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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 10-14

Ascaris lumbricoides-induced small bowel obstruction; Experience from a tertiary care center


1 Department of Paediatric and Neonatal Surgery, Sheri-Kashmir Institute of Medical Science, Srinagar, Jammu and Kashmir, India
2 Department of Surgery, Sheri-Kashmir Institute of Medical Science, Srinagar, Jammu and Kashmir, India

Date of Submission16-Aug-2020
Date of Acceptance15-Sep-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. Raashid Hamid
Department of Paediatric and Neonatal Surgery, Sheri-Kashmir Institute of Medical Science, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpai.jpai_6_20

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  Abstract 


Introduction: Ascaris lumbricoides induced intestinal obstruction is a sequel of this parasitic infestation. It presents as colic, vomiting (bilious or nonbilious), abdominal distention, and at times peritonitis. Management includes indoor admission, intravenous fluids, rectal enemas, and serial clinical and radiological assessment for detecting any indication of surgery. We, in our study, we analyzed the outcome of conservative management and the use of oral administration of 76% gastrograffin. Materials and Methods: Clinical parameters of all these patients were recorded and kept under close monitoring of the clinical parameters. Patients were initially subjected to conservative treatment whereby patients were advised nil per oral, nasogastric tube aspiration, intravenous fluid, rectal enemas, and antibiotics as indicated. In some patients, without signs of peritonitis and severe obstruction, contrast agent Gastrograffin was administered either per oral or vie6a nasogastric tube. Serial abdominal radiographs were taken. Surgical intervention was performed if worms were not expelled after 48–72 h of conservative treatment or contrast gets held up after 24–36 h in small intestines or clinical deterioration. Data were analyzed statistically. Results: A total of 240 patients were included in this study. The abdominal pain 156 (65%) was the most common symptom followed by distension in 168 (70%). Among patients, 65% were boys (n = 156) and 35% girls (n = 84). The clinical signs included abdominal distention in 168 (70%), tenderness in 28 (11%), rigidity 34 (14%), palpable worm masses in 115 (48%), and visible gut loops in 29 (23%). Most of the patients 204 (85%) responded to conservative management. Among 36 patients who needed surgery, 10 patients had received oral contrast. The peroperative findings included-impacted worms in 14 cases, impacted worm mass with gangrene 6 cases, intussusceptions without gangrene 7 cases, and gut volvulus with gangrene in 9 cases. The average hospital stay was 4.40 ± 2.25 days in cases managed conservatively, whereas about 10.35 ± 6.24 days in cases needing surgical intervention. There was no mortality in our series. Conclusions: Ascaris-induced worm obstruction should be managed conservatively; surgery is indicated if conservative management does not result in clinical improvement. The addition of Gastrograffin orally in some patients without complete obstruction significantly decreases the hospital stay and reduces the time period between admission to the expulsion of the worms.

Keywords: Ascaris lumbricoides, conservative management, obstruction, gastrografin


How to cite this article:
Hamid R, Shah A, Bhat NA, Baba AA, Mufti GN, Sheikh KA. Ascaris lumbricoides-induced small bowel obstruction; Experience from a tertiary care center. J Pediatr Assoc India 2020;9:10-4

How to cite this URL:
Hamid R, Shah A, Bhat NA, Baba AA, Mufti GN, Sheikh KA. Ascaris lumbricoides-induced small bowel obstruction; Experience from a tertiary care center. J Pediatr Assoc India [serial online] 2020 [cited 2020 Nov 25];9:10-4. Available from: http://www.indjpai.com/text.asp?2020/9/1/10/300104




  Introduction Top


Ascaris lumbricoides (A. lumbricoides) is the most common tropical intestinal helminth parasite, and it is estimated that the infested population is 0.8–1.2 billion worldwide.[1] Ascariasis can occur in all ages, but it is most common in children between 2 and 10 years of age and prevalence decreases above the age of 15 years. The massive infestation in children can result in serious complications, which include obstruction of the small intestine, appendiceal lumen, bile duct, and pancreatic duct. Intestinal volvulus, intussusceptions, peritonitis due to perforation of a viscus is also common.[2],[3] Intestinal obstruction has been estimated to occur in 2/1000 Ascarisis-infested children per year. Conservative treatment for partial intestinal obstruction due to roundworm is practised worldwide. In this study, we present our experience of conservative treatment for intestinal obstruction due to ascariasis. We evaluated clinical history, examination, investigations, and management, either conservative or operative. Various surgical procedures with per-operative findings were noted.


