Tropical Doctor,]anuary 1979

ASCARIASIS AND ACUTE ABDOMEN

I 33

Surgical Practice

Ascariasis and acute abdomen O. G. Ajao, FRCS, FMCS University College Hospital, Ibadan, Nigeria

and A. O. Ajao, BSc, MS, DMT Department of Microbiology, University of Ife, Ile-Ife, Nigeria

TROPICAL DOCTOR,

of the abdomen may show multiple fluid levels and an area of obstruction by a bolus of worms (Figs 1 and 2). The obstruction can be relieved either by manual removal of the worms after an enterostomy, or if located in the terminal ileum, the worms can be milked into the caecum which is of larger diameter. Post-operative deworming must be carried out in these patients. When an enterostomy has to be done to remove the worms, wound infection is likely to occur. In anticipation of this, the use of retention sutures is indicated.

1979,9,33-36 INTUSSUSCEPTION

Ascaris lumbricoides is widespread in the tropics. A large percentage of the population harbours this parasite without any apparent ill-effect. It has been shown that about 22% of routine stool examinations contain ova of ascaris (Ajao and Solanke 1977). This figure was obtained in a tropical urban area, such as Ibadan, where there is pipe-borne water, although its supply is irregular. The incidence is likely to be much higher in rural areas without pipe-borne water. Many practising doctors in the tropics tend to overlook the reports of stool examinations in patients with ova of ascaris because of the notion that as soon as the patients go back to their rural surroundings, they will be re-infected, It has been suggested (Gilles 1978) that in an endemic area where reinfection is likely to occur, only heavy or moderate infections are worth treating. In view of the seriousness of surgical complications of ascariasis which we see relatively frequently at the University College Hospital, Ibadan, the opinion is held that presence of ova of Ascaris in stool, even if the infestation is light, should be an indication for treatment. The purpose of this paper is to highlight the various potentially lethal surgical conditions that can occur as a result of ascariasis.

Another relatively common cause of intestinal obstruction especially in children is intussusception

INTESTINAL OBSTRUCTION

A frequent cause of acute abdomen in the tropics is intestinal obstruction, and a common factor of this, especially in children, is intestinal ascariasis. The Ascaris worms, coiled around one another, form a bolus occluding the intestines. Any part of the small bowel or even large bowel may be affected, but the obstruction is usually at the terminal ileum (Oluwasanmi 1968). This obstruction may be partial or complete, and may produce the typical clinical features of bowel obstruction. Plain roentgenograms

Fig. I. Plain abdominal X-ray showing intestinal obstruction. In the left lower quadrant is a bolus of worms causing the obstruction.

34 I ASCARIASIS AND

Tropical Doctor, January I979

ACUTE ABDOMEN

Fig. 3. Barium enema showing intussusception causing intestinal obstruction at the hepatic flexure of the colon. Cause of the intussusception in this patient is not known.

Fig. 3. Plain abdominal X-ray of bowel obstruction. In the left lower quadrant is a bolus of worms causing the obstruction. (Fig. 3). One cause that predisposes to the development of non-infantile intussusception is the mobility of the caecum and ascending colon (Solanke 1968). Another predisposing factor is the presence of intestinal neoplasms (Blum 1947). Ascaris worms have been seen during their manual removal for intestinal obstruction to attach themselves firmly to the wall of the intestines by their stomata. This may explain how intestinal ascariasis can initiate intussusception. Many cases of intussusception without any obvious cause, except for the presence of Ascaris in the gut, are seen regularly in our hospitals. Treatment of intussusception is reduction, but indications for resection include irreducibility, gangrenous bowel, chronicity and presence of a neoplasm initiating the intussusception. INTESTINAL PERFORATION

The belief that the only cause of ileal perforation in the tropics is typhoid fever is not correct. Whereas typhoid perforation is the commonest cause of ileal perforation in the tropics, it has been shown that Ascaris worms are also responsible for some cases of ileal perforation. Unlike typhoid perforation that

tends to be localized at the terminal ileum, perforation due to ascariasis has also been shown to occur at the caecum and hepatic flexure of the colon (A;ao and Solanke 1977). Patients with typhoid perforation are usually more toxic than those with perforation due to ascariasis. In the latter case there is also a high incidence of post-operative wound infection similar to that of typhoid perforation (Ajao 1977). APPENDICITIS

Appendicitis was once thought to be rare in tropical Africa (Walker et al. 1973). At the University College Hospital, Ibadan, appendicitis is now found to be a leading cause of acute abdomen. Ascaris worms have been found in the lumen of an appendix causing appendicitis (Waller et al. 1970) and in our experience Ascaris have been found in close relationship to some inflamed appendices. Ova of Ascaris have also been found in the lumen of some cases of appendicitis (Fig. 4). INFLAMMATORY GALL-BLADDER DISEASE

Compared with Europe and North America, inflammatory disease of the gall-bladder cannot be regarded as common in tropical Mrica. In a five-year review from Ibadan by Parnis (1964) 35 cases were reported; this gives an average of seven cases per year in a population of about two million people. A case of cholecystitis with biliary stone, containing a cuticle and multiple ova of Ascaris lumbricoides, has been reported (Romey et al. 1970). One of the patients

Tropical Doctor,January I979

ASCARIASIS AND ACUTE ABDOMEN

I 35

..

~!~\T, ''S..tJv4£~'~1~~

~~I~ct~~~;~~

~1~~J. ~,1~.>~~!i~:~·\~. ~.~~.

