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Surgical Complications of Ascariasis in Children

C. Esposito¹, A. Settimi¹, M. De Marco¹, C. De Fazio¹, Giurin I¹, A. Savanelli¹, Alicchio F¹ and G. Esposito¹,²

¹Chair of Pediatric Surgery “Federico II” University, Naples, Italy

²Department of Emergency “Ospedale Cardarelli”, Naples, Italy

 

Correspondence:

Ciro Esposito, MD, PhD

Associate Professor of Pediatric Surgery,Dept. of Pediatrics; Chair of Pediatric Surgery

“Federico II” University of Naples,School of Medicine, Naples, Italy

Tel: +39-081-7463378; Fax: +39-081-746336

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Abstract

Background: Ascariasis is usually a benign disease caused by the parasite Ascaris Lumbricoides, prevalent in tropical zones. Sometimes it leads to severe surgical complications requiring urgent treatment and having a high morbidity and mortality, especially in non endemic areas where the parasitosis is infrequent and in which the diagnosis may be retarded. Surgical complications may involve mainly the intestine and septicemia may be a severe postoperative complication, whose pathogenesis may be the release of endotoxins by dead worms.

Material and Methods: In a 5-years period, five children aged from 4 to 8 years (median 5.6) presented with acute abdominal symptoms lasting from 1 to 4 days and characterized by generalized abdominal pain, vomiting and closed alvus. The preoperative diagnosis was acute appendicitis for three patients, intestinal volvulus for one and intestinal intussusception for the last one.

Results: At laparotomy there were two purulent peritonitis, an intestinal volvulus and two invaginations, one ileo-ileal and the other ileo-cecal. Surgery consisted in an intestinal resection in the two patients with intestinal gangrene, in detorsion of the volvulus, and in desinvagination. Patients not requiring intestinal resection underwent enterotomy to remove the parasites. In all cases the lesion was due to the presence of a mass of about 200-300 worms located in the loops above the lesions responsible of peritonitis or above the intestinal obstructions. The postoperative course was uneventful in three cases and complicated by toxemic septic shock in two. Treatment was successful in three patients, whereas the two patients with the septic shock died after surgery.

Conclusions: Our study proves that the intestinal complications of ascariasis may be a fatal event that may occur in the countries where the parasitosis is infrequent because of the resulting retard of its diagnosis, as occurred in three of our five cases and the consequent delayed treatment.

Key words: Ascariasis, Ascaris lumbricoides, intestinal complications

  

Introduction

Ascariasis is an endemic parasitosis in countries with precarious socioeconomic and sanitary conditions. Although the majority of Ascaris Lumbricoides infections are asymptomatic, patients may present with non specific abdominal pain, nausea, vomiting, anorexia, and weight loss or with surgical complications. Among these, intestinal obstructions account for about 70% of cases, either for lumen occlusion by the mass of worms or for intestinal volvulus or intussusception; peritoneal perforations account for 10-15% of cases, while in the remaining 15-20% the affection may present as a primitive non perforating peritonitis, a biliary occlusion, or as an acute pancreatitis if the worms penetrate Wìrsung’s duct.

Our experience is based on five cases of surgical complications of ascariasis, represented by two cases of purulent peritonitis one due to an intestinal gangrene, and one non perforate peritonitis, a case of volvulus of the small intestine and two cases of intussusception, one ileo-cecal and another ileo-ileal complicated by intestinal gangrene.

Patients and Methods

In a 5-year period, five children aged from 4 to 8 years (median 5.6), presented with acute abdominal symptoms lasting from 1 to 4 days and characterized by generalized abdominal pain, vomiting and constipation (Table 1). At admission, all patients complained of generalized abdominal pain, while the physical examination found in all cases diffusely tender abdomen with decreased or absent abdominal sound, and in two cases the presence of a mass. At last, the rectal exploration revealed blood in the rectum. US showed presence of free liquid in the peritoneal cavity in three patients, a grossy thickened small bowel loop with linear echogenic non shadowing tubes within in one case and a pneumoperitoneum in another case.

