Ascaris lumbricoides a rare cause ileal perforation, a case report

Abstract

Introduction and importance

Ascariasis is a helminthic infection of humans caused by Ascaris lumbricoides. Pediatric patients infected with Ascaris can develop multiple complications including appendicitis, gastrointestinal bleeding, hepatobiliary disease like cholangitis or obstructive jaundice, intussusception, and bowel obstruction among others. Ascaris is a rare cause of intestinal perforation even in endemic areas.

Case presentation

A 2-year-old female Ethiopian toddler who was presented with a complaint of non-bilious, non-projectile vomiting of 06 days duration, about two-three episodes per day. Associated with this she had had progressive abdominal distension, intermittent abdominal cramps and loss of appetite. On examination, she was acutely sick looking. She had signs of dehydration. Subsequently, she was resuscitated, broad spectrum antibiotic started and operated. Finally, the child was discharged improved after 7 days of hospital stay.

Clinical discussion

The clinical presentation of ascariasis can vary from asymptomatic child to one with severe disease requiring surgical intervention like our patient. Severity of disease depends on the worm burden; heavy worm infestation produces a wide range of acute abdominal complications such as intestinal obstruction, intussusception, cholangiohepatitis, pancreatitis, and acute appendicitis. Intestinal ascariasis rarely causes volvulus and intestinal gangrene, perforation and peritonitis.

Conclusion

Ascariasis must be considered in the differential diagnosis in patients presented with peritonitis especially those living or from temperate and tropical countries with a history of passage of worms. Ileum perforation is possible in patients with ascariasis due to pressing directly into the bowel wall, inflammatory reaction, or volvulus and intestinal wall necrosis.

Highlights

• •Ascariasis is a helminthic infection of humans caused by Ascaris lumbricoides.
• •AL is a rare cause of intestinal perforation even in endemic areas.
• •A prompt surgical treatment should be undertaken at the earliest in a case of acute abdomen with ascariasis infestation.
• •Absence of eggs or worms by fecal microscopy does not necessarily rule out the diagnosis, especially in the early stages.

1. Introduction

Infecting one-quarter of the global population, ascariasis is considered as the leader of helminths infection [1]. Ascariasis is a helminthic infection of humans caused by Ascaris lumbricoides, a nematode. Ascaris is a cosmopolitan parasite and the most prevalent and largest of the human helminthic infections. The normal habitat of the adult worm is the jejunum. The infection is acquired by the ingestion of the embryonated eggs, and the larvae pass through a pulmonary migration phase for maturation [2]. The worm may produce symptoms at two stages in the life cycle of: the larval stage, where alveolar deposition and inflammation cause symptoms, and when the adult worms are lodged in the small bowel in which toxins may be released, producing a systemic reaction. If the mature worms migrate in sufficient numbers, an obstruction of the bowel may occur [3].

The high incidence of ascariasis and other intestinal parasitosis is a characteristic of underdeveloped countries like Ethiopia, where the great part of the population lives in low hygiene conditions and lacks basic sanitation. Consequently, the complications of these pathologies are more frequent and represent an important medical, social, and economical problem for these nations [1] [4].According to one study done in Ethiopia the prevalence of AL among school age children is around 6.2 % [5]. Pediatric patients infected with AL can develop multiple complications including appendicitis, gastrointestinal bleeding, hepatobiliary disease like cholangitis or obstructive jaundice, intussusception, and bowel obstruction among others [1]. Perforation of the small intestine is encountered in a variety of disorders, such as typhoid fever, regional enteritis, amoebiasis, tuberculosis and malignant lymphoma, AL is a rare cause of intestinal perforation even in endemic areas. Ascariasis is associated with many abdominal complications [6]. Here we present a case of ileal perforation due to Ascaris in a 2-year-old female toddler who was managed operatively and discharged improved.

This case report has been reported in line with the SCARE Criteria [7].

2. Clinical presentation

She is a 2-year-old female Ethiopian toddler who was presented with a complaint of non-bilious, non-projectile vomiting of 06 days duration, about two-three episodes per day. Associated with this she had had progressive abdominal distension, intermittent abdominal cramps and loss of appetite. Since one day prior to her presentation, the vomiting worsened and became bilious and the pain became persistent with associated failure to pass feces and flatus. She had a history of passage of Ascaris worm prior to the above symptoms. However, she had no history of urinary complaint. She had no trauma to the abdomen. She is fully vaccinated up to her age. She was exclusively breast fed for the first six months and started complementary feeding after that. She lives with her parents and her one sibling. Her father is a farmer and her mother is housewife. They use spring water for drinking. She has no known medical illness or any known drug allergy.