  Materials and Methods Top


All the patients with suspected roundworm intestinal obstruction who were admitted to Paediatric Surgery Department of Sheri-Kashmir Institute of Medical Sciences, India, from 2010 to 2019 were included in the study. Patients who presented with signs and symptoms of peritonitis or perforation were excluded from our study. A total of 240 patients of intestinal ascariasis were admitted during this period. All these patients were kept under close monitoring of the parameters, including heart rate, abdominal girth, nasogastric aspirate, hydration status, serum electrolytes, total and differential blood counts, and radiographic findings. All patients were initially subjected to conservative treatment whereby patients were advised nil per oral, nasogastric tube aspiration, intravenous fluid, rectal enemas, and antibiotics as indicated.

In some patients, without obstruction, contrast agent diatrizoate meglumine 76% (tazograff) was administered either per oral or through nasogastric tube. The patients were monitored with the serial assessment of vital parameters and abdominal girth measurements. Serial abdominal radiographs were taken at 0, 6, 24, and 48 h. Clinical improvement was defined as a decrease in abdominal pain and distension, decrease in abdominal girth, and associated passage of flatus or stool. In children who received diatrizoate meglumine, the clinical improvement was defined when the contrast reached to the colon within 24–36 h along with the passage of flatus or stool. The treatment included appropriate intravenous fluid, nasogastric aspiration, antispasmodic drugs, and antibiotics followed by rectal enemas. The patients were considered for surgical intervention if worms were not expelled after 48–72 h of conservative treatment or contrast gets held up after 24–36 h in small intestines or clinical deterioration. Clinical deterioration included increasing abdominal distension, guarding, and rebound tenderness bleeding per rectum, persistence of worm mass at the same site, or fixity of mass. Out of 240 patients, only 32 (13.6%) patients required surgical exploration. We used right transverse incision in all cases. In those cases were resection and anastomosis was needed for the gut gangrene, single layer interrupted anastomosis was performed between two healthy edges of the small gut. The postoperative orals sips were started at 48–72 h. In instances when there were large boluses of worms not amenable to kneading to either colon or stomach, an enterotomy was made for the retrieval of the worms. The enterotomy was made longitudinally and closed transversally. The patients with enterotomy were given oral sips at 48 h. The operative notes included preoperative findings as site of worm mass/masses, condition of gut, and mesentery lymph nodes. All patients were advised to attend follow-up clinics.


  Results Top


A total of 240 patients were studied in the range 12 months–12.6 (average-7.35 ± 2.25 years) with the most common age of presentation 3–7 years (60%). The most of the patients presented with abdominal pain 156 (65%) and distension 168 (70%). About 108 (45%) patients passed worm in vomitus and 152 (63.6%) patients passed worms per rectally [Table 1]. Among patients, 65% were boys (n = 156) and 35% girls (n = 84). The average duration of illness (in days) at the time of presentation was 1.84 ± 1.20 days. A total of 168 patients (70%) were from rural areas, and 30 patients (24%) belonged to urban areas. Only 12 patients (5%) belonged to high socioeconomic class, 168 patients (70%) belonged to low socioeconomic class. The colicky periumbilical abdominal pain was the most common symptom present in 144 (60%) of patients [Table 2], while as vomiting was the second leading symptom. About 25% of patients had a history of worms in vomitus, while 40%(n = 108) children presented with constipation. In 23% (n = 55) patients, there was a history of the passage of worms in stool after anti-helminthic treatment in the recent past.
Table 1: Clinical symptoms at the time of presentation in patients

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Table 2: Clinical signs observed in patients

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Of all twenty patients (8%) had a history of worm infestation. Sixty-seven (28%) patients presented with dehydration. Other signs included fever in 24 (10%) patients, pallor in 66 (27%) patients, and emaciation in 15 (6%) patients. The clinical signs included abdominal distention in 168 (70%), tenderness in 28 (11%), rigidity 34 (14%), palpable worm masses in 115 (48%), and visible gut loops in 29 (23%). Some patients had more than one clinical finding [Table 1]. X-ray abdomen and ultrasonography features revealed maximum quadrant palpable worm mass was seen in the umbilical quadrant. The whirlpool sign was present in 84 (35%) of cases. Other signs on radiograph and ultrasonography included distended gut loops, multiple air-fluid levels, worm bolus, inter loop fluid, fluid in the pelvis [Table 3]; [Figure 1], [Figure 2], [Figure 3]. The ultrasonographic findings were positive in 192 (80%). Investigations included hemogram and liver function. Hemoglobin <10.0 gm% was seen in 80 (33%) of patients. Eosinophilia was seen in 40 (17%) patients. 204 (85%) were managed conservatively and 36 (15%) underwent surgery. Among 36 patients who needed surgery, 10 patients had received oral contrast. The per-operative findings included-impacted worms in 14 cases [Figure 4], impacted worm mass with gangrene 6 cases, intussusceptions without gangrene 7 cases, and gut volvulus with gangrene in 9 cases. Eleven cases needed enterotomy [Figure 5] and in 7 cases, worms could be milked to the colon. Thirteen patients underwent resection anastomosis of the ilium. The average hospital stay was 4.40 ± 2.25 days in cases managed conservatively, whereas about 10.35 ± 6.24 days in cases needing surgical intervention. There was no mortality in our series [Table 4] and [Table 5].
Table 3: Abdominal X-ray and ultrasonography findings of worm obstruction

