World J Surg (2010) 34:963–968
DOI 10.1007/s00268-010-0450-3
Intestinal Ascariasis in Children
Imtiaz Wani • Muddasir Rather • Ghulam Naikoo
Abid Amin • Syed Mushtaq • Mir Nazir
Published online: 9 February 2010

Société Internationale de Chirurgie 2010
Abstract
Background Ascariasis is a staggering health problem
commonly seen in children of endemic areas. In the
abdomen, ascaris lumbricoides can cause a myriad of
surgical complications. Intestinal obstruction by ascaris
lumbricoides is commonly seen in children. Most cases are
managed conservatively. The purpose was to study the
clinical presentation and management of symptomatic
intestinal ascariasis in children.
Methods A 3-year study was performed from April 2006
to April 2009 of pediatric-age patients who had symp-
tomatic intestinal ascariasis. All patients had detailed
clinical history, examination, plain X-ray of abdomen, and
ultrasonography of abdomen. Peroperative findings were
recorded in all patients who had surgical intervention.
Results This prospective study had 360 patients. Male to
female ratio was 1.37:1. 187 patients (52%) presented
within 2–4 days of duration of illness. Mean ± standard
deviation (SD) age of patients was 6.35 ± 2.25 years. Age
group of 4–7 years (80%) was commonest group affected.
Abdominal pain was a leading symptom in 357 patients
(99%) with the pain in periumbilical area present in 215
patients (60%). In 227 patients (63%) abdominal distension
was seen and was the commonest physical finding. Palpa-
ble worm masses were seen in 129 patients (36%); 81
patients (63%) had palpable worm masses in the umbilical
quadrant. On X-ray of abdomen, visible worm masses were
I. Wani (&)
M. Rather
G. Naikoo
S. Mushtaq
M. Nazir
Department of Surgery, S.M.H.S. Hospital, Srinagar, Kashmir
190009, India
e-mail: imtazwani@gmail.com
A. Amin
GB Pant Hospital, Srinagar, Kashmir, India
•
seen in 83 patients (23%). Abdominal sonography showed
interloop fluid in 177 patients (49%) and free fluid in the
pelvis of 97 patients (27%). The number of patients who
were managed conservatively was 281 (78%), and 79
patients (22%) had surgical intervention. In patients who
had surgical intervention, 39 patients (49%) had enterot-
omy and 7 patients (9%) had kneading of worms. Postop-
erative complications occurred in 33 patients, and an
overall mortality of 1% (1 patient) was seen.
Conclusions Ascaridial intestinal obstruction is common
in children in the Kashmir. Abdominal pain is the leading
symptom in intestinal ascariasis. Plain X-ray and ultraso-
nography of the abdomen are used to diagnosis intestinal
ascariasis. The majority of the patients can be managed
conservatively.
Introduction
Ascariasis is a helminthic infection of global distribution
[1]. It is estimated that more than 1.4 billion people are
infected with ascaris lumbricoides, representing 25% of the
world population. The highest prevalence of ascariasis
occurs in tropical and semitropical countries. The domain
of worm extends from the stomach to ileocecal valve; 99%
of worms inhabit the jejunum and proximal ileum. Mode of
infection remains feco-oral.
Massive infestation in children may give rise to grave
complications that demand urgent versatile and expert
surgical care [2]. Ascaridial intestinal obstruction is an
especially acute problem in the developing world. Preva-
lence of Ascaris-related intestinal obstruction in India is 9.2
cases per 100,000 persons [3].
Ascaridial intestinal obstruction may be acute or suba-
cute, or can be due to ascaris-induced volvulus,
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intussusception, and may lead to gangrene of the small gut
[4, 5]. Plain X-ray and ultrasonography of the abdomen are
commonly used investigations to diagnosis intestinal
ascariasis. Regardless of the worm burden, the intestinal
form of ascariasis must be treated to avert possible com-
plications. If conservative therapy is not successful, diag-
nosis is not certain, or the obstruction is complete, surgical
