The Indian Journal of PediatricsDecember 2007; Volume 74 : Number 12

CONTENTS

Indian Journal of Pediatrics, Volume 74—December, 2007 1065

ORIGINAL ARTICLES

Clinico-Laboratory Profile of Pediatric HIV in KarnatakaRamesh R. Pol, T.A. Shepur and Vinod H. Ratageri .. 1071

Antibiotic Resistant βββββ-hemolytic StreptococciCharmaine A.C. Lloyd, Swarna E. Jacob and Thangam Menon .. 1077

Baseline Widal Titres in Healthy ChildrenAnand M. Patil, M.L. Kulkarni and Akhil M. Kulkarni .. 1081

Conservative Treatment for Round Worm Intestinal ObstructionA.N. Gangopadhyay, Vijai D. Upadhyaya, D.K. Gupta, S.P. Sharma and Vijayendra Kumar .. 1085

Prevalence and Correlates of Environmental Tobacco Smoke Exposure Among Adolescentsin Mangolia

Emmanuel Rudatsikira, Seter Siziya, Jargalsaikhan Dondog and Adamson S. Muula .. 1089

Tobacco Use Amongst Children in KarnatakaG. Gururaj and N. Girish .. 1095

SPECIAL ARTICLES

Accuflow an Infusion Rate Monitor: An Evaluation in Pediatric PatientsPrerana Shroff, R.D. Patel, Sona Dave, Anita Shetty, Darshan Dave and Vijaya Jaiswal .. 1099

Redefining the Management of Pediatric Tonsillopharyngitis with CefprozilNameet Jerath and Ganesh Shetty .. 1105

CLINICAL BRIEFS

Obstructed Morgagni’s HerniaA.N. Gangopadhyay, Vijai D. Upadhyaya, D.K. Gupta and S.P. Sharma .. 1109

Multiple Organ Dysfunction Syndrome Following Single Wasp StingR. Rathi Sharmila, G. Chetan, P. Narayanan and S. Srinivasan .. 1111

Kallmann’s SyndromeM.L. Kulkarni, M.D. Balaji, Akhil M. Kulkarni, S. Sushanth and Bhagyavathi M. Kulkarni .. 1113

Multicentric Castleman’s Disease in Two CasesRajni Sharma, Rachna Seth, V. Thavaraj, A. Bagga, S.K. Kabra, A.K. Karak and S. Atri .. 1116

Leukocyte Adhesion Deficiency Type 1 Presenting as Leukemoid ReactionPeymaneh Alizadeh, Akbar Ali Rahbarimanesh, Mirsaeid Ghazi Bahram and Hojjat Salmasian .. 1121

Neonatal Nonketotic HyperglycinemiaRahul P. Bhamkar and Prisca Colaco .. 1124

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CONTENTS

1066 Indian Journal of Pediatrics, Volume 74—December, 2007

Page

Hepatopulmonary Syndrome, an Unusual Cause of HypoxemiaS. Sindhu, P. Ramesh, R. Juneja and S.K. Kabra .. 1127

LETTER TO THE EDITOR

Polio Eradication in India:The Way ForwardSubhash C. Arya and Nirmala Agarwal .. 1130

Kuppuswamy's Socioeconomic Status Scale-Updating for 2007N. Kumar, C. Shekhar, P. Kumar and A.S. Kundu .. 1131

CONTENTS (Vol. 74; No. 1-11) .. 1133

SUBJECT INDEX (Vol. 74; No. 1-12) .. 1146

AUTHORS' INDEX (Vol. 74; No. 1-12) .. 1152

NOTES AND NEWS .. 1084

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Indian Journal of Pediatrics, Volume 74—December, 2007 1085

Original Article

Correspondence and Reprint requests : Dr. A.N. Gangopadhyaya,Professor, Department of Pediatric Surgery, IMS, BHU, Varanasi,221005. U.P. India[Received March 29, 2007; Accepted August 1, 2007]

Conservative Treatment for Round Worm IntestinalObstruction

A.N. Gangopadhyay, Vijai D. Upadhyaya, D.K. Gupta, S.P. Sharma and Vijayendra Kumar

Department of Pediatric Surgery IMS, BHU, Varanasi, India

ABSTRACT

Objective. The ascariasis is one of the most cosmopolitan intestinal parasite infections and it can be in inhospitable regionsinhabited by human being, but its biggest prevalence is observed in the tropical and subtropical areas. Intestinal obstruction hasbeen estimated to occur in 2 per 1000 ascaris-infected children per year. We are presenting a study emphasizing theconservative treatment for complete intestinal obstruction due to roundworms without sign and symptom of peritonitis andperforation.

Methods. A total of 22 patients of roundworm obstruction partial or complete without signs of and symptoms of peritonitis wereadmitted in the Department of Pediatric Surgery IMS, BHU Varanasi India in the period form 2003 - 2005. Patients were putnil by mouth, intravenous fluid, antibiotics, piperazine salt through nasogastric tube and glycerine + liquid paraffin emulsionenemas and were evaluated for duration of hospital stay, rate of conversion to surgical treatment and complications.

