Intestinal obstruction due to Ascaris lumbricoides in child: a case report

Abstract

Background

Ascariasis in humans is one of the most significant neglected tropical diseases. Usually, the manifestation of ascariasis may vary in each case. In severe cases, ascariasis may lead to intestinal obstruction or perforation of the intestine due to the large number of worms. Here, we report a case of intestinal obstruction due to A. lumbricoides in a 3-year-old boy.

Case presentation

A 3-year-old Maduranese boy was admitted to the pediatric division with constipation and an enlarged abdomen. During a day of in-hospital observation, the patient vomited worms, which were then identified, and he was diagnosed with ascariasis. The abdominal X-ray showed meteorism with suspected intestinal obstruction. The laboratory test showed anemia and leukocytosis. The exploration laparotomy and ileostomy were performed to extract the worms. The patient was given pyrantel pamoate and albendazole as antiparasitic treatment.

Conclusion

Intestinal obstruction is a rare manifestation of ascariasis but still should be considered, especially in an endemic area. Detailed anamnesis and comprehensive therapy, including surgery and parasitic treatment, may be beneficial for the patient. Increasing hygiene and taking antihelminthic drugs every 6 months may reduce the infection and complications.

What is already known about this topic: The intestinal nematode A. lumbricoides is among the most prevalent sources of infection among soil-transmitted helminths. The manifestation of ascariasis may vary from asymptomatic to severe symptomatic. In severe conditions, ascariasis may lead to an intestinal obstruction, which is very rare.

What this study adds: This study reported a rare case of intestinal obstruction due to A. lumbricoides in a 3-year-old boy. We also describe the method for extracting A. lumbricoides from the intestine using ileostomy and milking procedure.

How this study may affect research, practice, or policy: We hope this report may improve physician awareness regarding the rare cause of intestinal obstruction, especially in A. lumbricoides-endemic areas worldwide. Ileotomy continues with enterotomy and milking procedure plus antihelminth drug and hygiene improvement seems effective in treating intestinal obstruction due to worms.

Introduction

Ascariasis in humans is one of the most significant neglected tropical diseases (NTDs) [1]. Ascaris lumbricoides is one of the most prevalent parasites causing ascariasis, infecting 1.2 billion individuals globally [2]. Approximately 200 million people across 31 provinces in Indonesia have been predicted to be at risk of soil-transmitted helminth infections. Parasitological surveys in the 1980s and 1990s estimated the prevalence of A. lumbricoides, Trichuris trichiura, and hookworm to range from 14% to 90%, 1% to 91%, and 21% to 89%, respectively. This is owing to the capacity of female worms to generate enormous quantities of eggs that are highly resistant to environmental conditions. In addition, the ease of infection transmission among humans results from ingesting eggs carrying second-stage larvae and contaminated food and drink [3].

Usually, the manifestation of ascariasis may vary in each case. Some patients are asymptomatic, but others may feel abdominal pain, diarrhea, and anemia. In severe cases, ascariasis may lead to intestinal obstruction until perforation of the intestine due to the large amounts of worms [4]. Intestinal obstructions, especially in children, due to Ascaris lumbricoides are rare. A holistic approach from diagnosis until treatment is needed to avoid misdiagnosis and delayed treatment since the children are in the growth period. Here, we report a case of intestinal obstruction due to A. lumbricoides in a 3-year-old boy. This case report was prepared following Case Report (CARE) guidelines.

Case presentation

The authors obtained written informed consent from the patient’s parent to publish this case.

A 3-year-old Maduranese boy presented to the pediatrics division of Soebandi General Hospital with constipation and abdominal distention for 3 days. A week before the admission, the child complained of diarrhea and fever; then, the parents brought their child to the primary care, and he was diagnosed him with a urinary tract infection. A day after the treatment, the patient experienced abdominal discomfort and distension. In the emergency department, the patient was diagnosed with constipation. On day 1 of in-hospital observation, the patient vomited worms, and a diagnosis of ascariasis was considered. Figure 1 shows a worm that comes out of his mouth (orange arrow). The patient weighed 13 kg, and his height was 100 cm. The patient’s food intake was normal. There was no previous history of appetite decrease until the current week.

