Ascriasis is a common infection in underdeveloped and developing countries and usually detected incidentally on evaluation of nonspecific pain abdomen. Complications related to ascariasis occur mainly due to heavy worm load. We here report a rare case, in which a single live ascaris worm had caused jejunal perforation

Amit S,

Ashwani K,

Divya S,

Pankaj KG,

Reetinder C,

Vijay KS,

English

UKM Journal Article Repository

Ascariasis causing jejunal perforation                                                                                                                Reetinder C et al.                                                                                                                                                         Journal of Surgical Academia 2013; 3(1):35-37   35       Jejunal Perforation Due to Single Ascaris Lumbricoides – A Case Report  Reetinder C, Pankaj KG (), Divya S, Ashwani K, Vijay KS, Amit S  Department of Surgery, Rajindra Hospital and Government Medical College, Patiala, Punjab, 147001 India.  Abstract  Ascriasis is a common infection in underdeveloped and developing countries and usually detected incidentally on evaluation of nonspecific pain abdomen. Complications related to ascariasis occur mainly due to heavy worm load. We here report a rare case, in which a single live ascaris worm had caused jejunal perforation.    Keywords: Ascaris lumbricoides, jejunum, perforation, peritonitis, chemoprophylaxis  Dr. Pankaj Kumar Garg, Department of Surgery, Rajindra Hospital and Government Medical College, Patiala, Punjab, India, 147001. Tel: +919872229824 Fax: 01752212542 Email: dr.pankaj.garg83@gmail.com Correspondence:   Date of submission: 21 Nov, 2012          Date of acceptance: 5 Mar, 2013   Introduction  An important medical, social and economic problem in many underdeveloped countries is Ascariasis, where the precipitating factors are poverty, unhygienic conditions, sanitation, and unsafe drinking water supply (1,2,3). For the development of larval stage of worms, wet soil of Punjab and temperate climate serve as excellent conditions. Ascaris infestation causes common surgical problems like small intestinal obstruction, volvulus, intussusception and perforation usually involving the ileum (4,5,6,7,8). Incidence of children infested with Ascaris lumbricoides, in our environment is over 70% and surgical complications are common in them. However, surgical complications of ascaris worms in adults are less common (9). Here, we report a rare case of jejunal perforation due to a single round worm in adult.  Case Report  A 32-year-old vegetable vendor, chronic alcoholic for the past 15 years, presented to the emergency with complaints of pain abdomen, vomiting and abdominal distention for the past two days. After conducting routine blood and urine investigations, an erect chest x-ray was performed. It revealed free air under both domes of the diaphragm. An exploratory laparotomy was performed and the intra-operative findings were as follows: Single perforation was present in the jejunum, about 20cm distal to duodeno-jejunal junction, measuring 2x1.5 cm in size, on the anti-mesenteric border.  One round shaped worm measuring about 10 cm in length, was protruding out from the perforation site (Fig.1)  The round-worm was removed (Fig.2), whole of the small intestine examined for any other worm and the perforation site was closed in a single layer. Post-operatively, the patient was given broad spectrum antibiotics and anti-helminthic therapy was instituted. The histology of perforation margin showed edema and invasion of the lamina propria by polymorphonuclear leukocytes. On retrospective interrogation, the patient gave history of eating undercooked and partially cooked meat regularly and living in unhygienic conditions. His further stay in the hospital was uneventful, and he was discharged in a satisfactory condition.  Discussion  Ascaris is the earliest recorded human helminthes and has a worldwide distribution being prevalent especially in the tropics such as China, India, Bangladesh and South-East Asia. Pre-early school age children are most commonly affected by Ascaris infection, although it is prevalent in all age group of both sexes (1-3). Transmission of Ascariasis to humans is by faeco-oral route.  Case Report Ascariasis causing jejunal perforation                                                                                                                Reetinder C et al.                                                                                                                                                         Journal of Surgical Academia 2013; 3(1):35-37   36                Figure 1: Live Ascaris lumbricoides removal from jejunal perforation.  