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IJAIMS

10.5005/jp-journals-10050-10025
Ascariasis presenting as Acute Abdomen: A Rare Case
Case Report

Ascariasis presenting as Acute Abdomen: A Rare Case


1
Ranjan Agrawal, 2Parbodh Kumar, 3Nitesh Mohan

ABSTRACT On general examination, she was found to be emaci-


Ascaris lumbricoides is a common intestinal parasite found in ated and pale. Her oral temperature was 37.5C, and blood
humans prevalent in countries with low socioeconomic status. pressure was 100/60mm Hg. Pulse was regular with a
The disease can occur in all age groups but is more common rate of 120 beats per minute, and respiratory rate was
in preschool-aged children. It causes significant medical, surgi- 35 per minute. Cardiovascular examination was within
cal, and social complications. Reported complications include
small intestinal obstruction, volvulus, and intussusception.
normal limits. No neurological deficits were present.
Obstruction of the intestinal tract by a mass of A. lumbricoides Physical examination revealed abdominal tenderness
is one of the serious and lethal complications. and rigidity in the central and mid-abdomen. There
We present herein a case of A. lumbricoides infestation in a was no organomegaly. Auscultation revealed a silent
7-year-old girl, presenting as acute abdomen. Prompt surgical
abdomen. On investigation, her hemoglobin was found
intervention saved the child.
to be 10gm%, while the complete blood count, liver func-
Keywords: Acute abdomen, Ascaris lumbricoides, Intestinal tion test, and renal function test were within normal
obstruction.
limits. X-ray showed multiple fluid levels, indicative of
How to cite this article: Agrawal R, Kumar P, Mohan N. intestinal obstruction. Ultrasonography of the abdomen
Ascariasis presenting as Acute Abdomen: A Rare Case. Int J
Adv Integ Med Sci 2016;1(2):75-78.
revealed multiple linear echogenic foci in distal small
bowel loops with a railway track like appearance, which
Source of support: Nil
was suggestive of worms.
Conflict of interest: None Decision of immediate laparotomy was taken after
correction of fluid and electrolyte imbalance, prophylactic
INTRODUCTION broad spectrum antibiotics, blood transfusion, and anal-
gesics. No antihelminthic drug was used at this stage.
Ascariasis is an intestinal parasitic infection caused by
Intraoperative exploration through a right lower para-
Ascaris lumbricoides (roundworm). Its highest prevalence
median incision revealed serous collection. Laparotomy
is observed in tropical and subtropical areas. It is seen
revealed necrosis of ileum, measuring approximately
in underdeveloped countries where poor sanitation is
21cm along with bolus of worms (Fig. 1). The necrosed
common.1,2 Most cases remain asymptomatic. However,
part was resected and primary end-to-end anastomosis
heavy infestation, especially in children, can lead to
was performed.
serious complications like intestinal obstruction, requir-
At laparotomy, milking was performed by hand
ing urgent surgical intervention. We report a rare case in
to move the worms to the jejunum to facilitate their
a 7-year-old girl presenting with intestinal obstruction,
extrusion. An enterotomy was done in the intestine to
perforation, and gangrene following heavy ascariasis.
extract worms by sponge-holding forceps. The worms
CASE REPORT
A 7-year-old female child came to emergency with severe
colicky abdominal pain and vomiting. She had had con
stipation for the last 3 days. The girl came from a family
of very low socioeconomic status. Her father was a farmer.
The girl had a history of pica.

1,3
Professor, 2Professor and Head
1-3
Department of Pathology, Rohilkhand Medical College and
Hospital, Bareilly, Uttar Pradesh, India
Corresponding Author: Ranjan Agrawal, Professor, Department
of Pathology, Rohilkhand Medical College and Hospital , Bareilly
Uttar Pradesh, India, Phone: +919412291009, e-mail: drranjan
68@gmail.com Fig. 1: Resected segment of intestine showing gangrenous
portion () along with Ascaris worms ()

International Journal of Advanced & Integrated Medical Sciences, April-June 2016;1(2):75-78 75