Results. 19 (86%) patients were treated successfully with conservative line of management. Only 3 patients required surgicalintervention. No mortality, complication and mean hospital stay was 4.1 days (range 4 – 5 days).

Conclusion. Round worm intestinal obstruction can be effectively treated by conservative line of management. [Indian JPediatr 2007; 74 (12) : 1085-1087] E-mail : gangulybhu@rediffmail.com

Key words : Round worm; Intestinal obstruction; Piperazine salt

The ascariasis (AL) is most common in tropical andsubtropical areas. Estimations reveal near 1 000 000 ofnew annual cases and 60 000 fatalities in a year.1, 2,3

Ascariasis can occurs at all ages, but it is most common inchildren between 2 to 10 years of age, and prevalencedecreases over the age of 15 years. Although this illnesscourses with silent form or chronic symptomatology, themassive infestation in children can give place to seriouscomplications, which include obstruction of the smallintestine, appendiceal lumen, bile duct, and pancreaticduct; intestinal volvulus; intussusception; peritonitis dueto perforation of a viscus; and liver and lung abscess.4,5,6

In addition to these largely mechanical complications, itappears that secretions from the worms as well as toxicdecomposition products of disintegrating worms arecapable of provoking a severe and sometimes necrotizinginflammatory reaction in the bowel or bile ducts7 systemicand pulmonary hypersensitive reactions. Intestinalobstruction has been estimated to occur in 2 per 1000

ascaris-infected children per year. In Indian schoolchildren the incidence is more than 11%8 and it causesabout 15% of all intestinal obstruction.9 Many studiesadvocate for conservative treatment for partial intestinalobstruction due to round worm but we are presenting astudy emphasizing initial conservative treatment forcomplete intestinal obstruction due to round wormwithout sign and symptoms of perforation andperitonitis.

MATERIAL AND METHODS

All the patients with suspected round worm intestinalobstruction with out signs and symptoms of peritonitisadmitted in pediatric surgery department of Institute ofMedical Sciences B.H.U., Varanasi India from 2003-2005were included in study. Patients presented with sign andsymptom of peritonitis or perforation were excludedform our study. A total of 22 patients were admittedduring this period. All patients were initially subjected toconservative treatment (nil by mouth, intravenous fluid,nasogastric tube aspiration, rectal enemas (glycerine +liquid paraffin enema) and piperazine salt throughnasogastric tube for 3 consecutive days) after getting the

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1086 Indian Journal of Pediatrics, Volume 74—December, 2007

informed consent from patients. They were closelymonitored with assessment of vital parameters andabdominal girth measurement and serial abdominal X –ray. Serial follow-up X-rays were taken at 8, 24, and 48 h.Clinical improvement was defined as a decrease inabdominal pain and distension, decrease in abdominalgirth and associated passage of flatus or stool. TheRadiological improvement was defined as a decrease innumber of dilated bowel loops or decrease in thediameter of dilated small bowel. The treatment protocolfollowed at our center, is conservative with appropriateintravenous fluid, nasogastric suction, antispasmodic,antibiotics and anthelmintic therapy (Piperazine salt @75mg/Kg) followed by rectal enemas (glycerine + liquidparaffin enema) for three consecutive days. Patients areconsidered for surgical intervention if (three patients inour series).

(a) Worms are not expelled after 24 – 48 hr ofconservative treatment as per our protocol.

(b) There is any deterioration on clinical parameters

RESULT

All the cases were from low socioeconomic groups. Mostcommon age of presentation was 4-8 year (67%) Table 1.Male patients (63.6%) were slightly higher than females(35.4%). Most of the patients presented with abdominalpain (63.6%) and distension (72.7%). About 45.5%patients passed worm in vomitus and 63.6% patientspassed worms per rectally (Table 2). History ofanithelminthic treatment in recent pass was present in59% (13/22) cases. X-ray was suggestive for round wormobstruction in 54% (12/22) cases where asultrasonographic finding were positive in 77% (17/22)

cases. Out of 22 patients only 3 (13.6%) patient requiredsurgical treatments and rest responded well toconservative line of management. Mean hospital stay forconservative treatment was 4.1 days (range 4 – 5 days).Those patients who required surgical intervention stayedin hospital for about 2 weeks. There was no mortality inpresent series. In all patients who required surgicalintervention the bolus of the worm was pushed to thelarge bowl by milking the intestine and latter on wormswere expelled out of the rectum by its own. One patientrequired re-exploration that not improved afteroperation; he had ischemic changes in bowel andrequired bowel resection and end to end anastomosis.