On examination, she was acutely sick looking. She had signs of dehydration (sunken eye balls and dry buccal mucosa). Vital signs were; pulse rate 124 beats/min, respiratory rate 30 breaths/min and temperature of 38.9 °C. On anthropometric measurements she is 9.5 kg in weight and 78 cm in height (moderately stunted). She had clear and resonant chest. Abdominal examination revealed distended abdomen with diffuse tenderness, guarding and rigidity and there was stool on examining finger but no loss of liver dullness. Initial differential diagnoses considered were gangrenous small bowel volvulus and perforated appendicitis but the investigation results were not suggestive of it. On investigations, complete blood count (CBC) revealed anemia with hemoglobin of 9 g/dl, and white blood cell count of 8300 with 0.1 % eosinophil, other parameters were normal but peripheral morphology was not done. Serum electrolyte assessments showed hyponatremia (130 mmol/l), hypokalemia (2.94 mmol/l) and hypochloremia (90.7 mmol/l). On abdominal ultrasound; there were numerous tubular shaped structures inside bowel loops and it has echogenic parallel wall, there was 3 ∗ 2 cm loculated complex collection at the right lower quadrant area and the bowel loops adjacent to the collection were thickened with echogenic mesenteric fat stranding. Other abdominal viscera look normal. Plain abdominal x-ray showed distended small bowel loops with worm like structures at the right and left lower quadrants, but no pneumoperitoneum (air under the diaphragm) (Fig. 1).

Fig. 1.

Erect plain abdominal x-ray showing dilated small bowel loops and worm like structures at the right lower quadrant.

Therefore, she was resuscitated, broad spectrum antibiotic started (ceftriaxone 250 mg IV twice a day and metronidazole 100 mg IV three times a day) and nasogastric (NG) tube inserted. Subsequently, she was operated on under general anesthesia and supine position by a senior pediatric surgeon and general surgery residents at tertiary hospital. Intraoperatively, there was minimal reactive fluid in the peritoneal cavity, 30 cm of the distal ileum starting 5 cm from the ileocecal valve was twisted around its mesentery and it was frankly gangrenous with small perforation. There was large Ascaris ball inside the gangrenous ileal segment. There was huge mesenteric lymphadenopathy near the gangrenous segment. Therefore, derotation and resection of the gangrenous distal ileum was done along with the mesenteric lymph nodes (Fig. 2), proximal small bowel Ascaris worms milked distally and removed, primary end to end ileo-ileal anastomosis was done and finally peritoneal cavity thoroughly washed with warm normal saline and abdomen closed in layers. The resected segment sent for histopathology (Fig. 2). Subsequent histopathologic evaluation showed transmural suppurative gangrenous inflammation (Fig. 3, Fig. 4). Postoperatively, she was commenced on IV antibiotics (mentioned above) and paracetamol 125 mg suppository three times a day. The NG tube kept in situ for 24 h. Later the patient passed flatus after 36 h and she started sips which was advanced progressively. She was dewormed with albendazole. Finally the patient was discharged improved after 7 days of hospital stay with no postoperative complication. The parents were dewormed with albendazole. She did not have any complaint on subsequent follow-up at surgical referral clinic.

Fig. 2.

Gross image of massive aggregates of ascarides within the ileum causing obstruction and gangrenous perforation necessitating resection.

Fig. 3.

H and E (10×) Histopathology of small intestine showing one worm segment containing large number of ova of Ascaris along with multiple scattered both fertilized and unfertilized eggs eliciting transmural suppurative gangrenous inflammation.

Fig. 4.

H&E (100×) Fertilized egg of roundworm Ascaris lumbricoides, the causative agent of ascariasis.