Ranjan Agrawal et al

environment becomes intolerable for their living, they


migrate to more appropriate areas of the intestinal tract.
The symptoms are related to the migration of either the
larval form or the adult worm in the intestine. Majority
of the patients present with subacute or acute clinical
course with severe abdominal pain, fever, dehydration,
vomiting, and abdominal distension. In children, intes-
tinal obstruction caused by heavy worm burden is the
most common manifestation of the disease.6,7 Pulmonary
manifestations may be due to the larval migration
through the lungs. Adult worms can lead to serious
clinical problems during their migration, including acute
pancreatitis, acute cholecystitis, liver abscess biliary colic,
Fig. 2: Bolus of Ascaris filling almost the entire kidney tray cholangitis, intestinal obstruction when present in large
numbers, and even perforation. They may occasionally
cause appendicitis and obstructive jaundice. Massive
approximately filled a kidney tray (Fig. 2). The freshly
gastrointestinal bleeding with ulceration, perforation,
expelled worms were pinkish and cylindrical. Both male
and even gangrene of the bowel wall is a rare and fatal
and female roundworms were identified.
reported complication.5,6,8-11 Children are likely to suffer
Adult males measured 15 to 30cm in length and 2 to
from protein malnutrition and vitamin A deficiency.12
4mm in diameter. Their posterior end was curved with
In acute obstruction, patients are ill for several
two copulatory spicules. Adult females measured 20 to
days before presentation. There may be signs of severe
40cm in length and 3 to 6mm in diameter. Their posterior
dehydration and toxic appearance along with vomiting,
end was straight and conical. These worms were identified
abdominal pain, and distension. Fever and leukocytosis
as A. lumbricoides from their gross appearance and the size
are common. The passage of adult worms in sensitive
and shape of the eggs along with microscopic confirma-
persons may give rise to intense anal pruritus, vomit-
tion. Patient was discharged on the 7th postoperative day
ing of worms, and edema of the glottis. When the larvae
without complications. She is on regular follow-up.
wander into the brain, they cause granulomas, presenting
as small tumors in the eye, retina, or brain.
DISCUSSION
Complications of Ascaris infestation include obstruc-
Ascaris is the largest nematode to infect the human intes- tion of the small intestine, volvulus, intussusception,
tine as a facultative parasite throughout its adult life. pancreatitis, appendicitis, and cholecystitis. Intestinal
It is prevalent in the tropics and subtropics with an esti- obstruction can be fatal at times. Multiple worms form
mated prevalence of 25% worldwide, where unhygienic a large bolus, resulting in mechanical obstruction of
disposal of human excreta is common. The prevalence the bowel lumen, which is the most frequent cause of
of Ascaris-related intestinal obstruction in India is Ascaris-related bowel obstruction. The bolus of worms
9.2 cases per 100,000 persons.2,3 may serve as a leading point in intussusception or a
The mode of A. lumbricoides infection is by ingestion pivot in small bowel volvulus. The worms may inhabit
of embryonated eggs in raw vegetables, water, or soil- the ileocecal valve, where they secrete neurotoxins,
contaminated hands. The fertilized eggs hatch in the prompting small bowel contraction, which together
intestine. The released larvae penetrate the intestinal wall with high worm burden further obstruct the intestine.
to reach the right side of the heart, pulmonary circulation, A hosts inflammatory reaction to worm-derived hemo-
and then the alveoli. When the larvae are coughed up by lysins, endocrinolysins, and anaphylatoxins can further
the host, they are swallowed back into the intestine to aggravate the obstruction.7 Volvulus, intussusception,
develop into adult worms. They most commonly reside or increasing pressure on the intestinal wall leads to
in the jejunum and ileum.4,5 Ascariasis can occur at all necrosis. The roundworms do not attach to the intestinal
ages, but it is most common in children between 2 and wall, but rather remain in the lumen by powerful, con-
10 years of age. tinuous muscular movement. In the lumen, the worms
The clinical features of A. lumbricoides infection are feed on the nutrients in the hosts intestinal tract. These
variable. Depending upon the parasitic burden, they may worms remain in the intestines for several years without
remain asymptomatic or become symptomatic. Normally, causing disease.
they live in the stomach and reach upto the ileocecal valve The mechanism of Ascaris-induced perforation of
region without causing any serious symptoms. When the the small bowel is highly debatable. Patients residing in

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IJAIMS

Ascariasis presenting as Acute Abdomen: A Rare Case

the tropical countries suffer from diseases associated with the serosal layer. Damage to the worms during milking
intestinal ulcerations. These include typhoid enteritis, should be avoided as this may release toxins. Cases pre-
tuberculosis, and amoebiasis. During extreme condi- senting with gangrene, perforation, or intussusception
tions, such as inflammation, starvation, or worm bolus with nonviable bowel segment resection with primary
obstruction, some parasites are believed to migrate into anastomosis may be required.15,16
the ulcers, leading to perforations. Another possible
explanation is that the large worm bolus can lead to CONCLUSION
pressure necrosis and gangrene. The already diseased There should be a high suspicion for parasitic infesta-
bowel becomes susceptible to rupture by the burrowing tion in preschool children with sudden acute intestinal
action of the worms.3,6 obstruction to prevent serious life-threatening compli-
When the patients are febrile or are given anesthetic cations. Prompt surgical intervention in patients with
drugs, the worms may migrate and wander into the acute intestinal obstruction results in a good outcome.
bile ducts, ampulla of vater, appendix, perineal sinuses, Partial intestinal obstruction from A. lumbricoides may
and eustachian tubes. Thus, it is important not to give resolve spontaneously with conservative treatment.
any drugs, especially when there is a possibility of The awareness of ascariasis and its preventive mea-
Ascaris infection. Deworming should be carried out sures should be included in all health education pro-
when the children are ill and febrile or before giving an grammes and should be delivered to school children and
anesthetic drug. their mothers to overcome the risk of infection.
Frequent diagnosis with clinical symptoms and Early recognition based on local prevalence can
hematological investigation is not possible. Plain X-ray prevent serious surgical complications, morbidity, and
of abdomen may show a whirlpool pattern of intralu- mortality associated with intestinal obstruction.
minal worms in most of the cases.13 X-ray may show air
fluid levels. Perforation may be seen as free air under the ACKNOWLEDGMENT
diaphragm on an X-ray. Stool test shows abundant ova
We are thankful to the department of Surgery for provid-
and parasites, along with high number of eosinophils.
ing the details of the case.
Blood counts may demonstrate marked leukocytosis and
eosinophilia even up to 25% or more. Abdominal ultra-
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