Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. This research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management.
Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. This research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management.
Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. This research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management.
65 J uly-December 2008 / Vol 5 / Issue 2 African J ournal of Paediatric Surgery
Intestinal obstruction in children due to Ascariasis:
A tertiary health centre experience P. K. Mishra, A. Agrawal, M. Joshi, B. Sanghvi, H. Shah, S. V. Parelkar Department of Paediatric Surgery, K.E.M. Hospital and Seth G.S. Medical College, Mumbai, India Correspondence: Dr. Pankaj Kumar Mishra, Department of Paediatrics Surgery, Ward 3, K.E.M. Hospital, Parel, Mumbai, India. E-mail: drpankajmishra@gmail.com Original Article ABSTRACT Background: Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. The aim of this research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management. Materials and Methods: This is a single centre, two consultant based 5 year retrospective study of childhood intestinal obstruction due to worms. Diagnosis in the suspected patients was based on history of passage of worms per mouth or rectum and on x-ray and ultrasonography ndings. Only the patients of intestinal obstruction with documented evidence of roundworm infestation were included in the study and were followed for one year. Results: One hundred and three children with intestinal obstruction due to Ascaris lumbricoides were treated in the past five years at our centre. Abdominal pain was the most common presentation seen in 96 children followed by vomiting in 77 children. 20 children had history of vomiting worms and another 43 had history of passing worms in stool. Abdominal tenderness was present in 50 children, 48 had abdominal distension of varying degree, 50 had abdominal mass due to worm bolus, and 16 had or developed abdominal guarding or rigidity. All the children were managed as for acute intestinal obstruction along with hypertonic saline enema. The aim of management was to starve the worm and hydrate the patient. 87 patients (84.47%) responded favourably and were relieved of the obstruction by the conservative management, 16 children (15.53%) had abdominal guarding or rigidity and underwent emergency exploration. Conclusion: Roundworm obstruction should be considered in the differential diagnoses of all cases of intestinal obstruction in children. Clinical history and examination along with X-ray and ultrasonography are very helpful for diagnosis of this surgical emergency. Most cases of intestinal obstruction due to Ascaris can be managed conservatively; however emergency INTRODUCTION Ascari asi s i s a common probl em i n the tropi cs. Poor hygi eni c and l ow soci oeconomi c condi ti ons have been the mai n factors i ncri mi nated. Common surgi cal probl ems [1,2] caused by Ascari s i nfestati on i ncl ude smal l i ntesti nal obstructi on, vol vul us, i ntussuscepti on and perforati on usual l y i nvol vi ng the i l eum. In our envi ronment over 70% of chi l dren [1-5] are i nfested wi th Ascari s l umbri coi des, the l argest i ntesti nal nematode of man. I t i s esti mated that more than 1.5 bi l l i on peopl e are i nfested gl obal l y wi th Ascari s l umbri coi des, representi ng 25 percent of the worl d popul ati on. [6,7]
Ascari asi s causes about 10,00,000 new cases annual l y and 60,000 mortal i ti es i n a year the worl d over. [8,9]
Al though Ascari asi s occurs at al l ages, i t i s most common i n chi l dren 2 to 10 years ol d [10] and preval ence decreases over the age of 15 years. MATERIALS AND METHODS Thi s i s a si ngl e centre, two consul tant based, 5 year retrospecti ve study of chi l dhood i ntesti nal obstructi on due to roundworms. Onl y the pati ents of i ntesti nal obstructi on wi th documented evi dence of roundworm i nfestati on admi tted and managed over the peri od of fi ve years (January 2002- December 2007) i n the department of paedi atri c surgery were i ncl uded i n the study and were fol l owed for one year. Data were anal ysed retrospecti vel y for age, gender, cl i ni cal features, management and outcome of management. Di agnosi s i n the