Fig. 1

A. lumbricoides extracted from the patient’s mouth. Orange arrow: A. lumbricoides

Data from anamnesis showed that the patient lived in Bali, Indonesia, and recently moved to Jember. In Bali, he played with his friends in the river almost daily. He seldom wore sandals or foot protection when playing around. In Jember, he routinely followed his grandparents to pick up trash in landfills. The mother usually hand-fed the patient, and he drank unboiled water from the water source.

The laboratory test showed anemia and leukocytosis. The other laboratory test was normal. The abdominal X-ray (Fig. 2) showed meteorism and suspected intestinal obstruction. Whirlpool image and air-fluid level without free air were noted. Then, the patient consulted in the pediatric surgery division to perform an exploration laparotomy. During the surgery, we found three sites of intestinal obstruction along the jejunum until the ileum. We decided to make an ileotomy 50 cm from the ileocecal junction and performed a milking procedure to extract all of A. lumbricoides (Fig. 3). After the milking procedure, we closed the ileotomy using No. 3-0 silk suture with a simple suture.

Fig. 2

Bilayer open framework X-ray showed meteorism and intestinal obstruction. Orange arrow: “whirlpool image”; green arrow: air-fluid level

Fig. 3

Surgery photo of worms extraction from patient’s intestine

The extracted worms were sent to the parasitology department to determine their species (Fig. 4). The worms found during surgery were identified as A. lumbricoides. After the surgery, the patient was treated with intravenous fluid, antibiotics, and 250 mg of pyrantel pamoate once daily. On the seventh day after surgery, the patient was discharged with 400 mg of albendazole as take-home medicine.

Fig. 4

Worms were extracted from the patient’s intestine

Discussion

The intestinal nematode A. lumbricoides is among the most prevalent sources of infection among soil-transmitted helminths (STH) [5]. This infection happens primarily in poor tropical and subtropical nations with low personal hygiene and sanitation [6]. Indonesia is one of the endemic areas for ascariasis. The patient lived in Bali. A study by Widjana and Sutisna in 2000 revealed that A. lumbricoides is the most common STH in Bali with a percentage of 73.7% among all STH [7]. Another recent study in Bali in 2017 reported that A. lumbricoides is still one of the most common STH infections along with T. trichiura [8].

Adult yellowish-white Ascaris worms primarily live in the small intestines of humans and can grow quite long (males: 10–30 cm; females: 22–52 cm) and wide (0.6–0.8 cm). They are distinguished by their anterior three-lipped head capsule, the inner borders of which are fitted with fine teeth. Females can lay up to 200,000 eggs daily for an extended period (up to 1 year). These eggs, with a yellowish-brown and sculptured surface, are roughly oval and measure approximately 60 μm long when fertilized. As seen through a microscope, the freshly laid egg solely comprises the egg cell.

Outside of the body, under the influence of oxygen, the development of larva 1 begins, which molts into the infectious larva 2. The process is temperature-dependent and requires 8–50 days. Human infection arises as a result of oral ingestion of such larval eggs. Larva 2 emerges from the eggshell within the gut, enters the intestinal wall, and travels to the liver via blood vessels, and develops into larva 3. These larvae 3 enter the lungs after passing through the heart, remaining for approximately 14 days. They then travel down the trachea and esophagus into the small intestine, where they reach fertility after two additional molts in 45–60 days. Females initiate copulation with males and lay eggs for around a year. Although this appears to be a short span, they generate approximately 60 million eggs throughout this time. Some females may enter the stomach usually at night, creep up the esophagus into the mouth, and occasionally expectorate. Other adults penetrate the intestinal wall and eventually enter the peritoneal cavity, while others eventually enter the liver, both of which result in serious complications [9]. Here we can see the Ascaris life cycle (Fig. 5).