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Figure 1: Seriel Contrast Studies at 0, 1 and 24 hours

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Figure 2: Seriel Contrast Studies at 0, 1 and 24 hours

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Figure 3: Seriel Contrast Studies at 0, 1 and 24 hours

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Figure 4: Impacted worm mass

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Figure 5: Enterotomy to relieve obstruction

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Table 4: Per-operative findings in patients who underwent surgery

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Table 5: Operative procedure performed

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  Discussion Top


The intestinal ascariasis is the most common parasite infestation of human beings and it affects one-fourth of the world population. It can lead to symptomatic illness and death.[4] Ascarisis is highly endemic in this part of India. The most infected persons are asymptomatic with the clinical disease of restricted to subjects with heavy worm-load.[5] The majority of patients present in the first decade of life.[6] The rural areas have more prevalence of round infestation due to low socioeconomic status, poor hygiene, and cultural factors. The symptomatic patients present with dehydration, pallor, and emaciation. Some patients had a history of the expulsion of worms per rectum or mouth, which help in making the right diagnosis.[7] As demonstrated in our study, various symptoms include abdominal pain, vomiting, constipation, loose motions, ascaris in vomitus, and passage of worms in stool.

In our series, abdominal distension, tenderness, guarding, and palpable worm masses were observed on abdominal examination. The distribution of pain with reference to the quadrant of the abdomen shows the periumbilical quadrant being most common. As the jejunum and proximal ileum are the usual habitats of roundworm around the peri-umbilical area, which results in the periumbilical pain area. The worm masses are palpable around the umbilical quadrant as worms usually conglomerate in the distal jejunum. Worm bolus has a characteristic frequent directional change of position and breaking into small boluses. Disentangled worm bolus pass ileocecal valve under conservative treatment. In our series, ascaridial lump disappeared from the right iliac fossa within 48–72 h with conservative management. The change in position of palpable worm masses should be one of the criteria for assessing the efficacy of conservative treatment. Plain radiography and ultrasonography of the abdomen may reveal evidence of subacute or acute intestinal obstruction or features of peritonitis. A characteristic “cigarette ash'' appearance of worm mass is the usual appearance on x-ray. The abdominal X-ray shows air-fluid levels and multiple linear images of A. lumbricoides in the dilated intestinal loops and whirlpool sign was suggestive in 35% of cases in the present study, which is slightly less than other reported series. Ultrasonography diagnosed 80% of cases in the present study and is comparable to other reported series.

The serial radiological assessment is important to assess the progress of conservative treatment. Our conservative management for symptomatic intestinal ascariasis is similar to those reported by Surendran and Paulose,[8] Dayalan and Ramakrishnan,[9] Waller and Othersen.[10] With regard to conservative management, our results are similar to numerous studies reported in the literature who managed the majority of their cases conservatively.

The mechanical obstruction of the gut by worms is the commonest mode of intestinal obstruction. Other causes of ascaridial small gut obstruction include volvulus or intussusception. Intussusception can be jejuno-ileal, ileo-ileal, or jejuno-jejunal. The worm inside the vermiform appendix may incite appendicitis. Surgical intervention must always be weighed against the stigmata of morbidity and mortality of surgery. The criteria taken into account for deciding surgical intervention simulate those observed by Dayalan and Ramakrishnan[9] and Louw.[11] Based on the above criteria, 12 (22%) of 360 cases were subjected to operative intervention. The per-operative findings can be decisive in selecting cases for surgical procedures to be done. The factors for kneading or the enterotomy for worms are the site of worm bolus, number of worm boluses, length of worm bolus, pressure on the intestinal wall by worm bolus, and transerosal visibility of worms. Enterotomy for removal of worms should be performed when there is trans serosal visibility, otherwise kneading of worms to the large gut is sufficient. Enlarged mesenteric nodes can be seen with size and number depending on hyper-infestation with worms and the presence of any secondary infection. Only 1% of 79 cases had mortality compared with the observations of Ochoa[12] who had a mortality of 8.27% of cases in the operative series of patients. Mukhopadhyay et al.[13] had a mortality of 2.39% in his operative series of patients.