In children having history of passing worms frequently, ascaris induced intestinal obstruction is a common complication, along with intussuception, perforation and gangrene of bowel as further complication. But these are not very common because of intestine’s immense capacity for dilation. Some claim that more than 5000 worms may be present in the intestine and patient may remain asymptomatic so it is very rare that direct pressure by few ascaris may cause jejunal perforation (11,12). In our case only a single live ascaris worm was found causing jejunal perforation.  Two types of intestinal perforation by normal worms are recognized, primary and the secondary. In the primary type, the worm perforates through healthy intestinal, while in the secondary type there is associated intestinal disease like enteric fever, or a weakness in intestinal wall. In primary perforation, it has been suggested that the worm produces a lytic secretion and this combined with the nibbling effect of the head of the worm can lead to perforation of the normally impenetrable bowel wall. Despite the fact that ascaris is toothless and has soft lips, it is paradoxical that it can perforate normal healthy intestine (13). This fact describes cause of perforation in our case.  Provision of clean drinking water, safe deposal of human sewage, legislation to ensure high standards of food hygiene and programmes to detect and monitor chronic carriers are advocated (14). These efforts should be complemented by mass anti-helminthic chemoprophylaxis which may further ameliorate the risk of early intestinal perforation.  Conclusion   Despite the large number of cases of infestation with Ascaris lumbricoides reported in the literature, no case of jejunal perforation by a single ascaris worm per se was conclusively identified. Possibility of ascariasis should always be considered in patients                Figure 2: Live Ascaris lumbricoides. (Length about 10 cm)  with nonspecific abdominal pain, as a cause of perforation, especially in tropical countries. As a delay in management of the abdominal complications can have a fatal outcome, the surgeon and physician who are treating these patients should be aware of it.   References  1. Mahmoud AA. Intestinal nematodes. In: Mandell GI, Douglas RG, Bennet JE, eds. Principles and practice of infectious diseases. 3rd Ed. New York: Churchill Livingstone, 1990; pp-2137- 2138.  2. Surrendran N, Paulose MO. Intestinal complications of round-worms in children. J Paediatr Surg 1998; 23(10):931-5.  3. Markell EK, Voge M, John DT. The intestinal nematodes. In: Ozmat S, ed. Medical parasitology. Philadelphia: WB Saunders, 1992; pp-261-293.  4. Wani NA, Shah OJ, Wani MA. Surgical complications of abdominal ascariasis. Postgraduate Doctor Africa 2002; 24:38-40.   5. Otu AA. Tropical surgical abdominal emergencies: acute intestinal obstruction. Afr J Med Med Sci 1991; 20(2):83-88.   6. Archibong AE, Ndoma-Egba R, Asindi AA. Intestinal obstruction in south-eastern Nigerian children. East Afr Med J 1994; 71(5):286-9.  7. Hassan AW. Intestinal obstruction due to ascariasis. Nigerian Journal of Surgical Sciences 1993; 3:91-93.  8. Efem EE. Ascaris lumbricoides and intestinal perforation. Br J Surg 1987; 74:683-684.   Ascariasis causing jejunal perforation                                                                                                                Reetinder C et al.                                                                                                                                                         Journal of Surgical Academia 2013; 3(1):35-37   37  9. Ihekwaba FN. Ascaris lumbricoides and perforation of the ileum - a critical review. Br J Surg 1979; 66(2):132-4.  10. Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996;25(3):553-77.  11. Louw JH. Abdominal complications of Ascaris lumbricoides manifestation in children. Br J Surg 1966;53(6):510-21.  12. Basavaraju SV, Hote PJ. Acute GI and surgical complications of Ascaris lumbricoides infection. Infections in Medicine 2003; 20(3):154–159.  13. Kinde-Gazard D, Gangbo F, Anagonou S, Gninafon M, Massougbodji A. Granulomatous peritonitis from ascariasis: apropos of 1 case in a Benin child. Bull Soc Pathol Exot 2000;93(1):23-4.  14. White NJ, Parry CM. The treatment of typhoid fever. Curr Opin Infect Dis 1996: 9; 298-302. 

Abdominal complications of Ascaris lumbricoides manifestation in children.

Acute GI and surgical complications of Ascaris lumbricoides infection. Infections in Medicine

Ascaris lumbricoides and intestinal perforation. Br J Surg 1987; 74:683-684. Ascariasis causing jejunal perforation Reetinder C et al.

Ascaris lumbricoides and perforation of the ileum - a critical review.

Granulomatous peritonitis from ascariasis: apropos of 1 case in a Benin child. Bull Soc Pathol Exot

Jejunal perforation due to single ascaris lumbricoides – a case report.

Abstract

Similar works

Full text

Available Versions

UKM Journal Article Repository