Surgical Aspects of Intestinal Ascariasis Oluwole G. Ajao, MB,BS (Lond) Toriola F. Solanke, MB,ChB (St. And) Ibadan, Nigeria

At the University College Hospital, Ibadan, Nigeria, a common differential diagnosis of acute abdomen is intestinal ascariasis. This condition mimics many causes of acute abdomen so that accurate pre-operative diagnosis depends mainly on a high index of suspicion. The purpose of this paper is to call attention to this condition which is prevalent in tropical countries, where preventive and social medicine have not reached their peak, and to review the pathological processes resulting from this disease.

Materials and Methods During the 12-month period from January 1975 to December 1975, about 6,000 stool specimens of patients were examined at the University College Hospital, Ibadan, Nigeria. Of this number, 1,3 10 specimens contained ova of Ascaris lumbricoides. Also, a high incidence of associated medical conditions with intestinal ascariasis was found in this series (Table 1). Six patients in this series had emergency operations for acute abdomen due to intestinal ascariasis. Not included are four cases of ileocolic intussusception found in the age group of between three and seven years, for which there were no apparent causes apart from the presence of intestinal ascariasis. There were also eight cases of intestinal ascariasis with ileal perforation that are not included because the information about them is not sufficient and the cases do not fall within the period under review. In one of these cases, multiple perforations were

From the Department of Surgery, University College Hospital, Ibadan, Nigeria. Requests for reprints should be addressed to Dr. Oluwole G. Ajao, Department of Surgery, University College Hospital, Ibadan,

Nigeria.

found in the cecum and hepatic flexure of the colon with a couple of ascaris worms lying freely in the peritoneal cavity. A common cause of ileal perforation in the tropics is typhoid fever. But in these eight cases of ileal perforation associated with intestinal ascariasis, blood, stool, and peritoneal fluid cultures were negative for Salmonella. Only two of these cases had full serological investigations, and the serological tests were negative for Salmonella typhi Vi, Salmonella typhi 1,,2 Salmonella typhi H (d), and Salmonella paratyphi B 4COV).2-5 Discussion The clinical features of intestinal ascariasis depend on the complications associated with the infestation. In the cases reviewed, the age incidence varies between one and 40 years, but any age group could be affected. There does not seem to be any sexual bias in the infestation. The ratio of females to males, in this series, is 11:9.

Abdominal Pain This is the most common presentation of the intestinal ascariasis. Of the 1,310 cases reviewed, 917 (70 percent) presented with abdominal pain. Without perforation or obstruction, the pain is usually located in the periumbilical area and lower abdomen. It may

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 3, 1977

be more severe in the right lower quadrant, thus mimicking appendicitis.

Chronic Infestation In many cases of chronic infestation, without complication, the pain is usually dull and unrelated to food. It is a practice in this hospital, by some surgeons, to give levo-tetramisole (a worm expeller) to patients presenting with abdominal pain suggestive of peptic dyspepsia, before ordering an expensive barium meal.

Perforation In cases in which there is perforation, the abdomen is rigid. There is guarding and rebound tenderness with diminished bowel sounds. In the pediatric age group, physical findings may suggest peritonitis, even in the absence of perforation or obstruction. Perforation is usually at the last one foot of the terminal ileum.

Bowel Obstruction Obstruction is usually at the terminal ileum and is caused by a bolus of worms.' The obstruction may be complete or partial. One of the patients passed 103 worms after deworming. Many of the patients also passed a great number of worms. The presentations in these cases are the same as in any other case of bowel obstruction. In some cases, a mass can be felt in the right lower quadrant resembling an appendiceal mass or ileocolic intussusception.

Vomiting During the phase of acute intestinal ascariasis, vomiting often occurs, especially when there is bowel obstruction. Forty percent of the cases in this series presented with vomiting. On two 149

Table 1. Presentations of Intestinal Ascariasis (1,310 Cases)

Number

Percent

Cachexia

325

25

Vomiting

524

40

Abdominal Pain

917

70

Diarrhea with or without mucus and/or blood

720

55

occasions sizeable worms were present in the vomitus. Aspiration of a worm into the bronchial tree2 has also been reported in one case managed conservatively. In another case, operated upon, ascaris worms were found blocking the nasogastric tubes which were inserted to decompress the gastrointestinal tract.

Diarrhea Fifty-five percent of the patients presented with diarrhea. The stools are usually very loose and may or may not resemble that of intussusception. When worms are passed per rectum, or when they can be felt on digital examination, the diagnosis is easy. Profuse diarrhea and vomiting may cause dehydration and electrolyte imbalance.

Cachexia Cachexia may be associated with massive, chronic ascariasis infestation.3 Factors that may be responsible for cachexia include deprivation of the host of essential nutrients by the parasite (that may number well over 100). Associated medical conditions may, also, play a major role in the production of cachexia4 (Table 2). One of the deaths was a one-year-old girl who, in addition to having ascariasis, presented with bronchopneumonia, measles, kwashiorkor, and incipient cancrum oris.

