Ascaris and its surgical complications.pptx

Ascariasis and its surgical complications

1. Ascariasis and its surgical complications Dr. RUTAYISIRE François Xavier PGY1 Common surgical conditions module University of Rwanda Lecturer: Dr MUTABAZI Emmanuel

2. Definition Ascariasis is the most common helminthic infection. It is caused by Ascaris lumbricoides , which is the largest parasite from the class of nematodes commonly known as roundworms. Another type of Ascaris suum have been identified to cause ascariasis Usually A lumbricoides or A suum infection is asymptomatic. Symptomatic ascariasis occurs during the adult worm's intestinal or larval migration phase

3. Etiology Ascaris lumbricoides,  a soil-transmitted large nematode, causes   Ascariasis. The nematodes are pink/yellow/white roundworms. The adult females of this species can measure up to 45 cm long (males are generally shorter The average life of the adult parasite is one year, after which it dies, and it is spontaneously eliminated as it evacuates through the digestive tract. Spontaneous cure of disease can happen if there is no reinfection. Adult worms do not multiply in the human host. The adult worms live in the small intestine and eggs are passed in the feces.  A single female can produce up to 200,000 eggs each day! 

4. Epidemiology Ascariasis is one of the most common human parasitic infections. One billion people worldwide are infected with Ascaris lumbricoides,  and more than 60,000 people die from the disease annually. It was described in ancient Egyptian papyruses and has been identified in Egyptian mummies from around 800 B.C. Hippocrates and Aristotle described the helminth. It has been described in children and adults in tropical and subtropical areas with poor sanitation and poor personal hygiene and in places where human feces are used as fertilizer. There is a higher risk of infection in nonendemic areas due to the increased rate of migration and travel. It affects mostly tropical and subtropical countries around the world, and it is frequently documented in Sub-Saharan Africa, Latin America, China, and East Asia. Ascaris eggs are quite hardy and can survive extreme temperatures and persist for several months in feces and sewage.

5. Rwandan picture In a prospective study conducted between January 2015 and November 2018 at CHUB to study the surgical complications of Ascaris lumbricoides infestation

6. Pathophysiology Infection occurs when the host ingests eggs found in stool-contaminated soil. It is a soil-transmitted helminth. Its eggs hatch larvae in the duodenum and enter the circulation to the liver and lungs by 6 th or 8 th day. The alveolar membrane is damaged, and worms are expectorated and re-enter the intestinal tract by day 8 th or 10 th At the intestine level: 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 Later they are eliminated in the feces of the soil. In the appropriate conditions the eggs mature to infective form in two to eight weeks and remain viable for up to 17 months. They can be ingested and restart the infective cycle.

7. Lifecycle

8. Sign and symptoms Abdominal pain, nausea, vomiting, diarrhea. Presence of worms in vomit or feces. If the number of larvae passing through the lung is significant Symptoms like wheezing, dyspnea, cough, hemoptysis, and fever can develop. In superinfection, adult worms can migrate to tubular structures like the biliary and pancreatic system causing cholecystitis, cholangitis, pancreatitis, small bowel obstruction, volvulus, appendicitis, and intussusception. Children are more susceptible to complications than adults. P/E Abdominal tenderness, bloating, abdominal mass, or rigidity, jaundice, crackles, wheezes…

9. Diagnosis Examination of stool for eggs by direct saline smear method Searching for large oval brown trilayered eggs with a mamillated coat. I t is simple and effective. The eggs are easily found using this way due to a large number of the female oviposition, approximately 240,000 eggs per worm per day. So this method is the first choice . FBC can show eosinophilia during the active migration phase from the intestine to the lungs E xamination of sputum for Ascaris larvae is sometimes successful. Stool can be negative while the worm migrates and matures (approximately one month). Only when worms are mature do they start secreting eggs. Sometimes an adult worm can be seen in the stool or coming out of the rectum but can also be coughed up, vomitted or passed in the urine.

10. Imaging X-rays: air fluid levels and shadow of roundworms, with a “Whirlpool” image in some cases. U/S: 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. Endoscopic retrograde cholangiopancreatography (ERCP) can be used for diagnosis and treatment. Whirlpool

11. At CHUB In 4 out of the 22 cases (18%), the diagnosis of Ascaris infestation was made from clinical history (passing worms through the anus or through vomiting) and by imaging. In two of those the ultrasound clearly made the diagnosis of chunks of Ascaris forming an abdominal mass; for the other two the diagnosis of Ascaris was by plain abdominal x-rays which reported whirl-pool/ pack of cigars patterns, and air-fluid levels.

12. Complications Malnutrition Partial or incomplete IO Bowel perforation Peritonitis Cholangitis, Pancreatitis, Hepatic abscess, or Appendicitis.

13. Surgical complications at CHUB

14. Medical management Mild cases of Ascaris infection should be treated to prevent complications from parasite migration. However, during active migration through the lungs, medical therapy is not indicated, secondary to the increased risk of pneumonitis. Medical therapy with albendazole 400 mg as a single dose is the drug of choice. The 2 nd choice is mebendazole 100 mg BD x3/7 or 500 mg as a single dose or ivermectin 100 microgram/kg to 200 microgram/kg once. In pregnancy, piperazine 50 mg/kg/day for five days or 75 mg/kg one dose or pyrantel pamoate (11 mg/kg up to a maximum of 1 g) is administered as a single dose; the latter is the drug of choice. Medical therapy will target adult worms, which is the reason why treatment should be repeated after one to three months, to give time to larvae that can be present to mature to adulthood and be susceptible to therapy.

15. Surgical Mgt If partial bowel obstruction is present: NPO, NGT Give IV fluids and piperazine. If Complete bowel obstruction is present: Laparotomy for enterotomy for the extraction of worms. If necrosis is found, they may need resection and reanastomosis . Once the surgery is performed and intestinal transit is restored, medical anti-parasitic treatment should be given to kill any residual eggs.

16. Ileal perforation peritonitis associated with Ascaris lumbricoides infestation © Ahmed Kiswezi et al.

17. Prevention Education, I mproved sanitation, and avoidance of human feces as fertilizer are critical. A program of mass treatment in highly endemic areas has been suggested Certainly, improved personal hygiene among people who handle food is an important aspect of control.

18. References Kazigo , Ahmed Kiswezi , J. Bayisenga , L. Ndayizeye , J. Gashegu and Samuel Kanyesigye . “Surgical complications of Ascaris lumbricoides infestation: A prospective, observational study at a teaching hospital in Butare , Rwanda.” East and Central African Journal of Surgery 25 (2020) Murray Rossenthal Medical microbiology 7 th edition Medscape http://www.antimicrobe.org/Lifecycle/b17lc.asp D e Lima Corvino DF, Horrall S. Ascariasis. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430796/

19. MURAKOZE