Intestinal Obstruction in a 3-Year-Old Girl by Ascaris
lumbricoides Infestation
Case Report and Review of the Literature
Angel Medina Andrade, MD, Yeudiel Perez, PhD, Cecilia Lopez, MD,
Stephanie Serrano Collazos, MD, Alejandro Medina Andrade, MD,
Grecia Ortiz Ramirez, MD, and Laura Medina Andrade, MD
Abstract: Ascaris lumbricoides infection affects approximately 1.5
billion people globally. Children with environmental and socio-
economic risk factors are more susceptible to infestation, with serious
complications such as intestinal obstruction (IO), volvulus, intussuscep-
tion, and intestinal necrosis.
We present the case of a 3-year-old girl who arrived at emergency
department with abdominal pain and diarrhea for the last 3 days. The
previous day she took an unspecified anthelmintic. Symptoms worsened
with vomiting and diarrhea, with expulsion of roundworms through
mouth and anus. Physical examination revealed bloating, absence of
bowel sounds, abdominal tenderness, and a palpable mass in right hemi-
abdomen. Abdominal radiographs showed air-fluid levels with mild
bowel distention and shadows of roundworms. The diagnosis of IO by A
lumbricoides. infestation was established and surgical approach sched-
uled. During exploratory laparotomy an intraluminal bolus of round-
worms from jejunum to ascendant colon was evident. An ileum
enterotomy was performed and worms were removed. Fluid therapy
and antibiotics for 72 hours were administered, with posterior albenda-
zol treatment for 3 days. Patient was uneventfully discharged on the
tenth day.
Reduction in parasitic load by means of improvements in sanitation,
health education, and anthelmintic treatment must be implemented in
endemic zones to prevent serious life-threatening complications by A
lumbricoides. infestation, because some of them require urgent surgical
treatment.
(Medicine 94(16):e655)
Abbreviation: IO = intestinal obstruction.
Editor: Perbinder Singh Grewal.
Received: January 22, 2015; revised: February 22, 2015; accepted:
February 23, 2015.
From the General Surgery Department, Instituto Mexicano del Seguro
Social, Hospital General Regional No. 17. Cancún, Quintana Roo, (AMA,
YP, CL, SSC); Applied Biotechnique Department, Instituto Nacional de
Cardiologı́a Ignacio Chavez. Distrito Federal, México (AMA, GOR); and
Internal Medicine Department, Hospital de Especialidades, Distrito
Federal, México (LMA).
Correspondence: Angel Medina Andrade, General Surgery Department,
Instituto Mexicano del Seguro Social, Hospital General Regional No.
17.Av. Politécnico Manzana 1 Lote 1 Región 509 C.P. 55750, Cancún,
Quintana Roo, México (e-mail: buismedina_5@hotmail.com).
The authors have no conflicts of interest to disclose.
Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons
Attribution-ShareAlike License 4.0, which allows others to remix, tweak,
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terms.
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000000655
Medicine  Volume 94, Number 16, April 2015
INTRODUCTION
T here are 1.5 billion people infected with Ascaris lumbri-
coides. around the world, especially in tropical and sub-
tropical areas, representing a source of high morbidity and
mortality in sub-Saharan Africa, America, China, and East
Asia.1 –3 It is a soil-transmitted helminth; its eggs hatch larvae
in the duodenum and enter the circulation to the liver and lungs
by sixth or eighth day. The alveolar membrane is damaged, and
worms are expectorated and re-enter the intestinal tract by day
eighth or tenth, where they mature into adults with subsequent
oral, nasal, or anal passage. On the 24th day, they reach sexual
maturity; the females produce 200,000 eggs daily and their
worms grow up to 15 to 30 cm.4
CASE PRESENTATION
We present the case of a 3-year-old girl without patho-
logical background. She is a daughter of parents with low
educational and socio-economic level with no sewer service
at home; her father is a farm vet. The child weighed 10 kg,
measured 84 cm in height, and was in the 25 percentile weight
for her age. She came down with her condition in the previous
72 hours with a diffuse abdominal pain, progressive food intol-
erance, vomiting, and diarrhea associated with the presence of
worms in mouth and anus for the last 24 hours as referred by
parents. The previous day she received an unspecified anthel-
mintic with increased symptoms. During the physical examin-
ation, she was irritable, dehydrated, had tachycardia, bloating,
without bowel sounds, painful on palpation, and palpable
serpentine-structured mass in right iliac fossa. The laboratories
reported 10,300 leukocytes with eosinophilia of 10%. Abdomi-
nal radiograph showed bowel obstruction data, with multiple
air-fluid levels, and a ‘‘whirlpool’’ image into the right iliac
fossa (Figure 1). Due to intestinal obstruction (IO) and the
failure of anthelmintic treatment, urgent surgical management
was scheduled. During night, a pediatric surgeon is not available
in the state and a general surgeon performed the surgery.
