Small bowel obstruction complicating an Ascaris lumbricoides infestation in a 4-year-old male: a case report

Background

Ascariasis is the leading helminthic infection worldwide, with its peak prevalence noted in children aged 2–10 years. Although mainly asymptomatic, chronic and heavy infestation could lead to severe complications such as malnutrition, poor physical and cognitive development, as well as intestinal obstruction. We report the case of a 4-year-old boy with intestinal obstruction due to Ascaris lumbricoides infestation and discuss its public health significance.

Case presentation

A 4-year-old Black African boy (from a rural locality in the Menchum Division of the Northwest Region of Cameroon), with no remarkable past medical and family history, consulted our emergency unit for a 3-day history of generalized abdominal pains, vomiting, and obstipation. We also noted an abdominal distention which his mother ascertained to have been evolving for 6 months prior to consultation at our health facility. In addition, the child had never been dewormed since birth according to the mother.

A physical examination revealed a conscious but asthenic patient with signs of malnutrition and some dehydration. His conjunctivae were pinkish and sclerae were anicteric. His abdomen was distended, soft but mildly tender, mobile with respiration, and dull on percussion. There was no palpable abdominal mass or shifting dullness. Bowel sounds were hyperactive, and the rectum was void of fecal material on digital rectal examination. Initial laboratory investigations revealed hypokalemia and hyponatremia. A full blood count was normal. A plain abdominal X-ray revealed discrete air-fluid levels. Based on the aforementioned clinical and paraclinical findings, a diagnosis of IO was arrived at. Further exploration of the cause of the obstruction was inaccessible mostly because our patient’s family could not afford the cost, and the nearest referral facility capable of performing these tests was approximately 76 km away, on poorly motorable and hilly roads. Taking these circumstances and the deteriorating clinical picture of our patient into account, we decided to do an exploratory laparotomy after receiving a verbal and signed consent from our patient’s carer.

He was admitted, rehydrated with 2 L of Ringer’s lactate and 1 L of glucose 5% per m2/day for 3 days, and intravenously administered paracetamol 15 mg/kg per 6 hours, ceftriaxone 50 mg/kg per day, metronidazole 15 mg/kg per 8 hours, and gentamycin 5 mg/kg per day. His legal guardian was immediately counselled on the need for a laparotomy and a signed informed consent was obtained after which an anesthetic consult was sought. He was operated on the third day of hospitalization after correction of the associated electrolyte imbalance.

The surgical approach consisted of the traditional midline incision. Perioperative findings revealed a dilated small bowel obstructed by bundles of live worms (Fig. 1).

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Distended small bowel obstructed by bundles of Ascaris lumbricoides worms

An enterotomy of 2 cm in length which exposed the bundles of A. lumbricoides was done, followed by manual extraction and milking of the worms through the stoma (Fig. 2 a, b). Postoperative management involved intravenously administered fluids with Ringer’s lactate, and intravenously administered paracetamol 15 mg/kg per 6 hours, ceftriaxone 50 mg/kg per day, metronidazole 15 mg/kg per 8 hours, and gentamycin 5 mg/kg per day. Progressive oral sips were started 8 hours after surgery and semi-solid food was introduced from postoperative day 3. Evolution was favorable with full restoration of bowel function on postoperative day 3. Our patient was discharged on postoperative day 7 with no fresh complaints. He and his entire household were dewormed with a single dose of mebendazole 500 mg administered orally. A follow-up visit 1 week after discharge revealed a healed abdominal wound and normal bowel functions.

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a, b Bundle of Ascaris lumbricoides worms extracted after enterotomy

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