Background

Ascariasis is the most common helminthic infection, with an estimated worldwide prevalence of
25% (0.8-1.22 billion people).[1] Usually asymptomatic, ascariasis is most prevalent in children of
tropical and developing countries, where they are perpetuated by contamination of soil by human
feces or use of untreated feces as fertilizer.[2] For more information on ascariasis in children, see
the Medscape article Pediatric Ascariasis. Symptomatic ascariasis may manifest as growth
retardation, pneumonitis, intestinal obstruction, or hepatobiliary and pancreatic injury. In
developing countries, ascariasis may exist as a zoonotic infection in pigs, but little evidence has
shown transmission of porcine ascariasis to humans.[3]

The image below depicts a roundworm that infects humans through soil contaminated by human
feces.

Adult Ascaris lumbricoides.

Pathophysiology
Ascaris lumbricoides is the largest of the common nematodes (roundworms) that infect humans.
Adult A lumbricoides are white or yellow and 15-35 cm long (see first image below). They live
10-24 months in the jejunum and middle ileum of the intestine. Each day, female A lumbricoides
produce 240,000 eggs (see second image below), which are fertilized by nearby male worms. A
Chinese study showed that 45% of infected persons shed only fertilized eggs, 40% shed fertilized
and unfertilized eggs, and 20% shed only unfertilized eggs. Unfertilized eggs accounted for only
6-9% of eggs shed. Fertilized eggs released into favorable soil may become infectious within 5-
10 days.[4] Eggs may remain viable in soil for up to 17 months. Infection occurs through soil
contamination of hands or food, ingestion, and the subsequent hatching of eggs in the small
intestine (see third image below).
 Adult Ascaris lumbricoides.

Ascaris lumbricoides egg. Life cycle of Ascaris lumbricoides.

Second-stage larvae pass through the intestinal wall and migrate through the portal system to the
liver (4 d) and then the lungs (14 d). A significant exposure may produce subsequent pneumonia
and eosinophilia. Symptoms of pneumonitis include wheezing, dyspnea, nonproductive cough,
hemoptysis, and fever. Larvae are expectorated and swallowed, eventually reaching the jejunum,
where they mature into adults in approximately 65 days.

Adult worms feed on digestion products of the host. Children with a marginal diet may be
susceptible to protein, caloric, or vitamin A deficiency, resulting in retarded growth and increased
susceptibility to infectious diseases such as malaria.[5] Large and tangled worms may cause
intestinal (usually ileal), common duct, pancreatic, or appendiceal obstruction. Mean worm
burden varies from more than 16 to 4 and appears related to host factors, particularly age,
geophagy,[6] and immunity. Worms do not multiply in the host. For infection to persist beyond the
2-year maximum lifespan of the worms, re-exposure must occur.

Ascaris lumbricoides suum, a swine nematode, has been thought responsible for zoonotic
infection. Distinguishing this worm from A lumbricoides is difficult. A suum appears to
responsible for most ascariasis cases in well-developed countries with excellent sanitation (eg,
Denmark,[7] United States, UK[8] ). In this setting, infected children have a low worm burden and
may present with only acute eosinophilia or eosinophilic liver lesions visible on CT scans.
However, a molecular genetic study from China casts doubt that infections in pigs are a
significant reservoir for human infection.[3]

Epidemiology
Frequency

United States

In 1974, an estimated 4 million people, mainly in the southeast United States, had ascariasis.
Recent estimates of ascariasis prevalence are unknown, but probably much lower. Immigrants
from countries with a high prevalence of ascariasis comprise most recent cases.

International

The prevalence of ascariasis is highest in children aged 2-10 years, with the highest intensity of
infection occurring in children aged 5-15 years who have simultaneous infections with other
helminths such as Trichuris trichiura and hookworm. A recent Vietnamese study found that adult
women living in rural areas, especially those exposed to human night soil and living in
households without a latrine, were at surprisingly high risk for ascariasis.[9] The Centers for
Disease Control and Prevention (CDC) estimated that worldwide ascariasis rates in 2005 were as
follows: 86 million cases in China, 204 million elsewhere in East Asia and the Pacific, 173
million in sub-Saharan Africa, 140 million in India, 97 million elsewhere in South Asia, 84
million in Latin America and the Caribbean, and 23 million in the Middle East and North Africa.