suspected pati ents was based on hi story of passage of worms per mouth or rectum and on x-ray and ul trasonography fi ndi ngs. Al l pati ents were exami ned by ul trasound scanni ng i n both supi ne surgery is needed in patients with abdominal guarding and rigidity. Key words: Hypertonic saline enema, intestinal obstruction, roundworms, ultrasonography [Downloadedfreefromhttp://www.afrjpaedsurg.orgonWednesday,September25,2013,IP:103.10.67.52]||ClickheretodownloadfreeAndroidapplicationforthis journal African J ournal of Paediatric Surgery 66 J uly-December 2008 / Vol 5 / Issue 2 and i n l eft l ateral posi ti on to i ncrease the di agnosti c effi cacy. Management ai ms to starve the worms and hydrate the pati ent . Al l the pati ents were managed as for acute i ntesti nal obstructi on by keepi ng them ni l by mouth, nasogastri c aspi rati on, i ntravenous fl ui ds and hypertoni c sal i ne enema twi ce dai l y. The hypertoni c sal i ne enema was used onl y for di sentangl i ng and ex pul si on of col oni c worms and chi l dren were watched cl osel y for any features of dehydrati on. No anti hel menthi c drugs were gi ven to the pati ent duri ng the acute stage. However pati ents who had abdomi nal guardi ng or ri gi di ty or those who devel oped them i n due course were taken for emergency expl orati on. Eval uati on of other fami l y members was carri ed out whenever the di agnosi s was made because of the propensi ty of the i nfestati on to cl uster i n fami l i es. On fol l ow-up, al l the pati ents were gi ven al bendazol e therapy two weeks after di scharge from hospi tal and were eval uated at three months and at the end of one year to ensure that no ova were detectabl e i n stool , ei ther because of i nadequate el i mi nati on of adul t worms or because of re-i nfestati on, and an extra dose of al bendazol e therapy was gi ven to the posi ti ve cases. RESULTS One hundred and three pati ents wi th i ntesti nal obstructi on due to Ascari s l umbri coi des were treated i n the past fi ve years at our centre. There were thi rty- ei ght (36.89%) gi rl s and si xty-fi ve (63.11%) boys. Most of the chi l dren were i n the 4 to 8 years age group, wi th peak occurrence at 5 to 6 years of age. Abdomi nal pai n was the most common presentati on i n 96 (93.20%) chi l dren, fol l owed by vomi ti ng i n 77 (74.76%). Twenty (19.43%) chi l dren had hi story of vomi ti ng worms and another 43 (41.75%) had hi story of passi ng worms i n stool . Twenty-two (20.36%) had fever, 30 (29.13%) had hi story of consti pati on and four (3.88%) had hi story of di arrhoea. Ni ne chi l dren (8.74%) had hi story of taki ng anti hel menthi c drugs wi thi n one week of presentati on to the hospi tal . Fi fty (48.54%) chi l dren had abdomi nal tenderness, 14 (13.59%) of whom had abdomi nal guardi ng or ri gi di ty at presentati on and 2 (1.94%) devel oped them duri ng the course of conservati ve management. 48 (46.60%) chi l dren had abdomi nal di stensi on of varyi ng degrees, 50 (48.54%) had abdomi nal mass due to bol us of worms, and si x (5.83%) had features of dehydrati on. X-ray suggested the di agnosi s i n 54 pati ents (52.43%) and i n 91 pati ents (88.35%) the di agnosi s was confi rmed on ul trasonography. Ei ghty-seven chi l dren (84.47%) responded favourabl y to conservati ve management and passed worms per rectal l y from thi rd to fi fth day onwards and di d not requi re any surgi cal i nterventi on. However duri ng conservati ve management three chi l dren devel oped features of mi l d dehydrati on and el ectrol yte i mbal ance and were managed successful l y. Al l chi l dren who presented wi th abdomi nal guardi ng or ri gi di ty and those who devel oped them subsequentl y were taken for emergency expl orati on (14 and two respecti vel y). Of the 16 chi l dren who had emergency surgery, seven had bol us of worms, si x had vol vul us and gangrene of smal l bowel , two had i l eal perforati on [Fi gure 1] and one had appendi cul ar perforati on. Out of si x pati ents wi th vol vul us and gangrene, fi ve were managed by resecti on and anastomosi s and l oop i l eostomy was performed i n the si xth case. Of the two chi l dren wi th i l eal perforati on one was managed by doubl e l ayered repai r and resecti on and anastomosi s was performed for another. Appendectomy