Associated Conditions Patients with intestinal ascariasis seen at the University College Hospital almost always have other medical conditions associated with the disease. Invariably, other parasitic infestations 150

are found when stool specimens are examined. Associated diseases in order of frequency were trichuriasis, ancylostomiasis, amebiasis, strongyloidiasis, tuberculosis, pneumonia, trichomoniasis (hominis), kwashiorkor, and vesical

schistosomiasis (Table 2). Differential Diagnosis Intussusception: Where there is a watery stool containing mucus and blood and when a mass (due to a bolus of worms) is palpated in the right lower quadrant, intestinal ascariasis may be difficult to differentiate from intussusception unless the patient has previously vomited worms, or passed worms rectally. Typhoid perforation: Perforation of the terminal ileum occurs both in intestinal ascariasis and typhoid fever. The presence of ascaris in the bowel or lying freely in the peritoneum; negative cultures for Salmonella in the stool, peritoneal fluid and blood; and negative serological tests for Salmonella infestation will confirm the diagnosis. Usually, the toxicity in typhoid perforation is more severe than that due to perforation in intestinal ascariasis. Primary peritonitis: A five-year-old girl in this series had an exploratory laparotomy for peritonitis. Apart from multiple intestinal ascariasis which neither perforated the intestines nor caused bowel obstruction, nothing was found to have been responsible for the peritonitis. Culture of the peritoneal fluid yielded no growth. Bowel obstruction from any cause, especially when it occurs in the terminal ileum, may stimulate ileal obstruction by bolus of worms. Causes of diarrhea: Intestinal amebiasis, bacillary dysentery, or infestation with Schistosoma mansoni may produce certain clinical features of intestinal ascariasis. It is of interest to note that in all the cases operated upon in this series, Shigella was not cultured in the stool of any of the patients. Peptic dyspepsia: Chronic uncomplicated intestinal ascariasis may present with symptoms suggestive of peptic ulcer disease. Barium meal and small bowel follow-through will confirm the diagnosis as the worms can be clearly demonstrated radiologically during the upper gastrointestinal examination with a contrast material.

It is always advisable to obtain a contrast follow-through examination of the small bowel in the absence of peptic ulcer disease in a patient with peptic dyspepsia. Appendiceal mass: When ascaris worms fill the terminal part of the ileum or the proximal part of ascending colon, the presence of an illdefined mass may resemble appendiceal mass. The presence of an ascaris worm in the lumen of the appendix,5 causing appendicitis, has been reported. Mesenteric lymphadenitis: This is a differential diagnosis of acute abdomen in the pediatric age group in the temperate as well as in the tropical countries. In many cases, enlarged mesenteric lymph nodes are found associated with intestinal ascariasis. Histologically, these enlarged nodes show a non-specific inflammatory reaction.

Management Intestinal ascariasis is best managed conservatively unless there are complications. The three drugs widely used at the University College Hospital, Ibadan for the "deworming" of patients are piperazine citrate (Antepar), levo-tetramisole (Ketrax), and thiabendazole (Mintezol).6 Piperazine citrate: In addition to its effectiveness against ascaris, this drug is also effective against Oxyuris vermicularis (thread worm). For ascariasis the dose is 30 to 40 ml daily for seven days. Levo-tetramisole: This drug is very effective against Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus, Enterobius vermicularis, Trichuris trichuria, and Strongyloides stercoralis. The adult dose is 120 mg as a single dose. For children between five and 15 years of age, the dose is 80 mg as a single dose, and for children up to four years old, it is 40 mg as a single dose. This drug is preferred because of its actions against other parasites that are frequently associated with intestinal ascariasis. Thiabendazole: This drug is also effective against Ascaris lumbricoides (roundworm), Oxyuris vermicularis (pinworm), Ancylostoma duodenale (hookworm), and Trichuris trichuria (whipworm).

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Table

2.

Associated Conditions (1,310 Cases)

Number

Percent

Trichural Infestation

786

60

Strongyloidal Infestation

262

20

Ancylostomal Infestation

589

45

Amebiasal Infestation

393

30

65

5

(hominis) Infestation

131

10

Tuberculosis

262

20

Bronchopneumonia

196

15

65

5

Vesical Schistosomiasis Trichomonal

Kwashiorker

Pyrantel pamoate: Although we have limited experience with this drug at the University College Hospital, it has been claimed by some other workers to be very effective for the treatment of ascariasis. 7,8

Surgery Indications for operation in intestinal ascariasis include perforation, small bowel obstruction, peritonitis, and failure of conservative treatment for an acute condition of intestinal

ascariasis. During surgery, when there is perf oration, peritoneal toileting and closure of the perforation are indicated. When there is an obstruction, an attempt should be made to "milk" the bolus of worms from the narrow ileum to the colon where the lumen is larger, to relieve the obstruction. When this is not possible, enterostomy should be made to manually remove the obstructing worms.

