|Year : 2012 | Volume
| Issue : 3 | Page : 116-119
Surgical complications of Ascaris lumbricoides in children
Raghu S Ramareddy, Anand Alladi, OS Siddapa, V Deepti, Tanveer Akthar, B Mamata
Department of Paediatric Surgery, Vani Vilas Hospital, Bangalore Medical College and Research Institute, Bangalore, India
|Date of Web Publication||6-Jul-2012|
Department of Paediatric Surgery, Vani Vilas Hospital, Bangalore Medical College and Research Institute, Bangalore
| Abstract|| |
Aim : To report the surgical complications of Ascaris lumbricoides infestation in children. Materials and Methods : This is a retrospective study and cases of intestinal ascariasis managed conservatively were excluded. Results : Sixteen children presented with Ascariasis sequelae, which included ileal volvulus (n=5), perforations (n=4), intussusception (n=1), biliary ascariasis (n-1) and impacted multiple worm boluses (n=5). Plain abdominal radiographs showed pneumoperitoneum (3), cigar bundle appearance (3) and multiple air and fluid levels (13). Sonography showed floating worms with free fluid (2), sluggish peristalsis and moderate free fluid (7) and intestinal worm bolus (11). The surgical procedures included milking of worms (in all), bowel resection (6), closure of perforation (3) and manual reduction of intussusception (1). Biliary ascariasis was managed conservatively and the progress monitored with sonography. There were 3 deaths all of whom had intestinal volvulus, bowel necrosis and toxemia. Conclusion : Sonography can be helpful in diagnosing the presence of worms, its complications and in evaluating response to treatment. Early surgical intervention in those with worm bolus, peritonism, and volvulus may salvage bowel and reduce mortality.
Keywords: Acute abdomen, ascariasis, intestinal complications
|How to cite this article:|
Ramareddy RS, Alladi A, Siddapa O S, Deepti V, Akthar T, Mamata B. Surgical complications of Ascaris lumbricoides in children. J Indian Assoc Pediatr Surg 2012;17:116-9
|How to cite this URL:|
Ramareddy RS, Alladi A, Siddapa O S, Deepti V, Akthar T, Mamata B. Surgical complications of Ascaris lumbricoides in children. J Indian Assoc Pediatr Surg [serial online] 2012 [cited 2013 May 21];17:116-9. Available from: http://www.jiaps.com/text.asp?2012/17/3/116/98130
| Introduction|| |
Ascaris lumbricoides (A. lumbricoides) is one of the largest of the parasites that infest the human bowel, common in regions with poor sanitation, in the tropics and subtropics.  Common acute surgical abdomen caused by Ascaris infestation include small intestinal obstruction, volvulus, intussusception and perforation usually involving the appendix or Meckels diverticulum, ileum, and rarely through areas of pre-existing bowel pathology and biliary ascariasis. , Radiologic investigations are helpful in the managements of A. lumbricoides. ,, We present our experience of surgical complications of A. lumbricoides in 16 children.
| Materials and Methods|| |
This is a retrospective study of 16 children admitted with acute surgical complications of A. lumbricoides from 2008 to 2011. Patients with intestinal ascariasis managed conservatively were excluded.
| Results|| |
The children presented with vomiting, abdominal pain and distention. On examination, most of them had tenderness associated with guarding of the abdominal wall. Six children presented with acute intestinal obstruction due to ileal worm bolus and one of them had ileocecal intussusception which was detected preoperatively by sonography [Figure 1]. In addition to multiple air and fluid levels, the plain radiographs revealed a cigar bundle appearance in one [Figure 2]. Sonography revealed worm bolus [Figure 3] in all and the intussusception in one. All of these patients were managed by milking of worms distally to colon and the intussusception was reduced manually.
|Figure 2: Plain X ray film showing multiple air fluid levels and cigar bundle appearance (solid arrow)|
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Nine children presented with peritonitis and septic shock, 5 of whom had ileal volvulus, 2 ileal perforation and, 1 each of gangrene of Meckel's diverticulum and jejunal perforation. The last patient had a history of blunt abdominal trauma 2 days before admission. The plain radiographs revealed pneumoperitoneum in the 3 children with perforation, cigar bundle appearance in 2 patients with volvulus, and multiple air fluid levels in 6 patients. Ultrasonography demonstrated worm bolus in 5, free floating worms in the peritoneal cavity in 2 and free fluid in 8 patients. The child with blunt abdominal trauma had a contrast-enhanced computerized tomography of the abdomen after initial resuscitation which showed pneumoperitoneum, free fluid, worm infestation and normal solid organs. Resection, extraction of worms, and anastomosis were done in the 5 with ileal volvulus. There were 3 deaths among these due to delayed presentation with extensive involvement of bowel, severe dyselectrolytemia and acidosis at presentation. Of the 4 children with bowel perforation, 2 had ileal, 1 of whom was Widal positive, 1 post traumatic jejunum with a peeping worm, and the last a closed loop obstruction due to Meckel's diverticulum resulting in gangrenous perforation. The first 3 underwent simple milking of worms distally, closure of perforation and peritoneal toileting. The child with Meckel's diverticulum was managed by resection, and extraction of worms from peritoneal cavity and proximal bowel with reanastomosis [Table 1].