was performed for pati ent wi th appendi cul ar perforati on. One chi l d wi th l arge bol us of worms and thi nned out i l eal wal l requi red enterotomy for extracti on of the worms. The remai ni ng si x chi l dren were managed by manual mi l ki ng of the worms from the bowel [Fi gure 2]. Out of si xteen chi l dren who underwent surgery, two had wound i nfecti ons, and one wi th i l eostomy had peri stomal excori ati on but they al l responded to conservati ve management. One of the chi l dren wi th vol vul us and gangrene of smal l bowel managed by resecti on and anastomosi s had l eak from the anastomosi s si te; he underwent rel aparotomy and i l eal stoma was made but subsequentl y he devel oped septi caemi a and di ed. Ni nety pati ents turned up for the 1 st fol l ow up vi si t at the end of three months of whi ch 48 were posi ti ve for roundworm ova. Fi fty-one turned up for the 2nd vi si t at the end of one year of whi ch 32 were posi ti ve for roundworm ova. Al l posi ti ve cases were treated wi th an extra dose of al bendazol e. One pati ent, who di d not turn up for fol l ow up, presented at the end of 18 months wi th i ntesti nal obstructi on due to roundworms and was managed conservati vel y wi th good outcome. DISCUSSION Roundworm rel ated i ntesti nal obstructi on i s more common i n chi l dren because of the smal l er di ameter of the l umen of the bowel and, often, an i ncreased worm Mishra PK et al.: Round worm obstruction in children [Downloadedfreefromhttp://www.afrjpaedsurg.orgonWednesday,September25,2013,IP:103.10.67.52]||ClickheretodownloadfreeAndroidapplicationforthis journal 67 J uly-December 2008 / Vol 5 / Issue 2 African J ournal of Paediatric Surgery l oad. Transmi ssi on occurs mai nl y vi a i ngesti on of water or food contami nated wi th Ascari s l umbri coi des eggs and occasi onal l y vi a i nhal ati on of contami nated dust. Chi l dren pl ayi ng i n contami nated soi l may acqui re the parasi te from thei r hands and thi s can be the reason for greater i nci dence of thi s condi ti on i n boys as they are more exposed to outdoor acti vi ti es; si mi l ar hi gh i nci dence i n mal e pati ents i s al so reported by other authors. [11] Transpl acental mi grati on [12] of l arvae has al so occasi onal l y been reported. Adul t worms do not mul ti pl y i n the human host, so the number of adul t worms per i nfested person rel ates to the degree of conti nued exposure to i nfecti ous eggs over ti me. In Indi a, the preval ence of hi gh-i ntensi ty Ascari s i nfecti on, i n whi ch there i s a hi gh worm burden, i s 768 cases per 100,000 persons; [13] gl obal l y, there are an esti mated 62 mi l l i on persons [13] wi th hi gh-i ntensi ty Ascari s l umbri coi des i nfestati on. Intesti nal obstructi on i s an especi al l y acute probl em i n the devel opi ng worl d. [13]
The preval ence of Ascari s-rel ated i ntesti nal obstructi on i n I ndi a i s 9.2 cases per 100,000 persons. [13] There are nearl y 730,000 cases of Ascari s-i nduced bowel obstructi on and 11,000 deaths annual l y worl dwi de. The majori ty of i nfestati ons wi th Ascari s l umbri coi des are asymptomati c. However, the burden of symptomati c di sease worl dwi de i s sti l l rel ati vel y hi gh because of the hi gh preval ence of di sease. Cl i ni cal di sease [9,14]
i s l argel y restri cted to i ndi vi dual s wi th a hi gh worm l oad. [15] One revi ew esti mated the worm burden wi th i ntesti nal obstructi on to be >60 (and ten ti mes hi gher i n fatal cases). [16] When symptoms do occur, they rel ate ei ther to the l arval mi grati on stage or to the adul t worm i ntesti nal stage. Heavy i nfestati ons wi th Ascari s are frequentl y bel i eved to resul t i n abdomi nal di scomfort, anorexi a, nausea and di arrhoea. However, i t has not been confi rmed whether or not these non-speci fi c symptoms can trul y be attri buted to Ascari asi s. [17] Mishra PK et al.: Round worm obstruction in children Figure 1: Round worm causing ileal perforation Figure 3: X-ray showing multiple air uid level with cigar bundle appearance of round worms Figure 2: Milking of small intestine to evacuate round worms Figure 4: Ultrasound appearances of round worms [Downloadedfreefromhttp://www.afrjpaedsurg.orgonWednesday,September25,2013,IP:103.10.67.52]||ClickheretodownloadfreeAndroidapplicationforthis