Table 1: Characteristics of the patients observed:

Name  A.P. N.C. A.F. P.B. A.E.
Sex/Age M/6 years  M/4 years  M/6 years  M/4 years  M/8 years 

 Onset of

Symptoms 

 24 hours before 3 days earlier  24 hours before  3 days earlier  4 days earlier 

 Presenting

Symptoms 

Abdominal pain, vomiting, closed alvus, fever 40°C  Abdominal pain, vomiting, closed alvus, fever 40,5°C  Abdominal pain, vomiting closed alvus  Abdominal pain, vomiting, closed alvus  Rectorrhage, abdominal pain, vomiting 
 Physical Findings abdominal lump   15 x 8 cm mass in right iliac fossa tense, tender mass  Abdominal mass, distended and tender abdomen  large, ferm abdominal mass 
 Preoperative Diagnosis  acute appendicitis acute appendicitis  Volvulus of the small intestine  acute appendicitis  Intestinal intussusception 

 Postoperativ

Diagnosis 

 purulent peritonitis Seropurulent peritonitis, gangrenous loop  volvulus of the small intestine  Ileocecal intussusception  Intestinal intussusception 
 Surgery  Enterotomy, worm extraction  Resection, 15 cm, removal of worms  Volvulus detorsion, enterotomy, removal of worms Desinvagination, enterotomy, removal of worms  Intestinal resection, removal of worms 
 Prognosis  death  recovery  recovery recovery   death

 

The standard orthostatic X-ray of the abdomen showed in one case a peritoneal involvement (fig. 1), in two cases there was evidence of intestinal obstruction, in one case a capsized U-shaped loop with two air-fluid levels (fig. 2), and in a case a pneumoperitoneum. The diagnosis was acute appendicitis for three patients, intestinal volvulus for one, and intestinal intussusception for the last one.

At surgery - which was performed either with an enlarged Mac Burney incision or a right pararectal laparotomy - two patients had purulent peritonitis, one due to intestinal gangrene, and the other to a vascular involvement of an intestinal loop. The third patient of our series presented with a volvulus of the small intestine and the last two with intestinal intussusception - one ileocecal and the other ileo-ileal complicated by gangrene. In all cases the lesion was due to the presence of a mass of about 200-300 worms located in the loops affected by perforation or by intestinal obstructions. Surgery consisted in an intestinal resection in the two patients with gangrene, in detorsion of the volvulus, and in simple desinvagination. Patients not requiring intestinal resection underwent enterotomy to remove the parasites. All required a tubular drainage during the post-operative period.

Results

The postoperative course was uneventful in three cases and complicated by a toxemic septic shock in two. There was also an occlusive complication due to an adhesion one month following surgery. Treatment was successful in three patients, whereas the two patients with the septic shock died 48 and 72 hours, respectively, after surgery.

Discussion

The wide range of surgical conditions that we have observed, leads us to make some considerations on the complications of ascariasis, an infestation caused by Ascaris lumbricoides. This affection is among the most prevalent parasitic disease in the world[1,2,3] and it’s geographical distribution is influenced by climate, sanitary conditions, socioeconomic status of the region and cultural habits.

This parasitic infestation is more frequent in rural areas than the urban ones, it affects children more than adults (about 90% of cases occurring in individuals aged from 6 to 14 years) and especially people living in poor sanitary conditions.

Ascaris lumbricoides (phylum nematodes) are cylindric worms ranging from 15 to 30-40 cm in length and 3-4 cm diameter.

ascariasis 1 ascariasis 2
Figure 1. Abdominal radiography in the case of ileo-ileal intussuception, showing some dilatated loops of the proximal ileum with air-fluid levels  Figure 2. Abdominal radiography in the case of the intestinal volvulus, showing the caractheristic capsized U shaped loop with two large air-fluid levels. 

