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Intraperitoneal ascariasis
Intraperitoneal Ascariasis By P.L.N.G. Rao, G. Satyanarayana, and A. Venkatesh Manipal, India 9 S e v e n c h i l d r e n with intraperitoneal ascariasis are reported. One of them had t w o episodes. There w e r e f o u r instances of free worms in the peritoneal cavity, w h e r e a s others had peritoneal abscesses containing round worms. It is suggested that peritoneal ascariasis should be susp e c t e d whenever a child presents with peritonitis a n d / o r an inflammatory abdominal mass having evidence of a s c a r ial infestation.
9 1988 by G r u n e & S t r a t t o n . Inc.
INDEX WORDS: Ascariasis; peritonitis.
S C A R I S L U M B R I C O I D E S infestation, with a high incidence in tropics, can lead to serious complications because of the wanderlust of the worms. Though complications such as intestinal obstruction, volvulus, gangrene, pancreatitis, and biliary ascariasis have been reported to occur, intestinal perforation and peritonitis secondary to the worms is extremely rare and considered lethal. ]3 Our experience with this problem over the last 7 years is the basis of this report. MATERIALS AND METHODS
Children who had round worms in the peritoneal Cavity were reviewed. The cases were analyzed with respect to age and sex incidence,clinical presentation,and management.
been managed conservatively elsewhere. One of them was diagnosed by us as having appendicular abscess, and during drainage a round worm was extracted. Two months later, the same child came back with a right hypochondriac mass, and upon exploration, another abscess with a worm was noted: Apart from that, the patient had about six granulomas at various sites in the abdomen (Fig 2). The other child, who also had an acute abdomen, came to us with a periumbilical inflammatory mass. Upon surgery, apart from this inflammatory mass, we found two round worms in the peritoneal cavity adherent to the fundus of the urinary bladder (Fig 3). Two other children presented to us with subacute intestinal obstruction. While being treated conservatively, they developed acute symptoms requiring exploration. We found evidence of peritonitis with free worms in one, and an abscess containing a round worm in the other. Thus, four children had free worms in the peritoneal cavity and the others had intraperitoneal abscesses containing round worms. In two children the site of perforation could be located in the appendix, and in the rest we failed to identify the site of perforation. It is also interesting to note that in only two children was there evidence of peritonitis upon surgery, and none of the children had fecal peritonitis as one would expect.
RESULTS
Age and Sex There were eight instances of round worms in the peritoneal cavity in seven children. All patients were <5 years of age, the youngest being 9 months old. There were three girls and four boys.
Clinical Presentation and Operative Findings Three of the children presented with acute intestinal obstruction with evidence of peritonitis, and when explored, free worms were found in the peritoneum (Fig 1). In two of them, the appendix was the site of perforation. Two children presented to us with inflammatory abdominal masses. Both patients had acute symptoms about 3 weeks prior to admission and had
From the Departments of Pediatric Surgery and Pediatrics, Kasturba Medical College & Hospital, Manipal, South India. Address reprint requests to Dr P.L.N.G. Rao, MCh, Official Professor and Head, Department of Pediatric Surgery, Kasturba Hospital, Manipa1576 119, South India. 9 1988 by Grune & Stratton, Inc. 0022-3468/88/2310-0012503.00/0 936
Morbidity and Mortality Three children had postoperative complications such as wound dehiscence, prolonged ileus, and intestinal obstruction. The child who had intestinal obstruction required re-exploration. There was no death in the series and all children have been doing well at follow-up 1 to 6 years postoperatively. DISCUSSION
Though intestinal perforation can occur secondary to various disorders such as enteric fever, necrotizing enteritis, and amoebiasis, ascariasis, with its many abdominal complication, also appears to be an important cause. It is surprising that, in spite of its widespread nature, only about a dozen records were published in the last 20 years, and most are case reports. 26 However, localized intraperitoneal abscess formation due to round worms appears to be even more rare. 7 Intestinal perforation secondary to round worms can be either primary or secondary. De Sa, s in 1966, suggested that in the primary type, where the worm Journal of Pediatric Surgery, Vol 23, No 10 (October), 1988: pp 936-938
937
INTRAPERITONEAL ASCARIASIS
Fig 1. Operative photograph showing free round worms in the peritoneal cavity.
makes its way through the healthy intestinal wall, the worm produces a lytic substance, and this combined with the nibbling effect of the worm head can perforate the normal bowel wall. In the secondary type, the worm penetrates through the weakend intestinal wall due to diseases such as enteric fever and tuberculosis. In all of our cases, the lack of evidence for enteric fever and tuberculosis suggests the possibility of a primary perforation. The striking features in our cases, namely the lack of peritoneal inflammation and failure to locate the site of perforation in the majority of cases, are wellrecognized factors in round worm perforations. The intraabdominal abscesses in our series point out that
Fig 3. Operative photograph showing the round worm being separated from the urinary bladder.