Because the lifespan of adult worms in the intestine is only one year, persistent infection requires
frequent re-exposure and reinfection. The frequency and intensity of infection remain high
throughout life in endemic areas and pose a risk to both elderly and young persons. In a recent
study in rural southwest Nigeria, the intensity of excreted eggs per gram of feces among infected
persons was 2,371 for Ascaris species, 1070 for hookworm, and 500 for Trichuris species, with
only slightly lower rates among persons in urban areas.[10] Estimates of disability-adjusted years
of life due to ascariasis have fallen because of development and management programs during
the 1990s, especially in Asia, but still constitute a significant burden in some countries.

Mortality/Morbidity

Ascariasis is most common and intensive in children, who are more likely than adults to
be symptomatic. In children, intestinal obstruction caused by heavy worm burden (60) is
the most common manifestation of disease. An estimated 2 per 1000 infected children
develop intestinal obstruction per year.[11] Among children aged 1-12 years who presented
to a Cape Town hospital with abdominal emergencies between 1958-1962, symptomatic
A lumbricoides infection was responsible for 12.8% of cases , with 68% of those due to
intestinal obstruction, usually at the terminal ileum. The peak incidence was at age 2
years in a series from Colombia and age 4.8 years in a series from Turkey. The
prevalence of infection in Vietnam is estimated at 44.4%, more commonly in the northern
peri-urban and rural areas of the country.[12] In Vietnam, vegetable cultivation using night
soil fertilizer places adult women at especially high risk. Children with chronic ascariasis
may experiencedecreasedgrowthanddevelopment due to decreased food intake.

Adults with ascariasis are more likely to develop biliary complications due to migration
of adult worms (see image below), possibly provoked by other illnesses such as malarial
 fever. In Damascus, of 300 adults referred for complications of ascariasis between 1988
and 1993, 98% had abdominal pain, 4.3% had acute pancreatitis, 1.3% had obstructive
jaundice, and 25% had worm emesis. Twenty-one to 80% of patients had undergone
previous cholecystectomy or endoscopic sphincterotomy.

A recent review of biliary ascariasis suggests that this association may be causative as a
result of dilatation of the common bile duct and elevation of cholecystokinin levels with
resultant relaxation of the sphincter of Oddi.[13] A report from India indicated that, of
consecutive patients diagnosed with biliary ascariasis, 80% presented with recurrent
abdominal pain, 30% with acute cholecystitis, 25% with obstructive jaundice, 25% with
cholangitis,and only 5% with pancreatitis, 5% with perforated viscus, and 5% with
hepatolithiasis. Only 25% of the Indian patients required surgery. A postcholecystectomy
syndrome of pain and jaundice is frequently due to ascariasis in endemic areas,
presumably owing to enhanced patency of the biliary system after surgical or endoscopic

sphincterotomy.[14] Adult Ascaris lumbricoides in biliary

system.

Intestinal obstruction, usually of the terminal ileum in children, is the most commonly
attributed fatal complication, resulting in 8000-100,000 deaths per year, according to the
World Health Organization. Besides direct obstruction of the bowel lumen, toxins
released by live or degenerating worms may result in bowel inflammation, ischemia, and
fibrosis.

Age

See International and Mortality/Morbidity.

http://emedicine.medscape.com/article/212510-overview#showall

History
Early symptoms of ascariasis, during the initial lung migration, include cough, dyspnea,
wheezing, and chest pain. This may be seasonal after rains in some countries, such as
Saudi Arabia.
 Abdominal pain, distension, colic, nausea, anorexia, and intermittent diarrhea may be
manifestations of partial or complete intestinal obstruction by adult worms.

Jaundice, nausea, vomiting, fever, and severe or radiating abdominal pain may suggest
cholangitis, pancreatitis, or appendicitis.

Physical
Rales, wheezes, and tachypnea may develop during pulmonary migration, particularly in
persons with a high worm burden. Urticaria and fever may also develop late in the
migratory phase.

Abdominal distension is nonspecific but is common in children with ascariasis.

Abdominal tenderness, especially in the right upper quadrant, hypogastrium, or right

lower quadrant, may suggest complications of ascariasis.