intervention will be necessary [6, 7]. This study evaluated
prospectively the clinical presentation, management,
operative modality used, and various peroperative findings
of surgical intervention for symptomatic intestinal ascari-
asis in a children.
Methods
This prospective study was performed in the Department of
General Surgery, S.M.H.S. Hospital, Srinagar, Kashmir
during a period of 3 years from April 2006 to April 2009 in
a pediatric-age group of patients. A detailed clinical history
and examination of each patient was done with particular
reference to age, sex, duration of illness, abdominal pain,
constipation, loose motions, vomiting of worms, passage of
worms with stool, fever, abdominal distension, and any
recent intake of antihelminthic drug.
Plain X-ray of the abdomen was performed in all cases,
and findings in the form of gut loop distension, air fluid
levels, visible worm masses, and any feature of peritonitis
or perforation were recorded. Serial abdominal ultraso-
nography was done, and the scan findings in the form of
worms seen in gut, gut loops dilation, presence of worms in
peritoneal cavity, interloop, and fluid free fluid in pelvis
were recorded. On abdominal sonography, coiled up mas-
ses of worms were seen as hyperechoic and without
acoustic shadowing in fluid-filled segments of the gut
(Fig. 1). In some cases, linear hyperechoic shadows of
Fig. 1 Ultrasonography of abdomen showing worm bolus in gut
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World J Surg (2010) 34:963–968
ascaris in fluid-filled coils of intestine were seen in cross-
section.
Conservative management in this study included: noth-
ing per orally, nasogastric tube decompression (if needed),
intravenous fluids, antibiotics, and antispasmodics in
selected cases only. Enemas were used in cases that were
pain-free and had no features of peritonitis. Serial vital
checks and meticulous per abdominal examination was
done to assess progress and response to conservative
management coupled with timely available radiology
investigations. Antihelminthics were used approximately
24 h after patients were free of symptoms. The basic
consideration for selecting patients for surgical interven-
tion in this series were as follows (Wani Criteria):
• Unsatisfactory response to conservative management
• Toxemia out of proportion to the severity of obstruction
• Increasing abdominal distension, guarding, and
rebound tenderness
• Persisting abdominal pain and the tender worm mass
• Persistence of worm mass at the same site or fixity of
mass
• Bleeding P/R in addition to above signs and symptoms
• Increasing distension of gut loops and number of free
fluid levels or any evidence of volvulus or intussus-
ception and the presence free gas under diaphragm
suggestive of gut perforation on X-ray abdomen
• Ultrasonographic evidence of significant and progres-
sively increasing interloop fluid or free fluid in
peritoneal cavity and any evidence of peritonitis.
For patients who had surgical intervention, peroperative
findings were recorded as: site of worm mass/masses;
number of worm masses; mode of obstruction; number of
worms removed from the enterotomy wound/in the resec-
ted segment of gangrenous bowel (if resection done). All
patients were advised to attend follow-up clinics.
Results
A total of 360 patients were studied: age range, 9 months–
14.6 years, mean ± standard deviation (SD), 6.35 ± 2.25;
58% boys (n = 208) and 42% girls (n = 152); 171 patients
(48%) in 4–7 year age group, 117 patients (33%) in 8–
11 year age group. Mean duration of illness in days at the
time of presentation was 2.54 ± 1.20 days (187 [52%]
within 2–4 days; 129 patients [36%] \ 2 days; 3 patients
[1%] [ 10 days). The maximum number of cases belonged
to the age group 4–7 years (48%). A total of 317 patients
(88%) were from rural areas, and 43 patients (12%)
belonged to urban areas. Only 12 patients (3%) belonged to
high socioeconomic class, 61 patients (17%) belonged to
average socioeconomic class, and 287 patients (80%)
World J Surg (2010) 34:963–968 965