Post-operative wound obstruction is more likely to occur if there has been bowel perforation or if enterostomy has to be made to remove the obstructing worms. In anticipation of this, the use of retention sutures is mandatory for abdominal wall closure of the wound.

Complications of Intestinal Ascariasis In addition to the previously mentioned complications such as perforation,3 obstruction,9 peritonitis, and aspiration of worms into the bronchus causing bronchopneumonia7 have been reported. It has also been shown that the worms can migrate into the biliary tract causing cholangitis and hepatic abscess.10 They may migrate into the pancreatic duct.3 Ascariasis causing cholecystitis has also been reported. Romey, et al,1 1 reported a case of a biliary stone containing a cuticle and multiple ova of Ascaris lumbricoides. Roche reported a case of Ascaris lumbricoidesl 2 found in the nasolacrimal duct of a patient.

The Mode of Infection To clearly understand the mode of infection of Ascaris lumbricoides it is essential to review, briefly, the life cycle of this largest human-intestinal nematode. 1 3 Man is affected through contaminated drinking water and raw vegetables. The ingested eggs hatch and the larvae find their way into the small intestine where they burrow into the intestinal wall to enter the circulation. They are then carried to the lungs and remain in the alveoli for several days where they molt twice. From there, they migrate up the trachea and down the esophagus to reach the intestines again, where they molt for the last time. It takes about ten days for the journey from the first visit to the intestines, and back for the second and final time. During this period, the worms have grown about ten times their original size. The adult female lays about 200,000 eggs per day. The eggs eliminated in the human feces are not infective to man when passed, but infective larvae are present in the eggs found in the soil, water, or green vegetables.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 3, 1977

Summary During the 12-month period from January to December 1975, approximately 6,000 stool examinations were performed at the University College Hospital, Ibadan, Nigeria. Of these, 1,310 contained ova of Ascaris lumbricoides. Six patients had emergency operations for acute abdomen caused by intestinal ascariasis. Observation shows by other medical conditions are always associated with intestinal ascariasis. Presenting features of intestinal ascariasis include cachexia, vomiting, abdominal pain, and diarrhea. Complications include ileal perforation, bowel obstruction, and unex-

plained peritonitis.

Our management of the complications of intestinal ascariasis is essentially surgical.

Conclusion Intestinal ascariasis is not a major problem in temperate countries with good standards of hygiene, however, in tropical countries and some developing nations, it is a major surgical problem which presents a strong differential diagnosis of acute abdomen. Complications are usually fatal unless surgical intervention is promptly instituted.

Literature Cited 1. Oluwasanmi JO: Intestinal obstruction due to Ascariasis. Ghana Med J 7:149,

1968 2. Little MD, Most H: Anisakid larva from the throat of a woman in New York. Am J Trop Med Hyg 22:609-612, 1973 3. Piggot J, Hansbarger EA, Neafie RC: Human Ascariasis. Am J Clin Pathol 53:223-234, 1970 4. Phills JA, Harrold AJ, Whiteman GV, et al: Pulmonary infiltrates: Asthma and eosinophilia due to Ascaris suum infestation in man. N EngI J Med 286:965-970, 1972 5. Waller CE, Othersen HB: Ascariasis, Surgical Complications in Children. Am J Surg 120:50-54, 1970 6. Lawal-Solarin 0 (ed): Medical Index of Pharmaceutical Specialties in Nigeria (Medipharm). 7(3):38-39, 1975 7. Ghadirian E, Sanati A, Misaghian G, et al: Treatment of ascariasis with pyrantel pamoate in Iran. J Trop Med Hyg 75:195-197, 1972 8. Villarejos VM, Arguedas-Gamboa JA, Eduarte E, et al: Experiences with the antihelmintic pyrantel pamoate. Am J Trop Med Hyg 20:842-847, 1971 9. Solanke TF: Intestinal obstruction in Ibadan. West Afr Med J 12:191, 1968 10. Cole GJ: Surgical manifestations of Ascaris lumbricoides in the intestine. Br J Surg 52:444, 1965 11. Romey R, Lilly J, McHardy G: Bilary calculus of roundworm origin. Ann Intern Med 75:405, 1970 12. Roche PJL: Ascaris in the lacrimal duct. Trans R Soc Trop Med Hyg 65:540-542, 1971 13. B lacklock D B, Southwell: A G uide to Human Parasitology, ed 9. London, H K Lewis, 1973

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Surgical aspects of intestinal ascariasis.

Surgical Aspects of Intestinal Ascariasis Oluwole G. Ajao, MB,BS (Lond) Toriola F. Solanke, MB,ChB (St. And) Ibadan, Nigeria At the University Colleg...
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