929

Small Intestine
SURGICAL COMPLICATIONS OF
ROUNDWORM (Ascaris Lumbricoides)
Life Cycle
Eggs faecooral route larvae portal circulation liver
hepatic veins IVC, heart, pulmonary artery lungs matura-
tion of larvae (8 weeks) alveoli, trachebronchial tree coughed
out or swallowed to intestine adult roundworms male +
female worms union release of eggs stool reinfection.

Fig. 21.13: Roundworm removed from peritoneal cavity. Note the

faecal contamination.

Courage is grace under pressure.

930

Fig. 21.14: Specimen of ileum showing roundworm bolus. Bolus Fig. 21.16: Plain X-ray abdomen in a child showing features of
causes intestinal obstruction, commonly near terminal ileum. intestinal obstruction due to roundworms in the bowel.
o Loefflers syndrome is due to larvae in the alveoli causing
SRB's Manual of Surgery

fever, dry cough, chest pain, dyspnoea.

A B
Figs 21.15A and B: Gastroduodenoscopy view of roundworm. It was
removed through endoscopy. Roundworm in proximal bowel can cause
pancreatitis, cholangitis. Vomiting of roundworms signifies intestinal
obstruction. It need not be due to roundworm obstruction. Because of
the obstruction and proximal bowel irritation, worms move proximally
into stomach and come out through the mouth. (Courtesy: Dr Tantry
and Dr Sandeep Gopal, Gastroenterologists, KMC, Mangalore).

Features Fig. 21.17: Roundworm obstruction. Worms removed through an

enterotomy.
o Worm colic.
o Toxicityfever, tachycardia.
o Subacute intestinal obstruction. Investigations
o Acute intestinal obstruction with palpable roundworm bolus o Small bowel enema/barium meal follow through may show
per abdomen. roundworms in the ileum.
o Perforationcommon in the ileum. o US can demonstrate the worms/worm bolus/worm in CBD
or pancreatic duct.
Note:
o Blood may show eosinophilia, anaemia, hypoalbuminaemia.
Perforation usually occurs at the site of pre-existing disease like nonspe-
cific ileal ulcer, amoebic ulcer, typhoid ulcer, and suture line. LFT for worm in CBD.
o Chest X-ray may show bronchitis.
o Intraperitoneal abscess. o Sputum or bronchial wash may show larvae or Charcot-
o Dyspepsia, malabsorption, iron deficiency anaemia. Leyden crystals.
o Due to migration of worm into the CBD/pancreatic duct o Stool examination may show ova.
causes ascending cholangitis with fever, jaundice and upper o CT/MRI will show worms/obstruction/worm in CBD or
abdominal pain or features of pancreatitis. pancreatic duct.
Treatment 931
o Antihelminthic drugs like piperazine citrate 60 ml is given
immediately if there are features of obstruction, otherwise
at night time. Albendazole, mebendazole are other drugs
used. Proper nutrition is important.
o Nasogastric aspiration; IV fluids; observation is sufficient
in most of the situations. In 48 hours, obstruction will be
relieved and child passes worm bolus per anally.
o Occasionally laparotomy and milking of the worm bolus into
the caecum without enterotomy is needed. Once worms are
in the colon, hypertonic saline wash per anum makes them
to disperse and pass outside.
o Removal of worms by enterotomy is rarely done. Enter-
otomy should be securely sutured using silk otherwise
reperforation from sutured site can occur by worm toxins
or by worm activity and migration.
o If there is perforation (common site is ileum) or gangrene
with peritonitis, peritoneal worms should be essentially
removed. Ideally ileum should be exteriorised to prevent
suture line breakdown after closure due to worms. Once
patient recovers bowel ends are sutured to maintain the
continuity and abdomen is closed. Even though it is ideal
method, it is not commonly performed.
o ERCP, worm extraction and stenting is done for worm in
CBD/pancreatic duct.

Small Intestine
Treatment of roundworm obstruction
 Drugspiperazine citrate, mebendazole, albendazole
 Most often by conservative treatment, worms get dispersed
and passed per anally. But patient requires nasogastric aspira-
tion, IV fluids, antibiotics, and observation
 If patient is not responding then laparotomy is done. Worm
bolus in the distal ileum is milked into the caecum. Often
enterotomy and removal of worms is required
 Perforation due to worm requires immediate laparotomy,
removal of worms and closure of perforation
 Only rarely, resection and exteriorisation is required

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