Table 1 Clinical symptoms at the time of presentation in 360 Table 2 Various clinical signs observed in 360 patients
patients
Sign No. (%)
Symptom No. (%)
Distension of abdomen 227 (63)
Pain abdomen 357 (99) Abdominal tenderness 251 (70)
Vomiting 251 (70) Localized 159 (63)
Distension of abdomen 227 (63) Generalized 92 (37)
Constipation 191 (53) Rebound tenderness 109 (30)
Fever 141 (39) Rigidity and guarding 61 (17)
Loose motions 73 (20) Palpable worm masses 129 (36)
Bleeding per rectum 7 (2) Visible gut loops 166 (46)
More than one finding was present in several patients Visible worm masses 34 (9)
Hyperactive bowl sounds 97 (27)
Absent bowel sounds 46 (13)
belonged to low socioeconomic class. In this low socio-
Normal bowel sounds 217 (60)
economic class, the well and river forms the main drinking
Bleeding per rectum 7 (2)
water source and have open defecation practice.
Abdominal pain was the leading symptom (Table 1). More than one sign was present in several cases
Colicky pain with periumbilical distribution was the most
type of pain present in 276 patients (77%). Sixty-two patients Table 3 Abdominal X-ray findings of worm obstruction in 360
(17%) had dull ache type and 19 patients (5%) reported patients
mixed type of abdominal pain. Vomiting was the second Findings No. (%)
leading symptom; 31% of patients had ascaris in vomitus.
The average numbers of worms vomited was three. Consti- Gut distension 265 (74)
pation was present in 191 patients (53%). Loose motions Multiple air fluid levels 219 (60)
were present in 73 patients (20%). Passage of ascaris in stool Worm masses seen 83 (23)
was experienced in 171 patients (48%). Passage of worms Gasless 19 (5)
with stool as well as vomitus was present in 42 patients More than one finding was present in several patients. Gut distension
(12%). Nineteen patients (5%) had past history of worm was commonest finding recorded
infestation within past 3 months, whereas 27 patients had
intake of antihelminthic within the past 2 months.
Table 4 Abdominal sonography findings in 360 patients
Dehydration was present in 187 patients (51.9%), fever in
131 patients (40%), pallor in 93 patients (26%), and ema- Finding No. (%)
ciation in 7 patients (2%). Abdominal distension was the Worms seen in gut 141 (39)
leading clinical sign and other various clinical signs Gut loops dilated 207 (58)
observed on abdominal examination are shown in Table 2. Interloop fluid 177 (49)
Maximum quadrant wise distribution of palpable worm Free fluid in pelvis 97 (26.9)
mass was seen in umbilical quadrant X-ray abdomen and
Worms seen in peritoneal cavity 2 (1)
ultrasonography findings recorded are shown in Tables 3
and 4, respectively. Hemoglobin \10 g% was seen in 34% More than one finding was present in several patients
of patients. Eosinophilia[6% was seen in 37 patients (10%).
Of the total patients, 281 (78%) were managed conser- the surgical group; no mortality occurred in the conserva-
vatively and 79 (22%) underwent surgery. Impacted worm tive series. Mean ± SD hospital stay was 4.50 ± 2.25 days
mass was the commonest peroperative finding in 60 in cases managed conservatively, whereas mean ± SD
patients (80%) who had various surgical procedures hospital stay was 19.35 ± 6.24 days in cases with surgical
(Tables 5 and 6). Length of single worm mass ranges from intervention.
4–20 cm. Number of worm masses ranged from 1 to 6.
Total number of worms removed after resection of gan-
grenous gut were greater than removed from enterotomy Discussion
site (Table 7). Enlarged mesenteric nodes ranged in size
from 1–5 cm (Fig. 2). Even at the turn of this century with advanced medicine, it
Various postoperative complications observed are shown continues to cause symptoms, illness, and death. In India,
in Table 8. Mortality of 1% (1 patient) in this series was in the prevalence of high-intensity ascaris infection is 768

