Ascariasis is commonly seen in tropical areas. Most important risk factor for ascariasis are low socioeconomic and poor hygienic conditions. Surgical conditions caused by Ascaris infestation vary from small intestinal obstruction, volvulus, intussusception to perforation mostly seen in the ileum^1,2. In india approximately 70% of children are infested with Ascaris lumbricoides^3,4,5. Globally It is estimated that more than 1.5 billion people are infested  with Ascaris lumbricoides, representing approximately 25 percent of population of world^6,7. Annually about 10,00,000 new cases and 60,000 mortalities are caused by ascariasis all over the world^8,9. Ascariasis although may occur at any age, it is more commonly seen in children 2 to 10 years old, however prevalence after the age of 15 years decreases¹⁰.

Intestinal obstruction due to ascaris is commonly seen in children as the diameter of the bowel lumen is smaller as well as because of increased worm load. Transmission occurs mainly via fecal-oral route i.e ingestion of water or food contaminated with faeces containing Ascaris lumbricoides eggs and occasionally via inhalation of contaminated dust. The prevalence of  intestinal obstruction due to ascaris in India is about 9.2 cases per 100,000 persons¹¹.

Intestinal obstruction can occur as a result of bolus of worms in bowel lumen because of heavy ascaris infestation, most commonly occurring at the ileocecal valve. Symptoms include colicky abdominal pain, vomiting and constipation. Vomitus may contain worms. Approximately 85 percent of obstructions occur in children between the ages of one and five years¹². Complications including volvulus, ileocecal intussusception, gangrene, and intestinal perforation occasionally result.

This was a prospective study of childhood  intestinal obstruction due to ascaris lumbricoides over a period of 1 year.  The patients included in the study were only those children who presented with intestinal obstruction with documented evidence of roundworm infestation admitted and managed in the department of general surgery. Data were analysed  for age, gender, clinical features, management.
Diagnosis in  patients was based on history of passage of worns per oral or rectum and examination including abdominal findings of distension, guarding, rigidity and on x-ray and ultrasonography findings.

All the patients were managed by keeping them nil by mouth, nasogastric aspiration, intravenous fluids and hypertonic saline enema twice daily and children were watched closely for any features of dehydration, abdominal rigidity, distension.

Patients who presented with abdominal guarding or rigidity or developed them during the course of observation were subjected  to emergency exploration.

One hundred and three patients with intestinal obstruction due to Ascaris lumbricoides were treated in one year at our centre. There were thirty-eight (36.89%) girls and sixty-five (63.11%) boys. Most of the children were in the 4 to 8 years age group, with peak occurrence at 5 to 6 years of age. Abdominal pain was the most common presentation in 96 (93.20%) children, followed by vomiting in 77 (74.76%). Twenty (19.43%) children had history of vomiting worms and another 43 (41.75%) had history of passing worms in stool. Twenty-two (20.36%) had fever, 30 (29.13%) had history of constipation and four (3.88%) had history of diarrhoea. Nine children (8.74%) had history of taking antihelmenthic drugs within one week of presentation to the hospital. Fifty (48.54%) children had abdominal tenderness, 14 (13.59%) of whom had abdominal guarding or rigidity at presentation and 2 (1.94%) developed them during the course of conservative management. 48 (46.60%) children had abdominal distension of varying degrees, 50 (48.54%) had abdominal mass due to bolus of worms, and six (5.83%) had features of dehydration. X-ray suggested the diagnosis in 54 patients (52.43%) and in 91 patients (88.35%) the diagnosis was confirmed on ultrasonography. Eighty-seven children (84.47%) responded favourably to conservative management and passed worms per rectally from third to fifth day onwards and did not require any surgical intervention. However during conservative management three children developed features of mild dehydration and electrolyte imbalance and were managed successfully.

