Complications of helminthic infestation with illustration of a rare ca

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Kapil R et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-43 2016 546-549 546 IJAMSCR |Volume 4 | Issue 3 | July - Sep - 2016 Research article Medical research Complications of helminthic infestation with illustration of a rare case of intestinal obstruction and gut gangrene secondary to ascariasis. Dr. Kapil Rampal 1 Dr. Devendra K Prajapati 1 Dr Meghna Sharma 2 1 Senior Resident Department of Surgery Deen Dayal Upadhyay Hospital New Delhi 110064 2 Medical Officer at CHC Kasel Tarn Taran Punjab. Corresponding Author: Dr. Kapil Rampal Email id: ABSTRACT Intestinal obstruction secondary to helminthic infestation is extremely rare even amongst the tropical countries that are endemic for the causative agent. Here we have review the problem with a special illustration of a case of ascariasis with intestinal obstruction and gut gangrene. Keywords: Ascariasis Intestinal obstruction Helminths Antihelminths. INTRODUCTION Ascaris lumbricoides is one of the largest and commonest helminth that infests the humans. 1 Mode of infection is oral ingestion of ascaris eggs with contaminated food. The eggs release larvae in the intestine from where they go for pulmonary migration phase. From thence they further reach the small intestine where they achieve sexual maturity. 2 3 A large number of worms must be present in the intestine to cause obstruction. However this large number has not been defined in the available literature. 4 Ascariasis can produce life threatening complications like intestinal obstruction cholangitis pancreatitis intestinal perforation etc. intestinal obstruction is the most common complication reported. 5-7 The post operative complication rate continues to be high. 8 9 Delay in intervention is often fatal. 10 11 Diagnosis: 1. Anaemia. 2. Worms or ova in stools. 3. Xray: features of intestinal obstruction/perforation or worm shadows. 4. Ultrasound: features specific to complications and worms can be visualised. 5. CT scan: can diagnose the underlying pathology and also assess complications. CASE 19 year old unmarried lady presented to the surgical emergency with 03 days history of pain abdomen distension obstipation and vomiting. She also gave a history of similar episodes of pain abdomen for last 01 year. History of pica and passage of worms in stool also present. On examination the patient was thinly built and poorly nourished had normal vitals gross pallor present. On per abdominal examination abdominal distension with generalised peritonitis was observed and the bowel sounds were absent. Rest of systemic examination was within normal limits. ISSN:2347-6567 International Journal of Allied Medical Sciences and Clinical Research IJAMSCR

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Kapil R et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-43 2016 546-549 547 Haematology revealed a Hb of 7.2 gm and TLC of 14000/mm 3 . All biochemical parameters were normal. Xray chest and abdomen showed multiple air fluid levels and dilated bowel loops. Figure 1 No free gas under the diaphragm was seen. Patient was resuscitated with i.v. fluids blood and antibiotics and further planned for emergency exploratory laparotomy. Following intra operative findings were noted: 1. About 200 ml straw coloured free fluid in the pelvis. 2. Dilated small bowel loops 3. Gangrenous two feet of distal ileum ending 30 cm proximal to the IC junction.Figure 2 4. Entire bowel inflamed and loaded with ascaris Figure 3 5. A large obstructing ball of worms stuck at appoint about 40 cm proximal to the IC junction. The gangrenous segment of bowel was resected worms manipulated out and end ileostomy with mucous fistula fashioned. Post-operative period was uneventful. Deworming was done with Tab Albendazole 4000 mg stat on the 3 rd post-operative day as the patient was gradually started on oral diet. Albendazole was repeated after 07 days. The continuity of gut was restored after 03 months of initial surgery. Patient was asymptomatic after 06 months of follow up. FIGURE 1 FIGURE 2