DISCUSSION

The ascariasis is most common parasite infection ofHuman being and it is calculated that the worldpopulation’s fourth part is infected The prevalence ofascariasis is highest in children aged 2-10 years, with thehighest intensity of infection occurring in children aged 5-15 years,10 in the present series most of the patients werein age group of 2 – 6 years (67%) and is similar to theresults of N. E. Agugua et al10 who reported highestincidence in children aged between 3 – 7 years (74%)Table 1.

The clinical illness depends on the load of parasite2,11

the infested patients may not have any symptom, or canpresent with malnutrition, chronic abdominal colic pain,nausea, vomiting and the elimination of parasites instools or rectum and some time though mouth. Most ofour patients presented with abdominal pain anddistension (63.6% and 72.7% respectively) and is similarto other reported series.7,12,13 Many patients have historyof expulsion of ascaris by rectum or mouth which help inmaking a right diagnosis10,14,15 10 (45.5%) patients inpresent series had history of passing worms throughmouth and 14 (63.6%) patients passed worm in stool,Villamizar E et al9 reported 50% of their patients passedworm by stool or anus. In cases of massive infestationpatients can present with acute intestinal obstructioneither because of bolus of worm obstructing the lumen ofintestine or due to volvulus needing emergency surgery.16

Diagnosis of round worm obstruction is usuallysuspected on history and clinical symptom and issupported by radiological studies. The abdominal X-rayshows air fluid levels and multiple lineal images ofascaris lumbricoides in the dilated intestinal loops17 andwhirlpool sign9 was suggestive in 54% cases in presentstudy which is slightly less than other reported series.Most of the patients present late, had grossly dilatedbowel loops and are constipated, this may be the mainreason for smaller number of patients diagnosed on plainX-ray abdomen. Abdominal ultrasound coulddemonstrate a dilated intestinal loop, with thicker wall

TABLE 1. Patient’s Profile: Age and Sex Distribution

Male 14 (63.6%)Female 8 (35.4%)< 4 yrs 2 (9%)>4 yrs but < 8 yrs 14 (63.3%)> 8ys < 12 years 6 (27.7%)

TABLE 2. Clinical Presentation of Patients

Clinical presentationAbdominal Pain 14 (63.6%)Abdominal distension 16 (72.7%)Failure to thrive 12 (54.5%)Anemia 18 (81%)Lump in abdomen 10 (45.5%)Type of obstructionComplete obstruction. 22History of worm eliminationHistory of worm passed through mouth 10 (45.5%History of worm passed through rectum 14 (63.6%)

No history of worm passage 4

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Conservative Treatment for Round Worm Intestinal Obstruction

Indian Journal of Pediatrics, Volume 74—December, 2007 1087

and a mass of worms that cause the obstruction17 andcharacteristic sonographic features of round wormobstruction are ‘railway track’ sign and ‘bull’s eye’18 Thegroup of parasites images is described like an echogeniccomplex mass of intestinal air, parasites and fecal matter,with morphology of jellyfish head in the longitudinal axisand of rouselike in the transaxial cut. Ultrasonographydiagnosed 77% of cases in present study and iscomparable to other reported series. In present series 10patients had palpable lump and out of these 3 patientsrequired surgical intervention.

Few studies highlight that administration ofanthelmintic drugs in children with abdominal pain witha subacute obstruction may worse the clinicalpicture15and leads to serious complications likeintussusceptions, volvulus, hemorrhagic or necroticbowel; or even perforation.15,18,19 The medication duringthis period leads to complete paralysis of an importantnumber of parasites and accumulate them at level ofdistal small bowel blocking the lumen. History of recentanithelminthic treatment was observed in 59% cases inour series which may add to an important contributoryfactor for precipitation of intestinal obstruction.

Conservative management for partial wormobstruction is advocated in many studies,17, 20, 22 and can bemanaged with intravenous fluid administration,nasogastric suction, and instillation of oral piperazinesalt9, normal saline enema22 and hypertonic salineenemas.21 Few studies advocated use of gastrografin15,23

for evacuation of worms with variable results.Mukhopadhyaya et al22 used anthelminthic drug alongwith normal saline enema and reported 50% success toconservative treatment in their series. All these studiesadvocated conservative management in cases of partialworm obstruction only, but in present study we haveused conservative treatment in patients with completeintestinal obstruction without sign and symptoms ofperforation and peritonitis due to round worms.

The mean duration of hospital stay for the patientsresponded to conservative management was 4.1 days(range 4 – 5 days) which is comparable to 3 days ingastrografin group of Bar – Moar et al,23 3.5 days inhypertonic saline group and of 4 +/- 1.69 days by SoomroMAet al.21

CONCLUSION

Partial as well as complete roundworm intestinalobstruction (without signs of peritonitis) can effectivelybe managed conservatively by using nasogastricpiperazine salt and gylcerine + liquid paraffin enemas.This modality of treatment is quite safe, required lesshospital stay and is cost effective. Only in exceptionalcases surgical intervention is required.

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