Transmission of the disease is usually fecal - oral (hand to mouth) and by contaminated food, water, and agricultural products. Once the embryonated eggs have reached the duodenum, they hatch as a consequence of the action of the gastric juice. The larvae thus migrate to the small intestine and, via the intestinal vessels and the vena porta they reach the liver, the suprahepatic veins, the inferior vena cava, the heart, the pulmonary arteries and eventually, the pulmonary capillaries. From the lungs they ascend the bronchial tree, the trachea, the larynx, and the pharynx, to reach the esophagus, the stomach and thus the jejunum, where they mature into adult worms, reaching lengths of 11-30 cm (in about 70-80 days) [4] and lay up to 200.000 eggs daily which are passed in the feces and start the life cycle over again. From the intestine the worms may reach the ampulla of Vater and then the biliary or pancreatic ducts, or even other intestinal formations, as the appendìx or Meckel’s diverticulum.

The pathogenic role of this parasite may evolve through a toxic-allergenic action or a mere mechanical obstruction. In uncomplicated cases symptoms are seldom present and initially consist of an undefined ill feeling, followed by sporadic epigastric pain and vomiting, or even retarded physical and psychic growth, fever, pallor, loss of weight and appetite. More specific symptoms may involve specific organs, such as the hepato-biliary tract or the pancreas [5,6,7] (dyspepsia, jaundice, abdominal pain, pancreatic failure, malabsorption syndrome), or the airways (dyspnea, cough, purulent expectoration, hemoptysis, or radiological evident bronchopulmonary infiltration), due to the migration of the larvae to the lungs[8].

Recent travel to endemic areas, family members with helminthic infections, or the passing of worms in the vomitus or diarrhea are all important clues to the diagnosis. Surgical complications may involve the intestine, billiary tract, and pancreas.

In a case series of 454 patients reviewed by Pinus [9], the incidence of complications involved the intestine in 79% of cases, the bile in 12%, the liver (abscesses) in 7% and the pancreas in 0.4%. Among the intestinal complications, there is a prevalence of occlusions (50%), followed by volvulus (24%), perforation (11 %), appendicitis (8%), intussusception (2%). In the series of 225 patients seen at University of Cape Town there were 148 intestinal obstructions (65%), 68 billiary-hepatic complications (30,2%) and 9 pancreatic complications (4%)[10].

The pathogenic mechanisms underlying occlusion are the presence of masses of tangled worms obstructing the intestinal lumen, or an intestinal spasm induced by the toxins released by the worms, which cause the rigidity of a distal intestinal loop and consequently the intussusception in the loop lying below, also for the hyperperistalsis caused by the worms. On the contrary, the volvulus is often caused by the abnormal weight of the loop containing the mass of worms, also in relation to the peristalsis caused by the worms. Predisposing conditions to volvulus may be a mesenteritis or a long and mobile mesentery. Aside from the mechanism exclusively related to the mechanic obstacle, the intestinal occlusion seems to be associated also to the presence of toxins produced by the parasites; as a matter of fact, there is evidence that even in the absence of worms locally an intestinal spasm may occur due to a block of muscle receptors induced by the toxins released from the parasite. Also important is the fact that the stasis deriving from a mechanical occlusion may lead to intraluminal bacterial growth and an alteration of the components of enteric secretions which may further worsen the occlusion. Occlusion may be incomplete sub-acute, or total acute.

The symptoms are not much different from the other types of occlusions, except for the fact that the partial occlusion occurring in the sub-acute forms may be treated with the administration of antihelmintic drugs[11], although some authors believe that this treatment may favour the onset of total occlusion[12]. The symptoms of total occlusions are sudden episodes of intermittent colicky abdominal pain, often occurring at night, presenting as abscesses, located in the periumbilical region or the left hypochondrium, where an elastic oblong mass is often palpable. Strangulating occlusions (volvulus, intussusception) present with the same general symptoms[13], whereas intussusception may be exceptionally characterized by the presence of blood in feces due to the fact that intussusception is ileo-ileal.