Abdomen was explored finding bowel loops of jejunum, ileum,
and ascending colon filled with helminths, rejected to the bowel
wall (Figure 2). An ileum enterotomy was performed at 20 cm
from the ileocecal valve (Figure 3), and the worms were
removed with subsequent closure in 2 planes (Figure 4).
Hydration and antibiotics were administered for 72 hours,
and after restart of peristalsis, albendazole 100 mg twice a
day for 3 days. The patient was discharged uneventfully, with
a plan to deworm in 6 weeks.
DISCUSSION
A lumbricoides. infection has a high prevalence world-
wide, being present in almost 25% of the population. Host
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Andrade et al
FIGURE 1. Abdominal radiography presenting multiple air-fluid
levels, intestinal loops dilated, and a whirlpool image in the
inferior hemiabdomen.
genetics, socio-economic status, environmental exposure, and
immune response are infection determinants. After multiple
rounds of chemotherapy, it has been demonstrated that indi-
viduals tend to re-acquire similar worm burdens to those
FIGURE 2. Ileum with the presence of Ascaris rejected to the
intestinal wall.
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Medicine  Volume 94, Number 16, April 2015
FIGURE 3. Ileum longitudinal enterotomy with the extraction of
roundworms.
harbored before treatment.5 Chronic infection has an important
impact on growing up and development.6
An A lumbricoides infestation could present colecistitis,
cholangitis, pancreatitis, intestinal volvulus, intussusception,
appendicitis, intestinal necrosis, or IO, the latter being the more
frequent.7–9 Complications can be observed in all ages but
children between 3 and 5 years are especially susceptible, caused
by large number of worms in a diminished intestinal diameter and
the ileocecal valve. A lumbricoides. excrete a neurotoxin, which
produces spasticity conducing to obstruction, and intestinal
FIGURE 4. Milking roundworms from jejunum.
Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved.
Medicine  Volume 94, Number 16, April 2015
inflammation can be associated with liberation of other toxins
including anaphilotoxins, hemolysins, and endocrinolysins by
worms.6,10
Frequent symptoms are abdominal pain, nausea, vomiting,
diarrhea, and presence of worms in vomit or feces. The physical
examination can present abdominal tenderness, bloating,
abdominal mass, or rigidity. X-rays can reveal air fluid levels
and shadow of roundworms, with a ‘‘Whirlpool’’ image in some
cases.11 Ultrasound will be useful in identifying thick echogenic
strip with central anechoic tube; multiple linear or curvilinear
echogenic strips without acoustic shadowing; ‘‘railway track’’
sign; ‘‘3-line’’ or ‘‘4-line’’ sign, or ‘‘bull’s eye’’ appearances
on transverse scan.7
In the case of intestinal subocclusion, medical treatment
with intravenous fluids and electrolytes, broad-spectrum anti-
biotics, and nasogastric drainage must be done. Patients with
complete obstruction would be candidates for laparotomy after
initial resuscitation and antibiotic treatment. Single heavy dose
of anthelmintic has been suggested to prevent the spontaneous
resolution of the entangled bolus and may precipitate complete
IO.12
Surgical treatment includes the extraction of the worms
from the colon by enterotomy or, in case of necrosis, an
intestinal resection with entero-entero anastomosis. In the pre-
sented case the extension of the infestation did not allow milked
all A lumbricoides. to colon and could injure the intestinal wall,
reason why an ileum enterotomy was done, allowing the
evacuation of most roundworms and leaving the rest to medical
treatment with albendazole after the restart of intestinal transit.
The presence of at least 2 of the following criteria is considered
for resolution: disappearance of colicky pain, beginning of
defecation, or disappearance of air fluid levels. After resolution,
mebendazole or albendazole 100 mg twice daily for 3 days must
be started and repeated 6 weeks after discharge to eradicate any
worm.12
Informed consent for publication of this case was signed.
Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved.
Intestinal Obstruction by Ascaris lumbricoides
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