+Bioline International Official Site (site up-dated regularly)

Dear Editor,

Ascariasis is a common problem in the tropics. ¹ Poor hygienic and low socioeconomic conditions have been the main factors incriminated. ^{2,
3} Common surgical problems caused by ascaris infestation include small intestinal obstruction, volvolus, intussusception and perforation usually involving the ileum. ^1-5 In our environment over 70% of children are infested with ascaris lumbricoides. ⁶ Surgical complications of ascarid worms in adults are, however, less common.

A 65-year old farmer presented with a 6-day history of high grade fever and shivering followed a day later by abdominal pain, progressive abdominal distension and absolute constipation and vomiting. Physical examination revealed an acutely ill looking, severely dehydrated man, afebrile (T = 36.5ºC) and not pale. Pulse rate was 120/min, and blood pressure 100/80 mmHg. The abdomen was distended and there was generalised tenderness and guarding. Bowel sounds were reduced. Serum urea was 36mmol/L, HCO₃ˉ 8mmol/L, and other electrolytes were normal. Haematocrit was 38%. Plain abdominal X-rays revealed gaseous distension and multiple air-fluid levels. There was no evidence of pneumoperitoneum.

The patient was resuscitated and intravenous antibiotics (ampicillin and metronidazole) commenced. Exploratory laparotomy 6 hours later revealed 3 litres of faeculent peritoneal fluid, fibrinoid adhesions, a 25cm-long live ascarid worm in peritoneal cavity and a pre-pyloric perforation of the stomach. The peritoneal fluid was evacuated and the perforation closed in two layers after excision of the edge for histology. Saline peritoneal lavage was done. The patient developed fever (39ºC) and persistent hypotension (80/40mmHg) and tachycardia (pulse rate 124 per minute) on the second post-operative day. His condition deteriorated and he died on the 3^rd post operative day from multiple system organ failure. Histology confirmed ulceration with mild inflammatory infiltrates.

The adult roundworm, A. lumbricoides usually resides in the small intestines without producing significant symptom. ⁵ In individuals with heavy worm load, aggregation of the worm into masses can result in varied surgical abdominal conditions such as intestinal obstruction, intussuception, volvulus, ileal perforation, and hepatobiliary and pancreatic ascariasis.^1-5 Out ² reported that besides external hernias, ascaris worm was the commonest cause of obstruction in children in Calabar. In a review of 295 cases of intestinal obstruction in south-eastern Nigerian children, ascaris was the leading cause accounting for 25%. ³ Hassan ⁴ reported 5 cases of intestinal obstruction in children aged 4 - 8 years, due to ascariasis over a 12 month period in Maiduguri, Nigeria.

Bowel perforation is thought to follow ischaemia from pressure by the mass of worms in the Ileum. ¹ This view was however questioned by Efem ⁵ who posited that except in confined spaces like the appendix, Meckel's diverticulum and the biliary tree, the intestine is capable of immense dilatation to accommodate up to 5000 worms without symptoms. Typhoid perforations, non-specific ulcers and anastomotic suture lines are thought to provide exit for the ascarid worm. The worm could migrate proximally into the duodenum, biliary tree¹ and stomach, ^{1, 7} where it might be vomited ⁵ or cause nasogastric tube blockade. ⁷ There is no mention of perforation of the jejunum or stomach attributable to ascaris, but the propensity of the worm to explore small opening is known. ¹ In our patient, the worm may have converted a near perforation into frank perforation ⁵ or the perforation occurred followed by exit of the worm into the peritoneum. The later is more likely as histology did not show evidence of chronicity in the ulcer.

D. Iya, A. T. Kidmas, K. Ozoilo and A. A. Sani
Department of Surgery, Jos University Teaching Hospital, P. M. B. 2076, Jos, Nigeria.
E-mail: atkidmas@hotmail.com

REFERENCES