3. Discussion

Infestation with Ascaris is a worldwide problem with up to a quarter of the world's population, mostly the third world countries infected like Ethiopia. Ascaris mostly resides in the jejunem, however, perforations due to this organism is usually located in the terminal ileum, cecum, appendix, meckel's diverticulum, rarely duodenum [8], or stomach [9]. Ascariasis is common in tropical and subtropical areas where unhygienic disposal of human wastes is common. Ingestion of embryonated eggs in uncooked vegetables or water is the mode of transmission. The fertilized eggs hatch in the duodenum and larvae penetrate the bowel wall to reach the heart, pulmonary circulation, and alveoli. The larvae are coughed by the host, swallowed back into the intestine, and develop into adult worms. Since adults do not multiply in humans, symptoms depend on the worm load in the intestine [10]. The adult worm is a large, pink, elongated, cylindric organism, which tapers at both ends. The female worms are 20 to 49 cm long and 3 to 6 mm in diameter; the male worms are 15 to 30 cm long and 2 to 4 mm in diameter. The adult worm maintains itself in the lumen of the gut by virtue of its muscular activity [2]. The clinical presentation of ascariasis can vary from asymptomatic child to one with severe disease requiring surgical intervention like our patient. Severity of disease depends on the worm burden; heavy worm infestation produces a wide range of acute abdominal complications such as intestinal obstruction, intussusception, cholangiohepatitis, pancreatitis, and acute appendicitis. Intestinal ascariasis may cause volvulus and intestinal gangrene, perforation and peritonitis. GI perforation involving small intestine has been reported in children in approximately 10 % cases of surgical presentation [11].

Pediatric intestinal obstruction can be caused by a variety of etiological factors. Ascariasis must be suspected in children from endemic regions of the world presenting with acute abdomen. Infections may be asymptomatic when the worm load is less. In patients with high worm load, it can cause symptoms. Due to the wandering nature of the worms, they can penetrate cavities and cause a wide range of complications. Abdominal complications include acute pancreatitis, obstructive jaundice, acute cholecystitis, appendicitis, liver abscess, intestinal obstruction, perforation, massive gastrointestinal bleeding, and gangrene of the bowel [10]. In ascariasis, the cause of perforation of the small intestine remains controversial, with two main theories. In the tropics patients consistently have histories of diseases associated with ulceration of the intestines such as typhoid enteritis, tuberculosis and amoebiasis. During extreme conditions, such as inflammation, starvation or worm bolus obstruction, some parasites are believed to migrate into the ulcers and cause perforations. Another possible explanation is that the large worm bolus can lead to pressure necrosis and gangrene [9]. In our patient, the Ascaris ball causes volvulus (due to the weight of the roundworms) with perforation, we assume both theories might explain. The intestine has immense capacity to expand and it has been claimed that it can accommodate 5000 worms without symptoms occurring. It is thus unlikely that direct pressure by ascarids can produce intestinal perforation as claimed by some author, except in confined spaces such as the appendix, Meckel's diverticulumz and the common bile duct [12].

In patients with ascariasis who present with acute surgical conditions, an urgent laparotomy is indicated to deal with intestinal perforation, to control peritonitis and to decompress the worm bolus causing the acute intestinal obstruction [13]. Intestinal obstruction in ascariasis can have several mechanisms including: [1] obstruction of the lumen of the small bowel by an entangled bolus of worms, [2] spasmodic contraction of the small bowel on to a mass of worms with effectual obstruction at the ileocecal valve, [3] inflammation and matting of loops of the bowel at the site occupied by worms and [4] associated volvulus or intussusceptions [9] [14]. Under normal circumstances, Ascaris resides in the small intestine. When the environment in the intestine becomes unfavourable such as during starvation, inflammation and obstruction, the ascarid will migrate to other less hostile parts. They may thus migrate into the biliary system, the pancreatic duct, the stomach to be vomited through the mouth, into nasogastric tubes causing blockage, into the peritoneum through perforated ulcers or anastomotic suture lines, or through the anus. They may convert near perforations caused by typhoid, amoebiasis, tuberculosis and non-specific ulcers into frank perforation, but it is unlikely that they produce direct perforation of the intact intestine. It is of interest that perforation would in any case be deleterious to the species since it does not survive for long outside the intestinal lumen [12].