often the inflammatory reaction becomes localized, resulting in an abscess a n d / o r a granuloma formation. Though in the initial stages there was a diagnostic dilemma in these cases, we later became more and more aware of the condition and the diagnosis became easier. Now we believe that this possibility should be entertained in any child who presents with peritonitis with a previous history of passing worms in the stools. Though mortality in these cases is reported to be high, 1'4'9 the results of our experience are contrary to this. Though three of our children developed major complications, all survived and are doing well. Probably the early diagnosis and surgical intervention in our children altered the outcome. From our experience, we conclude that one should suspect the possibility of ascarial perforation in any child with peritonitis and/or inflammatory abdominal mass with evidence of ascarial infestation. Early diagnosis and surgical intervention improves the outcome for these children. ACKNOWLEDGMENT
We are grateful to the Medical Superintendent, Principal, and Medical Director of Kasturba Medical College & Hospital for allowing us to publish this work. REFERENCES
Fig 2. Operative photograph showing a round worm being removed from an abscess cavity.
1. Lauw JH: Abdominal complications of Ascaris lumbricoides infestation in children. Br J Surg 53:510-521, 1966 2. Mathur SC, Gupta RK, Gangwal KC: Intestinal perforation by Ascaris. J Indian Med Assoc65:49-51, 1975 3. IhekwabaFN: Ascaris lumbricoides and perforation of ileum: A critical review. Br J Surg 66:132-134, 1979 4. Morgano JO, Sahoy R: Intestinal perforation in ascariasis: Case reports. Trans R Soc Trop Med Hyg 73:183-184, 1979 5. Sinha SN, Sinha BN: Appendicularperforationdue to Ascaris lumbricoides. J Indian Med Assoc63:396-397, 1974
938
6. Mazumdar H, Sardessai S: Peritonitis with round worms in the peritoneal cavity. Indian Pediatr 14:73-75, 1974 7. Rao PLNG, Shenoy MG, Venkatesh A, et al: Intra peritoneal round worm abscess~Case report. Indian Pediatr 17:633-636, 1980
RAO, SATYANARAYANA, AND VENKATESH
8. De Sa AE: Surgical ascariasis. Indian J Surg 28:182-190, 1966 9. De Sa AE: Surgical ascariasis, in Basu AK, Rob C, Smith R (eds): Clinical Surgery, vol 8. London, Butterworth, 1965, pp 115-119
9 1988 by G r u n e & S t r a t t o n . Inc.
INDEX WORDS: Ascariasis; peritonitis.
S C A R I S L U M B R I C O I D E S infestation, with a high incidence in tropics, can lead to serious complications because of the wanderlust of the worms. Though complications such as intestinal obstruction, volvulus, gangrene, pancreatitis, and biliary ascariasis have been reported to occur, intestinal perforation and peritonitis secondary to the worms is extremely rare and considered lethal. ]3 Our experience with this problem over the last 7 years is the basis of this report. MATERIALS AND METHODS
Children who had round worms in the peritoneal Cavity were reviewed. The cases were analyzed with respect to age and sex incidence,clinical presentation,and management.
been managed conservatively elsewhere. One of them was diagnosed by us as having appendicular abscess, and during drainage a round worm was extracted. Two months later, the same child came back with a right hypochondriac mass, and upon exploration, another abscess with a worm was noted: Apart from that, the patient had about six granulomas at various sites in the abdomen (Fig 2). The other child, who also had an acute abdomen, came to us with a periumbilical inflammatory mass. Upon surgery, apart from this inflammatory mass, we found two round worms in the peritoneal cavity adherent to the fundus of the urinary bladder (Fig 3). Two other children presented to us with subacute intestinal obstruction. While being treated conservatively, they developed acute symptoms requiring exploration. We found evidence of peritonitis with free worms in one, and an abscess containing a round worm in the other. Thus, four children had free worms in the peritoneal cavity and the others had intraperitoneal abscesses containing round worms. In two children the site of perforation could be located in the appendix, and in the rest we failed to identify the site of perforation. It is also interesting to note that in only two children was there evidence of peritonitis upon surgery, and none of the children had fecal peritonitis as one would expect.
RESULTS
Age and Sex There were eight instances of round worms in the peritoneal cavity in seven children. All patients were <5 years of age, the youngest being 9 months old. There were three girls and four boys.