Whereas the causes of the well detectable damage occurring in the intestinal regions with necrosis or severe vascular injury are clear - the pathogenesis of the intestinal microperforations responsible of diffused or localized peritonitis is still debated. As a matter of fact, Ihekwaba[14] has hypothesized that they may be caused by the toxic action of the enzymes released by the worms, which may produce perforating micro-necrosis histologically corresponding to small necrotic areas on a region where a strongly eosinophil inflammatory reaction is taking place.

From a clinical point of view, perforations due to ascariasis are similar to any other intestinal pertoration[15, 16] with a picture of peritonitis: fever, toxic-infectious state, vomiting, closed alvus. A particular form of peritonitis is the one caused by the penetration of the worm along the appendicular lumen that manifests itself with a picture of acute appendicitis. Analogously, the penetration of a worm in Meckel’s diverticulum or other congenital or acquired intestinal diverticula may present as an acute diverticulitis. Among the peritonitis due to macroscopic intestinal perforations or to acute appendicitis, a possible event is peritonitis without perforation, caused by the presence of one or more worms in the peritoneum.

Reports in literature suggests that these parasites may cause microscopic intestinal lesions with their buccal apparatus, whereas other authors believe that the larva is unable to perforate the whole thickness of the intestinal wall since it tends to keep its head within the lumen and away from the intestinal wall[17,18].

Among the complications reported there is the penetration of either the larva or worm through the billiary tract via the ampulla of Vater, which is thought to occur when a large number of parasites are present in the duodenum.

The diagnosis of ascariasis is based on ultrasound evaluation, which may be able to detect in non complicated forms the worms as splecular, linear or tangles echogenic structures. The ultrasound may be used also to detect an intussusception or presence of free liquids in the peritoneal cavity, or a pneumoperitoneum. The diagnosis of complicated cases may be precised with the means commonly used to investigate each specific complication: a plain X-ray examination may be useful to evaluate multiple air-fluid levels in a case of simple occlusion, or the presence of a U-shaped loop with two large air-fluid basal levels, in case of a volvulus or pneumoperitoneum in a case of perforation. Barium enema is useful to detect an ileocecal invagination.

Regarding the therapy, treatment with an antihelmintic drugs (piperazine citrate, pyrantel pamoate - both having a paralyzing action on the worms), in non complicated cases, is usually effective in mild cases, and prognosis is excellent.

Also subacute or incomplete intestinal occlusions may require a medical treatment, (decisive in 83.5% of cases according to Rode) but sometimes the antihelmintic agents may cause a full occlusion.

The introduction of gastrografin into the stomach through a naso-gastric tube - as advocated by Bar-Maor[19]- may also be used to treat the infestation. Most important is the treatment of the toxic syndrome that should be based on antihistaminics agents sometimes in association with steroids.

As surgical treatment, the techniques used are the same as those employed for similar conditions with different etiopathogenesis, except for the removal of the parasites, which may be achieved through an enterotomy or – should it not result too invasive - by expression of the parasites.

Morbidity, particularly related to the intestinal complications, and mortality (40% in our experience), results significant[20,21,22] mainly related to the poor general conditions caused essentially by the toxic-allergic reaction produced by the worms and septic shock was the major cause of death. The high mortality, especially in the non endemic areas, is due to the fact that usually asymptomatic Ascaris Lumbricoides infection may result in a variety of complications that may mimic illnesses that are more commonly seen in an emergency department, and for this reason the diagnosis may be missed.

Conclusions

Ascariasis is a serious problem in tropical and subtropical countries because of its frequency, particularly in pre-school and young school aged children in unhygienic conditions. Awareness of this helminthiasis, in areas with large immigrant population from endemic countries and in which it is virtually unknown (as in Europe), is mandatory to establish proper diagnosis and urgent treatment especially in their complicated forms to avoid the morbidity and mortality of the patients tardily hospitalized and/or operated.

Our study proves that the intestinal complications of ascariasis may be a fatal event that may occur in the countries where the parasitosis is infrequent because of the resulting retard of its diagnosis, as happened in three of our five cases, and the consequent delayed treatment.

 

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