journal African J ournal of Paediatric Surgery 68 J uly-December 2008 / Vol 5 / Issue 2 A mass of worms can obstruct the bowel l umen i n heavy Ascari s i nfestati on, l eadi ng to acute i ntesti nal obstructi on. The obstructi on occurs most commonl y at the i l eocecal val ve. Symptoms i ncl ude col i cky abdomi nal pai n, vomi ti ng and consti pati on. Vomi tus may contai n worms. Approxi matel y 85 percent of obstructi ons occur i n chi l dren between the ages of one and fi ve years. [15] Someti mes an abdomi nal mass that changes i n si ze and l ocati on on seri al exami nati ons [18] may be appreci ated. Compl i cati ons i ncl udi ng vol vul us, [19]
i l eocecal i ntussuscepti on, gangrene, and i ntesti nal perforati on occasi onal l y resul t. The di agnosi s was kept i n mi nd i n al l cases of i ntesti nal obstructi on i n paedi atri c age group and was based on hi story of passage of worms i n vomi tus or stool [20,21]
al ong wi th X-ray and ul trasonographi c features of roundworm and i ntesti nal obstructi on. I n heavi l y i nfested chi l dren, l arge col l ecti ons of worms may be vi sual i sed on pl ai n fi l m of the abdomen as radi ol ucent areas [22] or wi th a ci gar bundl e appearance [Fi gure 3]. Occasi onal l y the mass of worms created contrasts agai nst the gas i n the bowel , typi cal l y produci ng a whi rl pool effect. [23] Radi ographs al so showed features of associ ated i ntesti nal obstructi on l i ke abdomi nal di stensi on, di l ated bowel l oops and mul ti pl e ai r fl ui d l evel s and free gas under di aphragm i n cases wi th i ntesti nal perforati on. Ul trasonography [Fi gure 4] of the abdomen has been advocated as a qui ck, safe, non-i nvasi ve and rel ati vel y i nexpensi ve modal i ty for suspected i ntesti nal Ascari asi s and vari ous appearances of roundworms have been descri bed l i ke a thi ck echogeni c stri p wi th a central anechoi c tube or mul ti pl e l ong, l i near, paral l el echogeni c stri ps wi thout acousti c shadowi ng. [24-28] Other characteri sti c fi ndi ngs were vi sual i sati on of si ngl e worm, bundl es of worms, or a pseudo tumour- l i ke (hel menthi noma) [29] appearances. Some ti mes i ndi vi dual body segments of worms were vi si bl e as mul ti pl e pai rs of curvi l i near echogeni c l i nes, and on prol onged scanni ng, the worms showed curl i ng movements. The al i mentary canal of the worm was seen ei ther as a si ngl e central echogeni c l i ne i n col l apsed state or as two paral l el hypoechoi c bands wi th a hypoechoi c centre i n di stended state al so descri bed as a wi ndi ng hi ghway or paral l el l i nes . [24-26] When exami ned transaxi al l y, the i ndi vi dual worm resembl ed a target wi th i ts ci rcul ar, echogeni c body wal l and i ts central dot-l i ke al i mentary canal . The ai m of our management to starve the worms and hydrate the pati ent i s based on the fact that roundworms are dependent on the parti al l y di gested nutri ents i n the smal l i ntesti ne for survi val . So by keepi ng the pati ents ni l by mouth we are i ndi rectl y starvi ng the worms whi ch promotes thei r movement and di sentangl ement. The hydrati on part of the management emphasi ses the need for proper fl ui d therapy so as to avoi d any untoward compl i cati on duri ng the conservati ve therapy. The hypertoni c sal i ne enema [30] causes i rri tati on and promotes di sentangl i ng and expul si on of col oni c worms, however duri ng i ts use chi l dren shoul d be watched cl osel y for any features of dehydrati on. We di d not use any anti hel menthi c agent duri ng the course of conservati ve management as they al ter the moti l i ty of the worms and hamper thei r cl earance and may l ead to seri ous compl i cati ons l i ke i ntussuscepti ons, vol vul us, haemorrhagi c or necroti c bowel and even perforati on. [21,31] Re-i nfestati on occurs frequentl y; more than 80 percent of i ndi vi dual s i n some endemi c areas become re- i nfested wi thi n si x months. [15] The overal l i nci dence of obstructi on i s approxi matel y 1 i n 500 chi l dren. [15] In endemi c areas, i t has been shown that between 5 and 35 percent of al l cases of bowel obstructi on are due to ascari asi s. [15] Mul ti pl e worms frequentl y remai n i n the i ntesti nes for several years