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Hookworm Infestation, the Neglected Cause of Melena and Overt Obscure

Gastrointestinal Bleeding in Farmers
Nimas Luthfiana Hapsari and 2Yudha Nurdian

1Student,Faculty of Medicine, University of Jember, Indonesia
2Facultyof Medicine, University of Jember, Indonesia
Corresponding author: Nimas Luthfiana Hapsari,;

Hookworm infestations remain a major cause of morbidity in the developing world. Prevalence is highest in
agricultural areas, where use of waste water for irrigation and poor hygiene increases infestation rates among
farmers. Infestations present with gastrointestinal symptoms and chronic anaemia, and there are usually no
signs of overt bloodloss. Adult hookworms live chiefly in the upper small intestine, attached to the mucosa by
their strong buccal capsules and biting plates or teeth. There are major differences between the two species.
Necator americanus is shorter, removes less blood (0.03 mL/day vs. 0.20 mL/day), lives longer (3 to 5 years
or more vs. 1 or 2 years), and produces fewer eggs (5000 to 10,000 vs. 10,000 to 25,000 per day) than
Ancylostoma duodenale. The hookworm constantly changes the adsorption site and secretion of anticoagulant
substances, resulting in wound blood loss is the main adverse outcome. Hookworms also secrete anticoagulant
peptide-1, inhibiting the blood coagulation in the attachment site and leading to the loss of blood from the
intestine. In addition, they can carry antigens and pass through a range of host tissues, surviving within the
host by warding off immune attacks. A research in China found that there are a few severe overt obscure
gastrointestinal bleeding cases because of hookworm infestation in farmers. It is hypothesized that hookworms
may damage the blood vessels of the small intestine for a long period of time, inducing acute massive intestinal
bleeding; heavy burden individuals can lose up to 250 ml of blood per day. In Pakistan, it is reported that a
52-year-old male, who was a resident of Rahim Yar Khan and a farmer by profession, presented to the
outpatient clinic with a 3-month complaint of melena, constipation and generalised abdominal pain. Clinical
examination was significant for tachycardia, conjunctival pallor and generalised abdominal tenderness.
Colonoscopy revealed colonic muscosa to be stained with greyish-black stools, but no point of frank bleed
was identified. However, the Oesophagogastroduodenoscopy (OGD) revealed a few alive hookworms
adherent to the duodenal mucosa and terminal ileum, with normal underlying mucosa. Abdominal Computed
Tomography (CT) scan showed no abnormal findings suggestive of another bleeding source. A systematic
review and metaanalysis has shown that the availability of sanitation facilities is associated with significant
protection against infestation with soil-transmitted helminths, indicating a need to prioritize improved
sanitation in parallel with preventive chemotherapy and health education.
This work explains melena and overt obsecure gastrointestinal bleeding can be caused by hookworm
infestation because hookworms may damage the blood vessels of the small intestine for a long period of time.

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