The diagnosis is usually based on the presence of Ascaris eggs or worms in stools, but occasionally the worm itself may be seen with plain abdominal roentgenograms as long negative intraluminal images with “whirlpool pattern” [15]. Ultrasonography of abdomen is a quick, safe, easily available, non-invasive and relatively inexpensive modality for suspected intestinal ascariasis [16]. When sonographically imaged longitudinally, an ascarid appears as a linear echogenic structure: 2 pairs of parallel echogenic lines, representing the body margins like the ultrasound description of our patient, flank a broader central sonolucent line, representing the digestive tract. When viewed transversely, the ascarid resembles a bull's-eye target, with an echogenic body margin encircling an inner dot-like sonolucent digestive tract. “These sonographic features have been variously designated as the “strip,” “four-lines,” “inner-tube,” “double-tube,” “bull's-eye,” “target,” or “zig-zag” sign and described as a “worm mass” or “spaghetti-like” appearance”. In addition, live ascarides exhibit nondirectional slow writhing movements, making them easy to identify on sonography. Whereas dead ascarides undergo calcification and appear as parallel stripes of calcification [17], CT scans are needed, especially when complications arise [18]. Intraoperatively, the failure to demonstrate the presence of any of the recognized agents of ileal perforation does not necessarily implicate A. lumbricoides merely by their presence. Evidence of bowel wall damage by an active process of round worms is necessary to implicate them in perforation of the gut. Induration of the tissues around the perforation is a common finding, and Ascaris worms are known to cause induration of the bowel wall by pressure, trauma and possibly by their toxic secretions. When Ascaris worms are found lying freely in the peritoneal cavity and the tissue around the site of perforations is replete with eosinophil cells, the conclusion is very pressing [19].

With regard to the management of Ascariasis, patients who presented early with a low grade or no fever, slight abdominal distension and mild diffuse tenderness can be managed conservatively. The conservative management included adequate fluid and electrolyte replacement to overcome the dehydration, nasogastric decompression and to relieve distension or vomiting and antibiotic coverage with analgesics. No antihelminthic was given at this stage, as it could worsen the obstruction by increasing the size of the worm bolus. Hypertonic saline enema has been recommended by some authors [20]. Most of the patients responded to the conservative management. In such patients, antihelminthic drug (albendazole 400 mg) was given in the hospital after relief of obstruction. The dose of anti-helminthic drug was repeated 6 weeks later to eradicate any worms that might have been in the larva phase at the time of admission [21].

Surgical intervention is relatively uncommon, with most patients successfully treated conservatively with supportive care and anti-parasitic medications. Reports of operative treatment range from approximately 20–30 % and vary on how extensive surgical treatment is needed [1].The preferred surgical treatment of worm-bolus obstruction in the distal ileum where there is no evidence of strangulation comprises milking the worms into the large bowel, whence they are passed spontaneously. If the worm bolus is more proximal, enterotomy is advised with extraction of the worm bolus using sponge-holding forceps, as milking the bolus distally down to the ileocecal valve is difficult and may be traumatic to the bowel wall. In severe cases, with strangulated bowel, resection with primary anastomosis is indicated like this patient. It is rarely necessary to bring out stomas [21]. The parents of our patient claimed, they were satisfied with the care her daughter was provided.

4. Conclusion

In patients presented with signs and symptoms suggestive of intestinal perforation or obstruction, Ascaris lumbricoides should be considered especially on those patients who had a history of passing parasite in the vomitus and/or stool. We should have a high index of suspicion, and a prompt surgical treatment should be undertaken at the earliest in a case of acute abdomen with ascariasis infestation. In addition, medical treatments like albendazole should be provided as well for deworming of other siblings and all family members and not just the index case.

Abbreviations

CT

Computed tomography

GI

Gastrointestinal

IV

Intravenous

NG

Nasogastric

US

Ultrasound

Consent

Written informed consent was taken from the parents for publication of this case report and any accompanying images. A copy of the written consent is available for review for the editor-in-chief of this journal.

Ethical approval

The case report has been submitted for Ethical Board Review and approved as ethically sound report.

Funding

Not applicable.

Guarantor

Dr. Andinet Desalegn and Dr. Amanuel Kassa.

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CRediT authorship contribution statement

All authors contributed to the conception, writing and editing of the case report. All authors are agreed to be accountable for all aspects of the manuscript.

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No potential conflict of interest relevant to this article was reported.

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The authors of this manuscript are willing to provide any additional information regarding the case report.