectal pouch. [15-17] In addition, some of
prone cross-table lateral radiography and 20% our patients presented late and could not be
diagnosed with plain abdominal erect subjected to the lateral invertogram, some
radiography. They also employed micturating films were of poor quality and were not
cystourethrogram to diagnose some cases of included in this study while others could not
recto-vesical fistula. [13] On the other hand, be retrieved at all. These are acceptable
Horsirimanont and co-workers [14] reported a limitations of a retrospective study.
sensitivity of 66.7% for lateral invertogram in
Thailand; the low sensitivity may be attributed An alternative radiological procedure (prone
to the limitations inherent in the procedure of cross-table lateral radiograph) could be used;
lateral invertogram. [14] this is an X-ray taken in the knee-chest
position with the baby positioned prone, the
The invertogram is a radiographic technique buttocks elevated to about 45o and the x-ray
used for estimating the level of the rectal taken laterally and centered at the greater
pouch in patients with anorectal trochanter. It provides equal or sometimes
malformations. Although the technique has better information compared to the
been employed for the diagnosis of anorectal invertogram, in the demonstration of the level
anomalies in the last eighty years, it is still an of rectal atresia. Its advantages include easy
investigation of choice for neonatal evaluation positioning, the better co-operation of the
of anorectal malformations. It has been patient, elimination of the effect of gravity and
considered the classic method for determining better delineation of the rectal gas shadow. [18]
the distance from the blind rectal pouch to a
marker placed on or within the anal dimple. To improve the diagnostic accuracy of the
The decision to use an invertogram to assess lateral invertogram and lateral prone cross-
the level of the rectal pouch should be taken at table X-ray in diagnosing anorectal anomalies

Annals of Health Research. Volume 6, Issue No 1, 2020_______________________56

Nwokoro CC, et al________________________________________________________

and other associated congenital evaluation and care of newborns with

malformations, several investigative adjuncts anorectal malformations. Its accuracy,
have been employed. These newer diagnostic sensitivity, and specificity in diagnosing and
techniques include abdominal classifying these conditions were found to be
ultrasonography. The use of ultrasound to satisfactory in the present study. It is attractive
determine the position of the terminal colon is to recommend the routine use of lateral
well known; initial reports involved scanning invertogram and lateral cross-table decubitus
from the anal dimple and measuring the radiograph in the initial diagnosis and
distance between the terminal colon and the classification of anorectal malformations in
skin at the anal dimple site. However, the children. The use of other diagnostic adjuncts
application of pressure at the anal dimple such as abdominopelvic ultrasonography,
distorts the distance between the anal dimple computerized tomographic scan, magnetic
and the terminal colon. [19-21] resonance imaging and techniques for pelvic
muscle stimulation improves the diagnostic
The computerized tomographic scan provides accuracy, classification of these anomalies and
increased detail, particularly of the osseous identification of other associated congenital
structures as well as being able to demonstrate malformations.
the pelvic floor musculature but has difficulty
in distinguishing meconium from the rectal Authors’ Contributions: NCC conceived and
wall and adjacent musculature due to designed the study. ABA, SBA, FOM, OAA, and
limitation in contrast resolution. There is also a EEA participated in data collection, analysis and
drafting of the manuscript. All the authors
risk of exposure to radiation in the use of a
approved the final version of the manuscript.
computerized tomography scan.[22] Magnetic
Conflict of Interest: None.
resonance imaging has similar properties as Funding: Self-funded.
CT but has improved contrast resolution Publication History: Submitted 08 November 2019;
which allows for easy differentiation of Accepted 28 February 2020.
meconium from the rectal wall and levator
musculature. MRI can accurately detect the
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Annals of Health Research. Volume 6, Issue No 1, 2020_______________________58