Fig. 5

Ascaris life cycle in human

The patient usually went out with his friends in the river and does not wear foot protection. He also went to the landfill and picked up trash with his hands without any protection. Drinking unboiled water was also his habit. This habit may lead to the transmission of A. lumbricoides, as we know that the infective state of A. lumbricoides may be on the ground or in the water. The patient’s habits, such as being hand-fed by the mother, may have influenced the transmission of the worms, contributing the re-infection process if it was done without proper hygiene.

The manifestation of ascariasis may vary from asymptomatic to severe symptomatic condition. The symptoms are abdominal pain, diarrhea, and anemia. Adult worms moving via the anal or oral cavity can cause diarrhea or bloody stools in some cases. In severe conditions, ascariasis may lead to an intestinal obstruction that is very rare [4]. Ascariasis has a mortality rate of 60,000 per year, mostly due to intestinal obstruction [10]. A meta-analysis by Djohan et al. reported that ascariasis in children may lead to stunting and underweight conditions [11]. Ascariasis may cause nutrient malabsorption by secreting digestive enzymes such as amylase, protease, and lipase into the intestinal canal [6].

Surgery is frequently suggested in the case of bowel obstruction [12]. Darlington and Anitha reported a case of ileal perforation with volvulus due to Ascaris lumbricoides in a 4-year-old boy without any history of trauma or pre-existing bowel disease. The patient had ileum resection and worm extraction, followed by anastomosis [13]. However, in a single-center study 103 children with intestinal obstruction due to Ascaris lumbricoides were treated conservatively. All the children were managed for acute intestinal obstruction and hypertonic saline enema to starve the worm and hydrate the patient [14]. In this case, we performed exploration laparotomy and ileotomy. We continued with an enterotomy and milking procedure to extract the A. lumbricoides from the intestine because there were multiple sites of obstruction. Three obstructions along the jejunum and ileum were identified during the surgery. The milking procedure was performed in the distal obstruction 50 cm from the ileocecal junction to minimize the surgical lesion and extract the worms. Surgical treatment includes milking of parasites removed in the intestine, enterotomy to remove parasites from the colon, or an intestinal resection with an entero–entero anastomosis, also needed in cases of necrosis [15]. If the obstruction is at the ileum level, the worm can be carefully milked up to the cecum without damaging the intestinal wall. If the obstruction is at the level of the jejunum, an enterotomy should be performed, as milking the bolus to the ileocecal valve may injure the bowel wall [10].

Although intestinal obstruction is rare in ascariasis, the differential diagnosis must be considered, especially in endemic areas of Ascaris sp. Delayed diagnosis and treatment may lead to intestinal perforation that may worsen the patient’s condition. Detailed anamnesis should be performed to address the risk factors of worm infection. Then, a collaborative approach of surgery and parasitic treatment should be used for the patient. In this case, the patient was given pyrantel pamoate and albendazole and a suggestion to increase hygiene as well as take an antihelminthic drug every 6 months. This treatment followed the World Health Organization (WHO) guideline about preventive chemotherapy (deworming) in children as well as mass drug administration (MDA) in endemic areas, using annual or biannual single-dose albendazole (400 mg) or mebendazole (500 mg) [16]. A single dose of albendazole, mebendazole, and ivermectin all appeared effective against Ascaris lumbricoides infection and appear to be safe for treating children and adults with confirmed Ascaris infection [17].

Conclusion

Intestinal obstruction is a rare manifestation of ascariasis but should be considered, especially in an endemic area. Poor hygiene and sanitation may influence this massive condition. Detailed anamnesis and correct treatment, including surgery and parasitic treatment, may benefit the patient. Increasing hygiene and taking antihelminthic drugs every 6 months may reduce the risk of infection and prevent further complications.