Evidence for nutritional deficiency due to ascariasis is strongest for vitamins A and C, as
well as for protein, as indicated by albumin and growth studies in children observed
prospectively. Some studies have not confirmed nutritional or developmental delay due to
ascariasis.

Pulmonary manifestions
Pulmonary manifestations occur 5 -26 days following ingestion of viable eggs.

Ascaris pneumonia may develop and consists of migratory, transient, localized intraalveolar
inflammatory reactions.

Pulmonary ascariasis is the most common cause of Loeffler syndrome, which is characterized by
fever, cough, sputum, asthma, eosinophilia, and infiltrates seen at chest radiography.

Differential Diagnoses
Biliary Colic

Colonic Obstruction

Pancreatitis, Acute

Pneumonia, Community-Acquired
Laboratory Studies
Stool examination for ova and parasites almost always discloses large, brown 60 m X
50 m trilayered eggs in persons with ascariasis. However, stool examination may be
negative for ova for up to 40 days after infection because of the time needed for
migration and maturation of the worm. The outer surfaces of fertilized eggs have an
uneven mucopolysaccharide coat.

Ascaris larvae may be observed in microscopic wet preparations of sputum during the
pulmonary migration phase.

CBC counts show eosinophilia during the tissue migration phase of the infection.

Serological tests are not clinically useful for ascariasis.

Imaging Studies
Chest radiographs may show fleeting opacities during pulmonary migration.

Abdominal radiographs may show a whirlpool (pusaran) pattern of intraluminal worms.

Narrow-based air fluid levels without distended loops of bowel on upright plain films
suggest partial obstruction. Wide-based air fluid levels with distended loops suggest
complete obstruction.

Worms have been increasingly identified in the biliary duct or gallbladder with
ultrasonography and CT scanning.[15] Liver granulomata due to A suum infection have
been described as ill-defined, 3- to 35-mm, nodular- or wedge-shaped lesions in the
periportal or subcapsular regions.

Radiographic features

For a discussion of the pulmonary appearances of ascariasis please refer to simple pulmonary
eosinophilia.

Plain film
Worms can often be seen on conventional abdominal radiographs as curvilinear soft-tissue-
density cords. If bowel obstruction is present, the typical pattern of air-filled, dilated loops of
small bowel with multiple air-fluid levels can be seen on an upright radiograph.

Fluoroscopy

Barium studies
Intestinal ascariasis appears as individual worms seen as longitudinal tubular structures on
barium enema. If the alimentary tract of the worm is empty, the worm may appear as a filling
defect. If its alimentary tract is distended, the worm appears as parallel bands. On transverse
sections, the worm appears as a target sign with body wall and a central dot representing its gut 1.

Ultrasound
Ultrasound will depict the adult worm as a hypoechoic tubular structure with well-defined
echogenic walls. During real-time evaluation, the worms can be seen making curling
movements.

CT
The worms can usually be visualized within the bowel lumen at CT with soft-tissue windowing.

http://radiopaedia.org/articles/ascariasis
Other Tests
Endoscopic retrograde cholangiopancreatography (ERCP) has become a commonly used
procedure for both diagnosis of ascariasis and removal of worms from the biliary tract. The ease
of diagnosis and therapy in the same setting makes ERCP particularly valuable when used with
real-time ultrasonography. The combined procedures yield a sensitivity of nearly 100%.[13]

Medical Care
Because of the risk of complications, patients with ascariasis who have other concomitant
helminthic infections should always undergo treatment for ascariasis first. Medical therapy is
usually not indicated during active pulmonary infection because dying larvae are considered a
higher risk for significant pneumonitis. Pulmonary symptoms may be ameliorated with inhaled
bronchodilator therapy or corticosteroids, if necessary.

Albendazole 400 mg one dose orally is the drug of choice. Ascariasis commonly coexists
with whipworm infection, which appears to be more susceptible to albendazole than to
mebendazole. Albendazole is not recommended during pregnancy; pyrantel pamoate is
the drug of choice in these cases.

Alternative therapy is mebendazole (100 mg bid for 3 d or 500 mg as a single dose).