All children who presented with abdominal guarding or rigidity and those who developed them subsequently were taken for emergency exploration (14 and two respectively). Of the 16 children who had emergency surgery, seven had bolus of worms, six had volvulus and gangrene of small bowel, two had ileal perforation [Figure 1] and one had appendicular perforation. Out of six patients with volvulus and gangrene, five were managed by resection and anastomosis and loop ileostomy was performed in the sixth case. Of the two children with ileal perforation one was managed by double layered repair and resection and anastomosis was performed for another. Appendectomy was performed for patient with appendicular perforation. One child with large bolus of worms and thinned out ileal wall required enterotomy for extraction of the worms. The remaining six children were managed by manual milking of the worms from the bowel Out of sixteen children who underwent surgery, two had wound infections, and one with ileostomy had peristomal excoriation but they all responded to conservative management. One of the children with volvulus and gangrene of small bowel managed by resection and anastomosis had leak from the anastomosis site; he underwent relaparotomy and ileal stoma was made but subsequently he developed septicaemia and died.

Ninety patients turned up for the 1^st follow up visit at the end of three months of which 48 were positive for roundworm ova. Fifty-one turned up for the 2nd visit at the end of one year of which 32 were positive for roundworm ova. All positive cases were treated with an extra dose of albendazole. One patient, who did not turn up for follow up, presented at the end of 18 months with intestinal obstruction due to roundworms and was managed conservatively with good outcome.

Ascariasis can result in gastrointestinal  complication including luminal occlusion, appendicitis, volvulus, intussusception or even perforation¹³. Similar trend of the surgical complications was shown by our series related to ascariasis. Most of the series report luminal occlusion as the common presentation ranging from 50-65%¹⁴. Intestinal obstruction can result because of the worm bolus mostly seen at the ileoceacal junction and also results increased spasticity of the terminal ileum due to effect of endotoxins of worms and inflammatory host response^15,16. Intestinal ascariasis may also result in intussusception and vovulus by acting as lead point and pivot point respectively^15,16,17.

Small bowel obstruction in children is the commonest surgical emergency encountered in our setup. Majority of the cases are attributed to ascariasis related obstruction. This is in contrast to western setup where adhesions is the common cause for obstruction. This is because of the climate variation and sanitation differences. Although children as well as adults are infested with the parasite, obstruction usually occurs in children because of the small lumen of the bowel. Also not all children infested with the parasite go in obstruction it depends on the worm load in the child. Worm infestation and obstruction is more common in rural population because of poor hygiene, lack of sanitation facilities, open field defaecation and eating of raw uncooked food.

Depending on the presentation of the patient decision is made whether to manage conservatively or surgical intervention is needed. Patients present with abdominal pain, vomiting (with sometimes worms in it), constipation, abdominal distention, bleeding per rectum, fever. Clinical signs include dehydration, tachycardia tachypnoea, abdominal tenderness, rebound tenderness, rigidity, guarding, palpable worm mass, visible peristalsis and increased bowel sounds. Majority of the patients present in early stages of obstruction when the symptoms and signs are not severe and patient is managed conservatively. Conservative management includes keeping patient nil per oral, ryles tube suction, giving iv fluids, iv antibiotics, iv analgesics, per rectal enemas. Clinical and radiographic monitoring is done. Clinical monitoring includes monitoring of vitals and looking for signs that point towards increase in severity like increasing heart rate, abdominal tenderness, guarding , abdominal distention, bleeding per rectum, worm bolus not resolving. Radiographic monitoring includes serial abdominal x-rays which shows increase in airfluid levels, increase in the diameter of distended bowel, and worm bolus not changing its position. In some hospitals oral contrast is given for relieving the obstruction however we did not included this option in our study. Maximum of the patients respond to conservative management and obstruction gets relieved in 24 to 48 hrs. However some patients do not respond and need surgical intervention. Surgical options include milking, enterotomy, resection anastomosis. If the condition of bowel is good and bolus is present near the ileocaecal junction milking is done and bolus moved into colon,if the bolus is near jejunum enterotomy is done longitudinally and worms taken out using sponge holding forceps and enterotomy is closed transversely by interrupted sutures. Sometimes multiple enterotomies can be done for boluses at multiple positions. If the bowel wall is gangrenous, or perforation has occured resection ananstamosis should be done.