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Kapil R et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-43 2016 546-549 548 FIGURE 3 DISCUSSION Ascariasis though cosmopolitan in distribution is endemic and a major health problem in tropical countries. Most cases respond well to conservative management with antihelminthic agents as albendazole/mebendazole. Intestinal obstruction has been reported as the commonest surgical complication of ascariasis. 12 13 Owing to its narrow diameter the terminal ileum is the commonest site of obstruction though the jejunum hosts most of the ascaris. The diagnosis is difficult even in endemic areas. 14 Causes attributed for obstruction are 15-19: 1. Ball of worms. 2. Entangled worms at the IC junction. 3. Inflammatory matting of the bowel wall. 4. Associated volvulus/ intussuception. 5. Early and partial obstruction can be managed conservatively but signs of peritonism warrant exploration. Haematology and biochemistry findings do not aid in clinching a final diagnosis but are of value in formulation of further treatment modality. Plain Xray chest and abdomen can reveal features of obstruction with shadow of worms and free gas under the diaphragm in case of perforation. Ultrasound can be confirmatory in expert hands showing typical signs of ascariasis bull’seye in transverse section and railway appearance in longitudinal section. 2021 Gastrograffin a hyperosmolar agent can be used for diagnosing the condition and has therapeutic value as it helps in relieving obstruction by making the worms slippery and dehydrated thus shrinking their size. CT scan of the abdomen can confirm the diagnosis with highest degree of sensitivity and specificity. CONCLUSION Ascariasis is a common medical condition with still rare occurrence of complications. Early diagnosis and surgical intervention holds the key for a favourable outcome. REFERENCES 1. Ashraf F HefnyYousif A Saadeldin Fikri M Abu-Zidan. Management algorithm for intestinal obstruction due to ascariasis: a case report and review of the literature. Turkish Journal of Trauma Emergency Surgery 153 2009 301-305. 2. Steinberg R Davies J Millar AJ Brown RA Rode H. Unusual intestinal sequelae after operations for Ascaris lumbricoides infestation. Pediatr Surg Int 19 2003 85-7.

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Kapil R et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-43 2016 546-549 549 3. Ochoa B. Surgical complications of ascariasis. World J Surg 15 1991 222-7. 4. N. R. de Silva H. L. Guyatt and D. A. P. Bundy. Worm burden in intestinal obstruction caused by Ascaris lumbricoides. Tropical Medicine and International Health 22 1997 189–190. 5. Mokoena T Luvuno FM. Conservative management of intestinal obstruction due to Ascaris worms in adult patients: a preliminary report. J R Coll Surg Edinb 33 1988 318-21. 6. Thein-Hlaing. A profile of ascariasis morbidity in Rangoon Children’s Hospital Burma. J Trop Med Hyg 90 1987 165-9. 7. Ghawss MI Willan PL. Subacute non-bolus intestinal obstruction caused by Ascaris lumbricoides. Br J Clin Pract 44 1990 243-4. 8. Louw JH. Abdominal complications of Ascaris lumbricoides infestation in children. Br J Surg 53 1966 510- 21. 9. De Silva NR Guyatt HL Bundy DA. Morbidity and mortality due to Ascaris-induced intestinal obstruction. Trans R Soc Trop Med Hyg 91 1997 31-6. 10. Adesunkanmi AR Agbakwuru EA. Changing pattern of acute intestinal obstruction in a tropical African population. East Afr Med J 73 1996 727-31. 11. Wasadikar PP Kulkarni AB. Intestinal obstruction due to ascariasis. Br J Surg 84 1997 410-2. 12. Coflkun A Ozcan N Durak AC Tolu I Güleç M Turan C. Intestinal ascariasis as a cause of bowel obstruction in two patients: sonographic diagnosis. J Clin Ultrasound 24 1996 326-8. 13. Villamizar E Méndez M Bonilla E Varon H de Onatra S. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: experience with 87 cases. J Pediatr Surg 31 1996 201-4 discussion 204-5. 14. Archibong AE Ndoma-Egba R Asindi AA. Intestinal obstruction in southeastern Nigerian children. East Afr Med J 71 1994 286-9. 15. Wynne JM Ellman BA. Bolus obstruction by Ascaris lumbricoides. S Afr Med J 63 1983 644-6. 16. Khuroo MS. Ascariasis. Gastroenterol Clin North Am 25 1996 553-77. 17. Akgun Y. Intestinal obstruction caused by Ascaris lumbricoides. Dis Colon Rectum 39 1996 1159-63. 18. Warren KS Mahmoud AA. Algorithms in the diagnosis and management of exotic diseases. xxii. ascariasis and toxocariasis. J Infect Dis 135 1977 868-72. 19. Chawla A Patwardhan V Maheshwari M Wasnik A. Primary ascaridial perforation of the small intestine: sonographic diagnosis. J Clin Ultrasound 31 2003 211-3. 20. Thein-Hlaing Myat-Lay-Kyin Hlaing-Mya Maung-Maung. Role of ascariasis in surgical abdominal emergencies in the Rangoon Children’s Hospital Burma. Ann Trop Paediatr 10 1990 53-60. 21. Mukhopadhyay B Saha S Maiti S Mitra D Banerjee TJ Jha M et al. Clinical appraisal of Ascaris lumbricoides with special reference to surgical complications. Pediatr. Surg. Int 17 2001 403-5. How to cite this article: Dr. Kapil Rampal Dr.Devendra K Prajapati Dr Meghna Sharma. Complications of helminthic infestation with illustration of a rare case of intestinal obstruction and gut gangrene secondary to ascariasis. Int J of Allied Med Sci and Clin Res 2016 43: 546-549. Source of Support: Nil. Conflict of Interest: None declared.

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