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
Fig. 2: Bolus of Ascaris filling almost the entire kidney tray
approximately filled a kidney tray (Fig. 2). The freshly
expelled worms were pinkish and cylindrical. Both male
and female roundworms were identified.
Adult males measured 15 to 30cm in length and 2 to
4mm in diameter. Their posterior end was curved with
two copulatory spicules. Adult females measured 20 to
40cm in length and 3 to 6mm in diameter. Their posterior
end was straight and conical. These worms were identified
as A. lumbricoides from their gross appearance and the size
and shape of the eggs along with microscopic confirma-
tion. Patient was discharged on the 7th postoperative day
without complications. She is on regular follow-up.
DISCUSSION
Ascaris is the largest nematode to infect the human intes-
tine as a facultative parasite throughout its adult life.
It is prevalent in the tropics and subtropics with an esti-
mated prevalence of 25% worldwide, where unhygienic
disposal of human excreta is common. The prevalence
of Ascaris-related intestinal obstruction in India is
9.2 cases per 100,000 persons.2,3
The mode of A. lumbricoides infection is by ingestion
of embryonated eggs in raw vegetables, water, or soil-
contaminated hands. The fertilized eggs hatch in the
intestine. The released larvae penetrate the intestinal wall
to reach the right side of the heart, pulmonary circulation,
and then the alveoli. When the larvae are coughed up by
the host, they are swallowed back into the intestine to
develop into adult worms. They most commonly reside
in the jejunum and ileum.4,5 Ascariasis can occur at all
ages, but it is most common in children between 2 and
10 years of age.
The clinical features of A. lumbricoides infection are
variable. Depending upon the parasitic burden, they may
remain asymptomatic or become symptomatic. Normally,
they live in the stomach and reach upto the ileocecal valve
region without causing any serious symptoms. When the
76
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,
cholangitis, intestinal obstruction when present in large
numbers, and even perforation. They may occasionally
cause appendicitis and obstructive jaundice. Massive
gastrointestinal bleeding with ulceration, perforation,
and even gangrene of the bowel wall is a rare and fatal
reported complication.5,6,8-11 Children are likely to suffer
from protein malnutrition and vitamin A deficiency.12
In acute obstruction, patients are ill for several
days before presentation. There may be signs of severe
dehydration and toxic appearance along with vomiting,
abdominal pain, and distension. Fever and leukocytosis
are common. The passage of adult worms in sensitive
persons may give rise to intense anal pruritus, vomit-
ing of worms, and edema of the glottis. When the larvae
wander into the brain, they cause granulomas, presenting
as small tumors in the eye, retina, or brain.
Complications of Ascaris infestation include obstruc-
tion of the small intestine, volvulus, intussusception,
pancreatitis, appendicitis, and cholecystitis. Intestinal
obstruction can be fatal at times. Multiple worms form
a large bolus, resulting in mechanical obstruction of
the bowel lumen, which is the most frequent cause of
Ascaris-related bowel obstruction. The bolus of worms
may serve as a leading point in intussusception or a
pivot in small bowel volvulus. The worms may inhabit
the ileocecal valve, where they secrete neurotoxins,
prompting small bowel contraction, which together
with high worm burden further obstruct the intestine.
A hosts inflammatory reaction to worm-derived hemo-
lysins, endocrinolysins, and anaphylatoxins can further
aggravate the obstruction.7 Volvulus, intussusception,
or increasing pressure on the intestinal wall leads to
necrosis. The roundworms do not attach to the intestinal
wall, but rather remain in the lumen by powerful, con-
tinuous muscular movement. In the lumen, the worms
feed on the nutrients in the hosts intestinal tract. These
worms remain in the intestines for several years without
causing disease.
The mechanism of Ascaris-induced perforation of
the small bowel is highly debatable. Patients residing in

the tropical countries suffer from diseases associated with
intestinal ulcerations. These include typhoid enteritis,
tuberculosis, and amoebiasis. During extreme condi-
tions, such as inflammation, starvation, or worm bolus
obstruction, some parasites are believed to migrate into
the ulcers, leading to perforations. Another possible
explanation is that the large worm bolus can lead to
pressure necrosis and gangrene. The already diseased
bowel becomes susceptible to rupture by the burrowing
action of the worms.3,6
When the patients are febrile or are given anesthetic
drugs, the worms may migrate and wander into the
bile ducts, ampulla of vater, appendix, perineal sinuses,
and eustachian tubes. Thus, it is important not to give
any drugs, especially when there is a possibility of
Ascaris infection. Deworming should be carried out
when the children are ill and febrile or before giving an
anesthetic drug.
Frequent diagnosis with clinical symptoms and
hematological investigation is not possible. Plain X-ray
of abdomen may show a whirlpool pattern of intralu-
minal worms in most of the cases.13 X-ray may show air
fluid levels. Perforation may be seen as free air under the
diaphragm on an X-ray. Stool test shows abundant ova
and parasites, along with high number of eosinophils.
Blood counts may demonstrate marked leukocytosis and
eosinophilia even up to 25% or more. Abdominal ultra-
sound shows the characteristic railway track sign and
bulls-eye appearance, thus helping in the confirmation
of diagnosis.14
Management of a majority of uncomplicated cases is
achieved successfully using antiparasitic drugs, such as
albendazole, mebendazole, or pyrantel pamoate. Partial
intestinal obstruction may resolve spontaneously with
conservative treatment, including bowel rest, intrave-
nous fluids, and nasogastric decompression.3 Prompt
treatment to prevent life-threatening complications
should be undertaken. If there is necrosis, resection
and primary anastomosis as emergency surgical treat-
ment become necessary. Subacute cases are successfully
treated conservatively until spontaneous resolution.5,15,16
The type of surgery depends on the findings during
laparotomy. If the bowel is viable and the obstruction
is at the level of ileum, milking of the worms to the
cecum can be done carefully without causing trauma
to the bowel wall. If the obstruction is at the level of the
jejunum along with multiple boluses of worms, enter-
otomy should be done through a longitudinal incision
with removal of worms by sponge-holding forceps,
taking care to avoid contamination of the peritoneal
cavity. In volvulus, where the intestinal wall is thin,
milking should not be attempted as it may cause tears in
International Journal of Advanced & Integrated Medical Sciences, April-June 2016;1(2):75-78
IJAIMS
Ascariasis presenting as Acute Abdomen: A Rare Case
the serosal layer. Damage to the worms during milking
should be avoided as this may release toxins. Cases pre-
senting with gangrene, perforation, or intussusception
with nonviable bowel segment resection with primary
anastomosis may be required.15,16
CONCLUSION
There should be a high suspicion for parasitic infesta-
tion in preschool children with sudden acute intestinal
obstruction to prevent serious life-threatening compli-
cations. Prompt surgical intervention in patients with
acute intestinal obstruction results in a good outcome.
Partial intestinal obstruction from A. lumbricoides may
resolve spontaneously with conservative treatment.
The awareness of ascariasis and its preventive mea-
sures should be included in all health education pro-
grammes and should be delivered to school children and
their mothers to overcome the risk of infection.
Early recognition based on local prevalence can
prevent serious surgical complications, morbidity, and
mortality associated with intestinal obstruction.
ACKNOWLEDGMENT
We are thankful to the department of Surgery for provid-
ing the details of the case.
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