|Table 1: Clinical presentations, operative findings, procedure and results of 16 children|
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A child with earlier infestation of round worms managed by deworming 6 months earlier, presented with recurrence of symptoms for 3 days for which he had received a repeat course of antihelminthic. Sonography revealed both intestinal ascariasis and worms in the gallbladder (GB) and the common bile duct (CBD). Liver function test, serum amylase and lipase were normal. He was managed conservatively with fasting and antihelminthic to which he responded by disappearance of biliary ascariasis. This was confirmed by sonography on day 4 of conservative management [Figure 4].
|Figure 4: Ultrasound showing worm in gall bladder and disappearance in follow up scan|
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Thirteen children had an uneventful post operative recovery except one who had wound infection, which resolved with dressings. All these were dewormed on postoperative day 2 with piperazine citrate at 75mg/kg/day for 3 days given through the nasogastric tube.
| Discussion|| |
Gastrointestinal sequelae of ascariasis include luminal occlusion, volvulus, perforations, appendicitis and intussusception. , Our series also report a similar trend of acute surgical problems associated with ascariasis. Although most series report intestinal luminal occlusion as the most common presentation ranging from 50% to 65%,  the incidence was only 35% in our series. This is probably because we have excluded those managed conservatively taking into consideration only those requiring surgical intervention. Ascaris worm bolus can initiate intra-luminal obstruction near the ileo-cecal valve and aggravates spasticity of distal ileum by combined action of endo toxins of worms and host inflammatory reactions. ,, It can also act as lead point for intussusceptions and pivot for volvulus. ,,, The incidence of volvulus has been reported to range from 24% to 36%. , Our series had a similar incidence (31%). Intestinal perforation is rare because of distensibility of intestinal lumen and generally occurs when worms obstruct the lumen of blind- ending structures, such as appendix or Meckel's diverticulum. It can also result from ischemic necrosis following volvulus. ,, Primary bowel pathologies such as typhoid perforations, amebiasis, intestinal ulcers, trauma, and anastomotic suture lines are thought to provide exit sites for the worms. , Ascaria does not have teeth and stay in the intestinal lumen. , It can still penetrate normal or pathologic bowel. , Of our 4 patients with perforation, 2 had primary bowel pathology, 1 each of enteric perforation and traumatic perforation, blind loop obstruction in 1 Meckel's diverticulum, and no predisposing factor in 1. One of the less common presentations of intestinal ascariasis is intussusception reported to occur in about 2%.  This has been hypothesized to result from hyperperistalsis of worm bolus and distal ileal muscle receptor blockade by toxins.  We had 1 patient with intussusception.
The wandering nature of A, lumbricoides results in their migration through the ampulla of Vater causing varied surgical complications of the hepatobiliary and pancreatic system. ,,, High fever, diarrhea, spicy foods, anesthesia, sub therapeutic antihelminthic treatment and other stresses have all been associated with an increased likelihood of worm migration.  Biliary ascariasis incidence varies from 10%to19% of ascariasis-related complications. Prior sphicterotomy and bilioenteric anastomosis and female sex predisposes to biliopancreatic ascariasis. ,, The presence of A. lumbricoides in gallbladder is rare due to the narrow and tortuous cystic duct.  Hepatobiliary ascariasis usually presents as bilary colic, cholangitis, cholecystitis, stricture, calculi, hepatic abscess and pancreatitis and are confirmed easily with sonography. ,,, Ultrasound sensitivity of pancreatobiliary ascariasis varies from 25%-91%. Conservative observation is the mainstay of management with response ranging from 83% to 90%. , Endoscopic retrograde cholangio-pancreatography and extraction of worms without sphicterotomy or surgery are other options available for failed conservative treatment in hepatobiliary and pancreatic ascariasis. ,, Most of the biliary complications have been reported in adults.
Diagnosis with clinical symptoms and hematologic investigations alone is not possible.  Plain radiographs of abdomen show radiolucent areas, cigar bundle appearance, "whirlpool" sign, pneumoperitoneum in a case of perforation and multiple air fluid levels in case of heavy worm infestation. ,,, Sensitivity of ultrasound diagnosing intestinal ascariasis varies around 88%. Our series had 93% sensitivity. Ultrasound findings suggestive of ascariasis include the following:- (a) a thick echogenic strip with a central anechoic tube; (b) multiple long, linear, parallel echogenic strips without acoustic shadowing in longitudinal (railway track) and transverse (bull's eye) views; (c) overlapping longitudinal interfaces in the main bile duct due to coiling of a single worm or several worms in the CBD (helmenthinoma). ,,,, The sinuous movement of the worms inside the gallbladder and the bile ducts is the pathognomonic of Ascariasis. 
A close monitoring and early surgical intervention in those with toxemia and features of peritonitis may salvage bowel and reduce mortality. Most of the morbidity and the mortalities are usually seen in children presenting with volvulus and peritonitis , which was also the case in the present series with 3 mortalities occurring in children who presented with volvulus and gangrene. Piperazine citrate, pyrantel pamoate, albendazole, and mebendazole are antihelminthic drugs of choice. The first one cause flaccid paralyses of the worms and are suitable in acute abdomen. Reinfection , occurs frequently, more than 80% in getting reinfected within 6 months in some endemic areas. This mandates periodic and repeated deworming.
| Conclusion|| |
Ascariasis infestation is the common helminthic disease in developing countries with wide spectrum of clinical presentations, one of which can be an acute abdomen. Use of high resolution sonography can be helpful in diagnosing the presence of worms, its complications and in evaluating response to treatment. Low threshold for intervention prevents high mortality and morbidity associated due to volvulus and toxemia.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]