In conclusion, intestinal obstruction due to ascariasis is a major cause of morbidity and mortality in children in our part of world and uses major part of our hospital resources. Early diagnosis, proper conservative management and early surgical intervention when needed helps in reducing this morbidity and mortality. However public health care workers should work towards educating people about the disease, proper hygiene and sanitation. Deworming campaings should be held and people participation should be ensured. Regular deworming should be done as reinfection rate is also high in our part of world. Inspite of deworming programmes held in recent past years the incidence has not decreased this may be attributed to less out reach programmes, resistance to anti helminthics, poor participation of people and reinfection. Health care workers should make there efforts to overcome these issues.

• Otu Aa. Tropical Surgical Abdominal Emergencies: Acute Intestinal Obstruction. Afr J Med Med Sci 1991;20:83-8.
• Archibong Ae, Ndoma-Egba R, Asindi Aa. Intestinal Obstruction In South-Eastern Nigerian Children. East Afr Med J 1994;71:286-9.
• Wani Na, Shah Oj, Wani Ma. Surgical Complications Of Abdominal Ascariasis. Postgrad Doctor Africa 2002;24:38-40.
• Hassan Aw. Intestinal Obstruction Due To Ascariasis. Niger J Surg Sci 1993;3:91-3.
• Efem Ee. Ascaris Lumbricoides And Intestinal Perforation. Br J Surg 1987;74:683-4.
• Embil J, Pereira L, White F, Garner J, Manuel F. Prevalence Of Ascaris Lumbricoides Infection In A Small Nova Scotian Community. Am J Trop Med Hyg 1984;33:595-8.
• Crompton D. How Much Human Helminthiasis Is There In The World? J Parasitol 1999;85:397-403.
• Drake L, Bundy D. Multiple Helmet Infections In Children: Impact And Control. Parasitological 2001;122:73-81
• Cooper Pj, Chico Me, Sandoval C, Espinel I, Guevara A, Kennedy Mw, Et Al . Human Infection With Ascaris Lumbricoides Is Associated With A Polarized Cytokine Response. J Infect Dis 2000;182:1207-13.
• Haswell-Elkins M, Elkins D, Anderson Rm. The Influence Of Individual, Social Group And Household Factors On The Distribution Of Ascaris Lumbricoides Within A Community And Implications For Control Strategies. Parasitology 1989;98:125-34.
• Gangopadhyay An, Upadhyaya Vd, Gupta Dk, Sharma Sp, Kumar V. Conservative Treatment For Round Worm Intestinal Obstruction. Indian J Pediatr 2007;74:1085-7.
• Chu Wg, Chen Pm, Huang Cc, Hsu Ct. Neonatal Ascariasis. J Pediatr 1972;81:783-5.
• Mishra Pk, Agrawal A, Joshi M, Sanghvi B, Shah H, Parelkar Sv. Intestinal Obstruction In Children Due To Ascariasis: A Tertiary Health Centre Experience. Afr J Paediatr Surg 2008;5:65-70.
• Wani I, Šnábel V, Naikoo G, Wani S, Wani M, Amin A, Et Al. Encountering Meckel’s Diverticulum In Emergency Surgery For Ascaridial Intestinal Obstruction. World J Emerg Surg 2010;5:15.
• Mukhopadhyay M. Biliary Ascariasis In The Indian Subcontinent: A Study Of 42 Cases. Saudi J Gastroenterol 2009;15:121-4.
• Esposito C, Settimi A, De Marco M, De Fazio C, Giurin I, Savanelli A, Et Al. Surgical Complications Of Ascariasis In Children. J Pediatric Surg Spec 2008;2(3):8-12.
• Refeidi A. Live Ascaris Lumbricoides In The Peritoneal Cavity. Ann Saudi Med 2007;27:118-21.