\, ~/ ~ . , ""

.~

~._~\:~~'"nI

_~ .......-:, "JI~ L",.

Fig. 5. A skein of about 60 adult Ascaris worms found on laparotomy for intestinal obstruction of the small bowel (Welleome Museum of Medical Science).

Fig. 4. Barium enema examination showing ascaris worms in the colon. Examination was performed for chronic pain in the right lower quadrant. treated in this hospital (A.S. Hosp. No. 334937) for cholecystitis and cholelithiasis was a 51-year old female who harboured a live adult female Ascaris worm in the common bile duet. The jejunum and ileum of this patient were loaded with Ascaris worms. Ascariasis has also been associated with cholangitis and liver abscess (Cole 1965). VOLVULUS, PANCREATITIS, PERITONITIS

Other conditions of acute abdomen in which ascariasis may playa part include volvulus, pancreatitis and peritonitis without intestinal perforation. The volvulus occurs as a result of a bolus of worms, especially, when present in a redundant, mobile segment of the colon. Pancreatitis can also occur when an Ascaris worm migrates into the pancreatic duet (Piggot et al. 1970). We have seen on a few occasions, in this hospital, cases of peritonitis in children, both male and female, without any obvious cause except for a full load of Ascaris worms in the bowel (Figs 5 and 6).

Fig. 6. An adult Ascaris worm in the bile duct and liver (Wellcome Museum of Medical Science). CONCLUSION

The seriousness of surgical complications of intestinal ascariasis makes it mandatory to treat any patient who harbours this parasite. We agree with Gilles (1978) that other parasites are usually present in association with intestinal Ascaris worms. Apart from the surgical complications there are well-established medical complications of ascariasis even though the patients may show no ill-effects at the onset. It is therefore suggested that in rural areas in the tropics, a worm-expeller should be administered

36 I ASCARIASIS

Tropical Doctor,]anuary 1979

A.ND A.CUTE ABDOMEN

routinely to patients on their first visits to medical institutions, and to those who have ova of ascaris in the stool. Some of us routinely give a worm-expeller to patients with a vague, chronic abdominal pain before ordering barium studies. A commonly used anthelmintic drug is laevotetramisole (Ketrax). The dosage for adults is three tablets (120 mg) taken as a single dose. This drug is also active against Ankylostoma duodenale, Necator americanus, Enterobius vermicularis, Trichuris trichiura and Strongyloides stercoralis. Some of these parasites are usually present in association with intestinal ascariasis. Other anthelmintic drugs used are bephenium hydroxynaphthoate (Alcopar), piperazine citrate (Antepar), thiabendazole (Mintezol), mebendazole (Vermox) and pyrantel pamoate (Combantrin).

Though it is too early to evaluate the result of this, there seems to be a slight reduction in our requests for barium studies. REFERENCES

Aiao, O. G. (1977). J. trop, MeJ. Hyg., 80, 192. Ajao, O. G., and Solanke, T. F. (1977). J. nat. med. Ass., 69,149. Blum, L. (1947). Surg. Clin. N. Amer., 27, 355. Cole, G. J. (1965). Brit.J. Surg., 52, 444. Gilles, H. M. (1978). Tropical Doctor, 8, 62. Oluwasanmi, J. O. (1968). Ghana med.J., 7,149. Parnis, R. O. (1964). Trans. roy. Soc. trap, Med. Hyg., 58, 437. Piggot, J., et al. (1970). Amer. J. din. Path., 52, 223. Romey, R., et al. (1970). Ann. intern. Med., 75, 405. Solanke, T. F. (1968) W. Afr. med.J., n.s. 17, 191. Walker, A. R. P., et al. (1973). Postgrad. med, J., 49, 243. Waller, C. E., and Otherson, H. B. (1970). Amer. J. Surg., 120,50.

Personal Experience

Bladder trocar for emergency cystostomy R. C. Braun, MD, DTM&H Medical Superintendent, Evangelical Presbyterian Church Hospital, Adidome, Ghana TROPICAL DOCTOR,

1979, 9, 36

Urinary retention is a common problem in the tropics, more so as the number of elderly men increases. Bladders are seen grossly distended, even above the umbilicus. Urethral catheterization is sometimes unsuccessful, especially if the aetiology is urethral stricture. Recourse to supra-pubic cystostomy often has to be made in order to empty the bladder and relieve the patient's intense discomfort. Open cystostomy is time-consuming, often bloody, and leaves a dense scar which makes subsequent definitive surgery more difficult. A trocar such as that designed for abdominal paracentesis is handy for evacuating the bladder, but has the disadvantage that it is usually not possible to insert any kind of self-retaining catheter through the lumen. To overcome this obstacle, a nasal speculum has been modified to serve as a bladder trocar. A bi-valve speculum of the Killian type, with three-inch blades,

Fig.!. An improvised bladder trocar.

was filed down so that the points of the blades formed a trocar (Fig. I). To perform the cystostomy, a few ml of local anaesthetic are infiltrated into the skin and fascia in the mid line, about 4 ern above the symphysis pubis. A stab incision I em in length is made in the skin and extended through the fascia. The trocar is then inserted in the wound and thrust into the distended bladder. With the first gush of escaping urine the blades of the trocar are separated and a catheter of any size or type can be quickly inserted. The whole procedure takes only a minute or two, and blood loss is minimal.