Mebendazole is not recommended during pregnancy; pyrantel pamoate is the drug of
choice in these cases.

Paralyzing vermifuges (eg, pyrantel pamoate, piperazine, ivermectin) should be avoided

in patients with complete or partial intestinal obstruction since the paralyzed worms may
necessitate or further complicate surgery.

Vitamin A supplementation improved growth development of children in Zaire;

deworming did not improve growth development in this study.[16]
 Drug therapy affects only adult worms. If the patient lives in an endemic area or has
recently relocated, he or she may still be carrying larvae that are not yet susceptible. Such
patients should be re-evaluated in 3 months and retreated if stool ova persist. In endemic
areas, reinfection rates approach 80% within 6 months.

Nitazoxanide, a drug used primarily for protozoal infection, was shown to have 89%
clinical efficacy for the treatment of ascariasis in rural Mexico and may offer a future
alternative to other medications.[17]

Surgical Care
Conservative management of partial intestinal obstruction and biliary ascariasis is usually
effective. The patient is maintained on nothing-by-mouth status, and the partial obstruction
usually spontaneously resolves. Preventing oral intake decreases the risk of food compounding
the obstruction while normal peristalsis redistributes or evacuates the worms. A controlled trial
from Pakistan found that, in patients without peritonitis, hypertonic saline enemas relieved
obstruction more quickly (1.6 d vs 3.4 d) and resulted in shorter hospital stays (4 d vs 6 d) than
intravenous fluids alone. A recent study from India demonstrated that conservative therapy was
successful in 19 of 22 (89%) children with intestinal obstruction. The regimen used consisted of
no oral intake, intravenous fluids, antibiotics, piperazine salt per nasogastric tube, and glycerine
plus liquid paraffin emulsion enemas.[11]

Recommended criteria for surgical exploration include the following:

o Passage of blood per rectum

o Multiple air fluid levels on abdominal radiographs

o An ill child with abdominal distension and rebound tenderness

o Unsatisfactory response to conservative therapy

o Appendicitis and primary peritonitis

o Hepatobiliary disease

o Pancreatic pseudocyst

Most (49-90%) worms eventually migrate from the biliary system spontaneously. Drug
therapy should be delayed in patients with right upper quadrant or pancreatic pain, as no
evidence has shown that drugs are active against worms located in the biliary tree.
Regardless, death of the worm in the duct may provoke both inflammation and
obstruction. Patients with ascariasis who have only minor symptoms can undergo
observation for 3 days. If the minor symptoms persist after 3 days or the patient develops
frank cholangitis or pancreatitis, removal of the worms with ERCP should be attempted,
 if available. Although technically challenging at times, ERCP extraction rates have
exceeded 90%.[13]

Intestinal or biliary surgery may be necessary for complications of ascariasis.

o Intestinal gangrene usually occurs at the terminal ileum, more often after the use
of pyrantel pamoate, which tetanically paralyzes worms and thereby enhances the
risk of obstruction. Recently, 2 cases of delayed distal intestinal disease have been
reported, which were thought to be secondary to toxins from the worms.
Therefore, patients should probably be monitored for some time after the surgical
removal of worms.

o Milking of worms to the large bowel, resection of gangrenous bowel, ileostomy,

and enterotomy are the most common surgical procedures used to manage bowel
obstruction.

o Invasion of the gall bladder necessitates cholecystectomy, common duct

exploration, and T-tube drainage until the patient is stabilized and dewormed.

Any elective gastrointestinal surgery in patients with ascariasis should be delayed until
they have been dewormed and adequately nourished. In particular, patients who live in
endemic areas should be dewormed before and after elective cholecystectomy.

Pyrantel pamoate (Pin-Rid, Reese's Pinworm Medicine)

Neuromuscular blocking agent used to slowly paralyze worm to be eliminated from GI
tract. May be DOC during pregnancy.

ransfer
Patients with ascariasis who have partial or complete obstruction should be treated at
facilities with surgical support.

Deterrence/Prevention
Community control of ascariasis has been difficult to achieve. The most successful
control programs, such as those in Japan, have consisted of combined approaches,
including improved sanitation, night soil disposal, and mass community treatment.
Concern has increased for the emergence of drug resistance among heavily retreated
populations.

