Suhasini Gazula, Super Specialist - Senior Scale & Head, Department of Paediatric Surgery, ESIC Super speciality Hospital,
Sanathnagar, Hyderabad, India, E-mail:
We report a 2-year old child who presented with massive lower GI bleed as the presenting feature due to volvulus and gangrene of the ileum caused by roundworm bolus. He also developed early extensive bowel adhesions which have been seldom reported following ascariasis and can be probably attributed to worm toxins. Though primary anastomosis after resection of a bowel segment with a worm bolus may be the generally acceptable procedure, in cases with evidence of serosal contact with worm toxins is present, a bowel diversion procedure may be a better option. Mechanisms for intestinal obstruction and intestinal sequelae in ascariasis are also discussed.
The most frequent clinical presentation in ascariasis is intermittent colicky abdominal pain and incomplete bowel obstruction [11,14]. Heavy infestation results in a tangle of adult worms producing subacute intestinal obstruction. It is imperative to recognize these complications expeditiously and initiate early, aggressive management [5,12]. Plain radiographs may reveal a mass of worms described as "whirlpool pattern" in addition to air-fluid levels though this sign was not evident in our patient . The roundworms may be detectable as tubulous, moving, echogenic structures on ultrasonography with anechoic fluid filled alimentary canal of the worm described as "the inner tube sign". Majority of children with subacute intestinal obstruction resolve spontaneously on conservative treatment with bowel rest, antispasmodics, anthelminthics, and intravenous fluids . Hamid et al reported that while use of gastrograffin resulted in faster relief of signs and symptoms of Ascaris lumbricoides induced subacute bowel obstruction with early passage of worms/flatus and return to oral feeds, its role in reducing the likelihood of laparotomy remained inconclusive . Other acute conditions include hepatobiliary and pancreatic ascariasis, acute appendicitis, bowel perforation, peritoneal granulomas, small-bowel volvulus and intussusceptions . Volvulus and ischaemic bowel, the two most serious intestinal complications, account for less than 10% of cases  but warrant prompts surgical intervention. In our case too, a high index of suspicion and timely surgical intervention helped us manage the child
The factors responsible for ascaris-related intestinal obstruction include; a) multiple worms forming a large bolus causing mechanical obstruction, which is most common, b) worm bolus may serve as a lead point in intussusception or a pivot in volvulus, c) worms may inhabit the ileocecal valve and secrete neurotoxins which prompt small bowel contraction; which, alongwith high worm burden can obstruct the intestine, d) host inflammatory reaction to worm-derived hemolysins, endocrinolysins, and anaphylatoxins can also be severe enough to obstruct the gut lumen .
Our patient also developed early severe postoperative adhesions and by using bowel diversion (ileostomy) as the initial procedure, we were able to avoid ileal anastomotic leak in the early recuperative period. It has been shown that worm secretions and decomposition products of disintegrating worms are capable of provoking a severe reaction in the bowel which may be distant from the site of the primary worm bolus [11,12]. Moreover, when the worm enters the peritoneal cavity, the host immune response may result in masses of inflamed tissue and granulomas seeded throughout the greater omentum, serosal covering of the liver and spleen, and the peritoneum . Steinberg et al reported severe postoperative intestinal sequelae in 2 infants with ascaraisis presumably in response to serosal contamination by worm fragments at the initial surgery . Being faced with intestinal obstruction or anastomotic leak in the immediate postoperative period in a critically ill child may have devastating consequences. Our report as well as the aforementioned report illustrate that though primary anastomosis after resection of a bowel segment with a worm bolus may be generally acceptable, in cases where evidence of perforation or serosal contact with the worm toxins is present, a bowel diversion procedure may be a better option, more so in a critically ill child.
In summary, this case highlights the importance of considering ascaris infestation as a cause of lower gastrointestinal bleeding among pediatric patients without hint of other causes and need for prompt surgical intervention in this ominous scenario. Also, one should be aware of possible sequelae and exercise caution while planning the surgical procedure. Surgical procedure should be modified in the presence of suspected bowel wall contact with worm products.
- Bethony J, Brooker S, Albonico M, Geiger SM, Loukas A, Diemert D, et al. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. 2006;367(9521):1521-1532.
- Khuroo MS. Ascariasis. Gastroenterol Clin North Am. 1996;25(3):553-577.
- Sangkhathat S, Patrapinyokul S, Wudhisuthimethawee P, Chedphaopan J, Mitamun W. Massive Gastrointestinal Bleeding in Infants with Ascariasis. J Pediatr Surg 2003;38(11):1696-1698.
- 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(5-6):403-405.
- Rode H, Cullis S, Millar A, B. Cremin, S. Cywes. Abdominal complications of Ascaris lumbricoides in children. Pediatr Surg Int. 1990;5(6):397–401.
- Jacob GS, Al Nakib B, Al Ruwaih A. Ascaris producing upper gastrointestinal hemorrhage. Endoscopy. 1983;15(2):67.
- Bhasin DK, Chhina RS. Hematemesis in gastric ascariasis. Am J Gastroenterol. 1989;84(12):1585-1586.
- Wilairatana P, Wilairatana S, Charoenlarp P. Gastric ascariasis associated with upper gastrointestinal hemorrhage. Southeast Asain J Trop Med Public Health. 1994;25(2):401.
- Pontes JM, Leitao MC, Portela F, Andrade P, Lopes H, Vasconcelos H, et al. Gastric ascariasis: A rare cause of upper gastrointestinal bleeding. Endoscopy. 1996;28(9):792-793.
- Sarda AK, Kannan R. Massive lower gastrointestinal hemorrhage due to ascariasis. Am J Gastroenterol. 1992;87(9):1233.
- Louw JH. Abdominal complications of Ascaris lumbricoides infestation in children. Br J Surg. 1966;53(6):510–521.
- Steinberg R, Davies J, Millar AJW, Brown RA, Rode H. Unusual intestinal sequelae after operations for Ascaris lumbricoides. Pediatr Surg Int. 2003;19(1-2):85-87.
- Murray CL, Lopez AD. Global Health Statistics: A Compendium of Incidence, Prevalence and Mortality Estimates for Over 200 Conditions. Vol II. Boston: Harvard University Press; 1996:394-405.
- Rode H, Cullis S, Millar A,. Abdominal complications of Ascaris lumbricoides in children. Pediatr Surg Int. 1990;5(6):397–401.
- Vilamizar E, Mendez M, Bonilla, Varon H, de Onatra S. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: experience with 87 cases. J Pediatr Surg. 1996;31(1):201-205.
- Lynser D, Handique A, Daniala C, Pranjal P, Evarisalin M. Sonographic images of hepato-pancreatico-biliary and intestinal ascariasis: A pictorial review. Insights Imaging. 2015;6(6):641-646. doi: 10.1007/s13244-015-0428-7.
- Hamid R, Bhat N, Baba A, Mufti G4, Khursheed S, Wani SA, Ali I, et al. Use of gastrografin in the management of worm-induced small bowel obstruction in children. Pediatr Surg Int. 2015;31(12):1171-1176. doi: 10.1007/s00383-015-3793-x.
- Akgun Y. Intestinal obstruction caused by Ascaris lumbricoides. Dis Colon Rectum. 1996;39(10):1159-1163.
- Ochoa B. Surgical complications of ascariasis. World J Surg.1991;15:222-227.