wi thout causi ng di sease. There are 4 major factors that resul t i n Ascari s-rel ated i ntesti nal obstructi on.: [23] 1. Mul ti pl e worms can form a l arge bol us, resul ti ng i n mechani cal obstructi on of the bowel l umen. Thi s i s the most frequent cause of Ascari s- rel ated bowel obstructi on. 2. The worm bol us may serve as a l ead poi nt i n i ntussuscepti on or a pi vot i n smal l bowel vol vul us. 3. Ascari s worms may i nhabi t the i l eocecal val ve, where roundworm secreti on of neurotoxi ns prompts smal l -bowel contracti on. Thi s acti on, coupl ed wi th hi gh worm burden i n the i l eocecal val ve, can obstruct the i ntesti ne. 4. A host i nfl ammatory reacti on to worm-deri ved haemol ysi ns, endocri nol ysi ns, and anaphyl atoxi ns can be severe enough to obstruct the gut l umen. Bowel perforati on i s thought to fol l ow i schemi a from pressure by the mass of worms i n the i l eum. Thi s vi ew was however questi oned by Efem [5] who postul ated that except i n confi ned spaces l i ke the appendi x, Meckel s di verti cul um and the bi l i ary tree, the i ntesti ne i s capabl e of i mmense di l atati on to accommodate up to 5000 worms wi thout symptoms. Typhoi d perforati ons, Mishra PK et al.: Round worm obstruction in children [Downloadedfreefromhttp://www.afrjpaedsurg.orgonWednesday,September25,2013,IP:103.10.67.52]||ClickheretodownloadfreeAndroidapplicationforthis journal 69 J uly-December 2008 / Vol 5 / Issue 2 African J ournal of Paediatric Surgery non-speci fi c ul cers and anastomoti c suture l i nes are thought to provi de exi ts for the worm. Vari ous other authors [32,33] have performed si mi l ar studi es i nvol vi ng paedi atri c pati ents and exami ned the use of conservati ve versus surgi cal management of i ntesti nal obstructi on due to Ascari asi s and reported a hi gh success rate wi th conservati ve therapy. Unl i ke the other mechani cal causes of i ntesti nal obstructi on most cases of acute i ntesti nal obstructi on due to Ascari asi s can be managed conservati vel y. At the ti me of di scharge and i n fol l ow up chi l dren and thei r parents were advi sed regardi ng use of toi l et faci l i ti es, safe excreta di sposal , protecti on of food from di rt and soi l , thorough washi ng of raw food materi al s, hand washi ng, and common-sense sani tary measures. Mass treatments wi th si ngl e dose mebendazol e or al bendazol e for al l school -age chi l dren every three to four months have been used i n some communi ti es. Thi s serves the dual functi on of treati ng the chi l dren and reduci ng the overal l worm burden i n the communi ty. Indeed, mass communi ty therapy has been shown to reduce Ascari s burden and transmi ssi on. Al though i t has a greater effect on the i ntensi ty of i nfestati on than on the overal l preval ence, [34-37] thi s approach has been shown to be cost-effecti ve. [38] Because re-i nfestati on occurs so frequentl y, shorter i nterval s between treatments have been found to be preferabl e. Targeted treatment hel ps control the morbi di ty of i nfestati on but does not have a substanti al effect on transmi ssi on. [29,39,40] I n concl usi on, roundworm obstructi on shoul d be the di fferenti al di agnosi s of al l cases of i ntesti nal obstructi on i n chi l dren. 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Targeted antihelmenthic treatment of school children: Effect of frequency of application on the intensity of Ascaris lumbricoides infection in children from rural Nigerian villages. Parasitology 1996;113:87-95. Mishra PK et al.: Round worm obstruction in children Aut hor Help: Online Submission of t he Manuscript s Art icles can be submit t ed online from ht t p:/ / w w w.journalonw eb.com. For online submission art icles should be prepared in t w o files (first page file and art icle file). Images should be submit t ed separat ely. 1) First Page File: Prepare t he t it le page, covering let t er, acknow ledgement , et c., using a w ord processor program. All informat ion w hich can reveal your ident it y should be here. Use t ext / rt f/ doc/ pdf files. Do not zip t he files. 2) Art icle f ile: The main t ext of t he art icle, beginning from Abst ract t ill References (including t ables) should be in t his file. 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