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Table 5 Peroperative findings in 79 patients

Operative findings No. (%)

Impacted worm masses only 46 (58)

Impacted worm masses with gangrene 14 (18)
Gut volvulus without gangrene 5 (6)
Gut volvulus with gangrene 2 (3)
Intussusception without gangrene 2 (3)
Intussusception with gangrene 1 (1)
Appendicitis (normal appendix with worm inside) 5 (3) (6)
Meckel’s diverticulitis 2 (3)
Meckel’s diverticulitis with perforation 1 (1)
Perforation of gut 1 (1)
More than one finding was present in several cases

Fig. 2 Enlarged mesenteric nodes and associated worm bolus in gut

Table 6 Various surgical procedures performed in 79 patients
Surgery No. (%)
Table 8 Postoperative complications in 33 patients
Enterotomy 39 (49) Complication No. (%)
Kneading of worms 7 (8)
Wound sepsis 14 (18)
Reduction of volvulus 5 (6)
Septicemia 4 (5)
Resection anastomosis 15 (19)
Anastomotic leak 2 (3)
Resection with ileotransverse anastomosis 1 (1)
Burst abdomen 3 (4)
Resection anastomosis with Ileostomy 3 (4)
Respiratory tract infection 9 (11)
Meckel’s diverticulectomy 3 (4)
Death 1 (1)
Appendectomy 5 (6)
Reduction of intussusception 1 (1)

Abdominal distension, tenderness (localized or diffuse),

Table 7 Number of worms removed after enterotomy in 39 patients rigidity or guarding, and palpable worm masses are find-
and from the resected specimen of gangrenous small bowel in 19 ings observed on abdominal examination. Distribution of
patients pain with reference to quadrant of abdomen shows peri-
No. of worms Enterotomy no. Resection anastomosis no. umbilical quadrant being commonest. Jejunum and proxi-
removed (%) (%) mal ileum are the usual habitat of roundworm located
around the periumbilical area, therefore, abdominal pain is
\200 11 (28) 1 (3)
distributed commonly in the periumbilical area. Abdominal
200–400 19 (49) 4 (10)
distension is a late sequel of intestinal ascariasis, but
400–600 7 (18) 11 (28)
sometimes ascaris-induced ileus of small gut is a contrib-
600–800 2 (5) 3 (8)
uting factor. Worms usually lodge and conglomerate in the
distal jejunum and proximal ileum so the majority of pal-
cases per 100,000 persons [8]. Ascaris is highly endemic in pable worm masses present in an umbilical quadrant.
the Kashmir valley. Although ascaris infestation is usually Worms usually remain entangled with each other to form
asymptomatic, ascariasis-related clinical disease is restric- palpable small worm masses or boluses. Ascaridial bolus
ted to subjects with heavy worm load [1]. can conglomerate to form a single, large, lump [5 cm,
The majority of patients present in the first decade of life which is easily palpable on abdominal examination.
[9]. Female cases are relatively less than male. Rural areas Peculiarity of worm bolus or the ascaridial lump is its
bear the major brunt of ascaridial infestation because of characteristic frequent directional change of position and
low socioeconomic and cultural factors. Dehydration, pal- breaking into small boluses to pass ileocecal valve under
lor, and emaciation are usually present on general physical conservative treatment. In our series, the most static lump
examination. Various symptoms observed are abdominal seen in the right iliac fossa could be due to the narrowest
pain, vomiting, constipation, loose motions, ascaris in part of gastrointestinal system. Time interval for disap-
vomitus, and passage of worms in stool. pearance of ascaridial lump from right iliac fossa ranges