The prevalence of ascariasis in Japan in 1949 was 63%; the disease was essentially
eliminated by 1973. Hand washing may be a neglected means of prevention, even in
endemic areas, as shown by a recent study from Sri Lanka.
 A program of latrine construction, health education, and twice-annual anthelmintics
decreased the prevalence of ascariasis in Korea from 80% in 1949 to 55% by 1971. After
a 4-year educational campaign and latrine construction program in northern Bangladesh,
36% of children aged 5-13 remained infected. Rates of infection were lower among
children who used latrines and who had been educated concerning the risks of ascariasis.
[18]
As rates of ascariasis lessen, specific infected families should be targeted.

Current ascariasis treatment strategies recommend repeated mass treatment of

communities to reduce intensity of worm burden until socioeconomic progress allows
improved sanitation. Although such targeted therapy programs may control the morbidity
of ascariasis by decreasing the number of worms per patient, they do not seem to
decrease transmission rates. The ascariasis reinfection rate after a single community
campaign in South Africa was 40% at 29 weeks. Children have been targeted in school
campaigns, but continued worm burden and shedding by adults have blunted impact. A 6-
month educational program directed at behavioral remediation of school children and
their parents in Java has shown promise when combined with a deworming campaign.

Avoiding pigs and pig manure prevents A suum infection in developed countries.

Work continues on a vaccine. A recombinant, nasally administered 16-kd secretory

protein, As16, was shown to result in a 56% decrease in worm burden in mice challenged
with A suum larvae.[19]

Prognosis
Immediate cure rates after single-dose albendazole in South Africa were 95%, with egg
reduction rates of more than 99%.[20]

Most treated patients become reinfected within months unless they are relocated to an
area of significantly improved sanitation.

Overlooking the abdominal X-ray the peril of

ascariasis
N. Mahomed, M.B. B.Ch., F.C.Rad. (Diag.) S.A.

Z. Docrat, M.B. B.Ch.

L. Mkhonza, M.B. B.Ch.

L. Keating, M.B. B.Ch.

Department of Radiology, Chris Hani Baragwanath Hospital and University of the

Witwatersrand, Johannesburg
Summary

A young child presented with intermittent bowel obstruction. The abdominal X-ray was not
closely examined, and a contrast study was performed that demonstrated multiple tubular filling
defects indicative of worms. The patient was treated accordingly. Reviewing the abdominal X-
ray demonstrated numerous serpigenous, tubular, soft-tissue densities in gas-filled bowel loops.

A 9-year-old boy presented with intermittent bowel obstruction. The abdominal X-ray (Fig. 1)
was initially overlooked and a contrast study (Fig. 2) was performed that demonstrated multiple
tubular filling defects in the stomach, duodenum and proximal small bowel consistent with
worms. The patient was treated for worms which he subsequently passed and his symptoms
improved. Re-evaluation of the abdominal X-ray demonstrated numerous serpigenous, tubular,
soft-tissue densities in gas-filled bowel loops in the left mid and lower quadrants.

The abdominal X-ray has a sensitivity of 70% in the detection of worms. Large collections of
worms may be visualised on plain film, outlined by intestinal gas, with the interface between the
worm bolus and adjacent gas shadows appearing irregular. Isolated worms may be visualised as
linear or bubble-shaped radiolucencies, indicating the presence of gas within the lumen of the
worm.1 Worms may appear as areas of tubular, linear soft-tissue densities in gas-filled bowel
loops on abdominal X-ray, as in our patient.2 Radiographs can also demonstrate bowel
obstruction and free gas under the diaphragm in patients with intestinal perforation.1

On barium studies, worms appear as filling defects that are cylindrical, elongated and smooth
within the contrast-filled intestinal lumen. In fasting patients, worms may ingest the contrast,
resulting in outlining of their alimentary canals.3

The specific features of worms should not be overlooked on abdominal X-ray, thereby avoiding
the radiation dose, discomfort and cost of contrast studies.

REFERENCES
1. Ellman BA, Wynne JM, Freeman A. Intestinal ascariasis: New plain film features. AJR
1980;135:37-42.

2. Khan EA, Khalid A, Hashmi I, Jan IA. Gastrointestinal obstruction due to ascariasis
management issues. Inf Dis J Pakistan 2008;17:72-74.