Clinical Presentation and Operative Findings Three of the children presented with acute intestinal obstruction with evidence of peritonitis, and when explored, free worms were found in the peritoneum (Fig 1). In two of them, the appendix was the site of perforation. Two children presented to us with inflammatory abdominal masses. Both patients had acute symptoms about 3 weeks prior to admission and had
From the Departments of Pediatric Surgery and Pediatrics, Kasturba Medical College & Hospital, Manipal, South India. Address reprint requests to Dr P.L.N.G. Rao, MCh, Official Professor and Head, Department of Pediatric Surgery, Kasturba Hospital, Manipa1576 119, South India. 9 1988 by Grune & Stratton, Inc. 0022-3468/88/2310-0012503.00/0 936
Morbidity and Mortality Three children had postoperative complications such as wound dehiscence, prolonged ileus, and intestinal obstruction. The child who had intestinal obstruction required re-exploration. There was no death in the series and all children have been doing well at follow-up 1 to 6 years postoperatively. DISCUSSION
Though intestinal perforation can occur secondary to various disorders such as enteric fever, necrotizing enteritis, and amoebiasis, ascariasis, with its many abdominal complication, also appears to be an important cause. It is surprising that, in spite of its widespread nature, only about a dozen records were published in the last 20 years, and most are case reports. 26 However, localized intraperitoneal abscess formation due to round worms appears to be even more rare. 7 Intestinal perforation secondary to round worms can be either primary or secondary. De Sa, s in 1966, suggested that in the primary type, where the worm Journal of Pediatric Surgery, Vol 23, No 10 (October), 1988: pp 936-938
937
INTRAPERITONEAL ASCARIASIS
Fig 1. Operative photograph showing free round worms in the peritoneal cavity.
makes its way through the healthy intestinal wall, the worm produces a lytic substance, and this combined with the nibbling effect of the worm head can perforate the normal bowel wall. In the secondary type, the worm penetrates through the weakend intestinal wall due to diseases such as enteric fever and tuberculosis. In all of our cases, the lack of evidence for enteric fever and tuberculosis suggests the possibility of a primary perforation. The striking features in our cases, namely the lack of peritoneal inflammation and failure to locate the site of perforation in the majority of cases, are wellrecognized factors in round worm perforations. The intraabdominal abscesses in our series point out that
Fig 3. Operative photograph showing the round worm being separated from the urinary bladder.
often the inflammatory reaction becomes localized, resulting in an abscess a n d / o r a granuloma formation. Though in the initial stages there was a diagnostic dilemma in these cases, we later became more and more aware of the condition and the diagnosis became easier. Now we believe that this possibility should be entertained in any child who presents with peritonitis with a previous history of passing worms in the stools. Though mortality in these cases is reported to be high, 1'4'9 the results of our experience are contrary to this. Though three of our children developed major complications, all survived and are doing well. Probably the early diagnosis and surgical intervention in our children altered the outcome. From our experience, we conclude that one should suspect the possibility of ascarial perforation in any child with peritonitis and/or inflammatory abdominal mass with evidence of ascarial infestation. Early diagnosis and surgical intervention improves the outcome for these children. ACKNOWLEDGMENT
We are grateful to the Medical Superintendent, Principal, and Medical Director of Kasturba Medical College & Hospital for allowing us to publish this work. REFERENCES
Fig 2. Operative photograph showing a round worm being removed from an abscess cavity.
1. Lauw JH: Abdominal complications of Ascaris lumbricoides infestation in children. Br J Surg 53:510-521, 1966 2. Mathur SC, Gupta RK, Gangwal KC: Intestinal perforation by Ascaris. J Indian Med Assoc65:49-51, 1975 3. IhekwabaFN: Ascaris lumbricoides and perforation of ileum: A critical review. Br J Surg 66:132-134, 1979 4. Morgano JO, Sahoy R: Intestinal perforation in ascariasis: Case reports. Trans R Soc Trop Med Hyg 73:183-184, 1979 5. Sinha SN, Sinha BN: Appendicularperforationdue to Ascaris lumbricoides. J Indian Med Assoc63:396-397, 1974
938
6. Mazumdar H, Sardessai S: Peritonitis with round worms in the peritoneal cavity. Indian Pediatr 14:73-75, 1974 7. Rao PLNG, Shenoy MG, Venkatesh A, et al: Intra peritoneal round worm abscess~Case report. Indian Pediatr 17:633-636, 1980
RAO, SATYANARAYANA, AND VENKATESH
8. De Sa AE: Surgical ascariasis. Indian J Surg 28:182-190, 1966 9. De Sa AE: Surgical ascariasis, in Basu AK, Rob C, Smith R (eds): Clinical Surgery, vol 8. London, Butterworth, 1965, pp 115-119