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Table 9 Comparison between

Study Year No. (%) Conservative (%) Operative (%)
various studies in literature and
present study Rahman et al. [9] 1992 50 70 30
Chrungoo et al. [14] 1992 876 75.5 24.43
Mohta et al. [15] 1993 74 78.4 31.57
Villamizer et al. [16] 1996 87 73.5 26.43
Wasadikar and Kulkarni [17] 1997 92 73.9 26.09
Pandit and Zargar [18] 1997 85 70.5 29.42
Present study (2010) 2009 360 78 21.9

from \24 to 96 h with conservative management. Direc-

tional change of position and disappearance of palpable
worm masses should be one of the criteria for assessing
efficacy of conservative treatment.
Serological diagnosis remains unsatisfactory [10]. Plain
X-ray and ultrasonography of the abdomen may reveal
evidence of subacute or acute intestinal obstruction or
features of peritonitis. Mass of the worms on X-ray may
appear as ‘‘cigarette ash.’’ Serial radiological assessment
can assess progress of conservative treatment.
Our conservative management for symptomatic intesti-
nal ascariasis simulates those reported by Surendran and
Paulose [4], Dayalan and Ramakrishnan [11], Waller and
Othersen [12], and Pinus [13]. With regards to conservative
management, our results are at par with numerous studies
reported in the literature who managed the majority of their Fig. 3 Enterotomy for removal of worms
cases conservatively (Table 9).
The mode of ascaridial small gut obstruction is
mechanical, volvulus, or intussusception. Mechanical bolus, number of worm boluses, length of worm bolus,
obstruction of gut by worms is the commonest mode of pressure on intestinal wall by worm bolus, and transerosal
intestinal obstruction. Intussusception can be jejunoileal, visibility of worms. In cases with bolus obstruction with
ileoileal, or jejunojejunal. Meckel’s diverticulum in intes- transerosal visibility of worm bolus but with viable gut
tinal ascariasis can pursue asymptomatic course or ascaris where kneading of worms is not possible or in cases of
can lead to perforation, gangrene, or diverticulitis. failed kneading of worms, enterotomy for removal of
Lodgement of ascaris inside vermiform appendix may worms should be performed (Fig. 3); otherwise kneading
incite appendicitis. of worms to the large gut is sufficient. Enlarged mesenteric
Surgical intervention must always be weighed against nodes can be seen with size and number depending on
the stigmata of morbidity and mortality of surgery. The hyperinfestation with worms and the presence of any sec-
golden principle to be followed is ‘‘let the worms come out ondary infection.
on their own’’ and ‘‘early recognition of this morbid con- Only 1% of 79 cases had mortality compared with the
dition to avoid serious complications with minimal surgical observations of Ochoa [5] (1991), who had mortality of
intervention.’’ 8.27% of cases in operative series of patients. Mukho-
Criteria taken into account for deciding surgical inter- padhyay et al. [20] (2001) had mortality of 2.39% in his
vention simulate those observed by Dayalan and Rama- operative series of patients. We are at par with Mukho-
krishnan [11] and Louw [19]. Based on the above criteria, padhyay et al. [20] who did not have any mortality in the
79 (22%) of 360 cases were subjected to operative conservative series. Early detection of disease, well
intervention. acquaintance with disease, avoidance of delay for those
Peroperative findings can be decisive in selecting cases requiring surgical intervention, appropriate antibiotic
for surgical procedure to be done. Decisive factors for cover, and serial radiological assessment helped to reduce
kneading or the enterotomy of worms are site of worm morbidity and mortality.

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Conclusions
Ascaris is still endemic in the Kashmir valley. The majority
of the children belong to rural areas and low socioeco-
nomic strata of the society. Symptomatic children usually
present with colicky periumbilical pain and have distension
of abdomen. Serial per abdominal examination with plain
X-ray of the abdomen and serial abdominal ultrasonogra-
phy are useful for early diagnosis and decisions about
conservative versus surgical treatment. The golden rule is
‘‘let the worms come out on there own’’ and ‘‘minimal
surgical intervention.’’ Most of the patients respond to
conservative treatment. Surgical intervention is required
for complicated intestinal ascariasis.
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