Conservative management for partial worm obstruction is advocated in many studies and can be managed with intravenous fluid administration, nasogastric suction, and instillation of oral piperazine salt,[9] normal saline enema, and hypertonic saline enemas. Few studies advocated the use of Gastrografin.[14],[15] for the evacuation of worms with variable results. Hamid et al. Use of gastrografin resulted in faster relief of signs and symptoms of round worm-induced small bowel obstruction, the early passage of worms or flatus, and return to oral feeds.[16] Mukhopadhyay et al.[13] used anthelminthic drug along with normal saline enema and reported 50% success to conservative treatment in their series. All these studies advocated conservative management in cases of partial worm obstruction only, but in the present study, we have used conservative treatment in patients with complete intestinal obstruction without signs and symptoms of perforation and peritonitis due to roundworms.

The results of our study are similar to Mukhopadhyay et al.[13] who did not have any mortality in the conservative series. Early detection of disease, well acquaintance with the disease, avoidance of delay for those requiring surgical intervention, appropriate antibiotic cover, and serial radiological assessment helped to reduce morbidity and mortality.


  Conclusions Top


Intestinal asicarisis is still endemic in children belonging to rural areas and low socioeconomic strata of the society. Colicky periumbilical pain and distension of the abdomen are common initial presenting symptoms. Serial plain radiograph of the abdomen and pelvis are useful for early diagnosis and management. Conservative management is successful in most of the cases. Surgical intervention is required for complicated intestinal ascariasis.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Drake L, Bundy D. Multiple helmet infections in children; impact and control. Parasitological 2001;122:73-81.  Back to cited text no. 1
    
2.
Villamizar E, Mendez M, Bonilla E, Varon U, Onatara S. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children experience with 87 cases. J Pediatr Surg 1996;31:201-5.  Back to cited text no. 2
    
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Akgun Y. Intestinal obstruction caused by Ascaris lumbricoides. Dis Colon Rectum 1996;39:1159-63.  Back to cited text no. 3
    
4.
Basavaraju SV, Hotez PJ. Acute GI and surgical complications of Ascaris lumbricoides infection. Infect Med 2003;20:154-9.  Back to cited text no. 4
    
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Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996;25:553-77.  Back to cited text no. 5
    
6.
Rahman H, Pandey S, Mishra PC, Sharan R, Srivastava AK, Agarwal VK. Surgical manifestations of ascariasis in childhood. J Indian Med Assoc 1992;90:37-9.  Back to cited text no. 6
    
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Banwell JG, Variyam EP. Worm infestations-ascariasis. In: Ian AD, Robert NA, Hodgson HJ, editors. Gastrointestinal Clinical Science and Practice. 2nd ed.. Philadelphia: WB Saunders; 1993. p. 1403-6.  Back to cited text no. 7
    
8.
Surendran N, Paulose MO. Intestinal complications of round worms in children. J Pediatr Surg 1988;23:931-5.  Back to cited text no. 8
    
9.
Dayalan N, Ramakrishnan M. The pattern of intestinal obstruction with special reference to ascariasis. Indian Pediatr 1976;13:47-9.  Back to cited text no. 9
    
10.
Waller CE, Othersen HB. Ascariasis: Surgical complications in children. Am J Surg 1970;120:50-4.  Back to cited text no. 10
    
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Louw JH. Abdominal complications of Ascaris lumbricoides in children. BJS 1966;53:510-21.  Back to cited text no. 11
    
12.
Ochoa B. Surgical complications of ascariasis. World J Surg 1991;15:222-7.  Back to cited text no. 12
    
13.
Mukhopadhyay B, Saha S, Maiti S, Mitra D, Banerjee TJ, Jha M, et al. Clinical appraisal of Ascaris lumbricoides, with special reference to surgical complications. Pediatr Surg Int 2001;17:403-5.  Back to cited text no. 13
    
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Vásquez Tsuji O, Gutiérrez Castrellón P, Yamazaki Nakashimada MA, Arredondo Suárez JC, Campos Riveral T, Martínez Barbosa I. Anthelmintics as a risk factor in intestinal obstruction by Ascaris lumbricoides in children. Bol Chil Parasitol 2000;55:3-7.  Back to cited text no. 14
    
15.
Bar Moar JA, Chappel J. Gastrograffin treatment of intestinal obstruction due to Ascariasis lumbricoides. J Indian Assoc Pediatr Surg 2012;17: 116–9.   Back to cited text no. 15
    
16.
Hamid R, Bhat N, Baba A, Mufti G, Khursheed S, Wani SA, et al. Use of gastrografin in the management of worm-induced small bowel obstruction in children. Pediatr Surg Int 2015;31:1171-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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