3. Das CJ, Kumar J, Debnath J, Chaudhry J. Imaging of ascariasis. Austr Radiol 2007;51:500-
506.
Fig. 1. Abdominal X-ray showing multiple serpigenous, tubular, soft-tissue densities
(arrowed) in gas-filled bowel loops in the left mid and lower quadrants. The large
numbers of impacted worms appear as a convoluted mass outlined by gas.
Fig. 2. Contrast study showing multiple tubular filling defects in the stomach, duodenum and
proximal small bowel.

http://www.sajs.org.za/index.php/sajs/article/view/911/451
Fig. 1: Film detail from a small bowel series showing worms in bowel lumen. Barium
is present in the worm's intestinal tract.

Fig. 2: Radiograph of expelled worm showing barium in its intestinal tract

ontributed by: Sam Hofman, Resident, Lutheran General Children's Hospital, Illinois, USA.
Patient: 8 year old female
History: Eight year old female with intermittent abdominal pain and nausea.
Findings: Upper GI study showed thin lines of barium bisecting lines of lucency within the
small bowel.
Diagnosis: Ascariasis
Discussion:

Ascaris lumbricoides infects 1.4 billion people worldwide and is the third most
frequent helminth infection in the United States behind the hookworm and whipworm. A.
lumbricoides can grow to 40 cm in length and 6 mm in diameter and is the largest intestinal
nematode of man. Ascariasis is most common in tropical countries and areas with poor
sanitation. Children aged 2 to 10 years old are the most commonly infected, but ascariasis
can occur at any age. A number of factors contribute to the prevalence of ascariasis infection.
Female worms can produce 200,000 eggs per day which are resistant to chemical water
purification and can last up to 10 years in a variety of environmental conditions. They are
found all over the world and asymptomatically infected individuals can continue to shed eggs
for years. Also prior infection does not provide protective immunity. Transmission is mainly
fecal/oral and is primarily through ingestion of contaminated water or food. Children may
acquire the parasite from playing in contaminated soil. Transplacental infection has also been
reported. Ova develop into larvae in the environment and when ingested by humans they
penetrate the intestinal wall and migrate through blood or lymph vessels to the lungs. From
there they migrate up the bronchi to the trachea and are then swallowed. When they again
reach the small intestine (most commonly the jejunum) they complete there maturation into
adult worms. Infection with A. lumbricoides is often asymptomatic. When symptoms do
occur they are commonly intestinal and include abdominal pain, anorexia, nausea, diarrhea,
and in heavy infections, intestinal obstruction. Other organ systems can also be involved and
symptoms related to pulmonary and hypersensitivity manifestations and hepatobiliary and
pancreatic obstruction can occur. The diagnosis of ascariasis is typically through finding
characteristic eggs on stool microscopy, however, if no female worms are present this would
not be seen. Peripheral eosinophilia can also be a nonspecific marker. Occasionally worms
can be seen on abdominal plain films in particularly heavily infested individuals producing a
"whirlpool" effect. Barium studies may also show the worms as they ingest the barium which
appears as a thin white line in their digestive tract. IgG antibodies can also be detected in
previously or currently infected individuals. Treatment of ascariasis typically includes a
benzimidazole such as mebendazole or albendazole. Single doses of either of these drugs has
an efficacy of >97 percent. If the patient is pregnant however, pryantel pamoate is the drug of
choice. Patients should be reevaluated in 2 to 3 months and family members should also be
evaluated. Prevention is the key limiting this disease and this can be accomplished through
good sanitation, education, and possibly widespread prophylactic treatment in endemic areas.

http://www.mypacs.net/cases/ASCARIASIS-IN-A-PEDIATRIC-PATIENT-5329118.html

Figure 2: Plain X ray film showing multiple air fluid levels and cigar bundle appearance
(solid arrow)
Figure 3: Ultrasound showing intraluminal worm bolus and free fluid
Figure 4: Ultrasound showing worm in gall bladder and disappearance in follow up scan
http://www.jiaps.com/article.asp?issn=0971-
9261;year=2012;volume=17;issue=3;spage=116;epage=119;aulast=Ramareddy