Ascaris lumbricoides: A Rare Cause of Gastric Perforation with Intraperitoneal Migration in Pediatric Patient with Systematic Review of Literature

Abstract

Ascaris lumbricoides is one of the most common helminthic infections globally, mainly prevalent in tropical and subtropical developing countries with poor hygiene and sanitation. Though rare, intestinal perforation can occur due to clumping up of worms, causing partial or complete obstruction, eventually leading to bowel wall necrosis and perforation. We report a case of a 14-year-old boy from rural North India, who presented with abdominal pain, vomiting, abdominal distension, and anemia for 5 days. An immediate exploratory laparotomy was done, and an enterotomy was performed to remove the worm masses. Gastric perforation was found and repaired, and a loop ileostomy was performed. The majority of intestinal obstructions due to ascariasis are managed conservatively. However, in case of complications like perforation, early surgery is required to reduce morbidity and mortality. Ascariasis remains a global health challenge. Prevention through health education and awareness programs is essential, especially in the endemic areas. Improvements in sanitation, periodic deworming, and early diagnosis are crucial. In cases with complicated presentations like perforation peritonitis, timely surgery is lifesaving.

Keywords

albendazole - ascariasis - intraperitoneal migration - parasitic infection - perforation peritonitis

Introduction

Ascaris lumbricoides (AL) is the most common parasitic (helminthic) infection affecting humans worldwide and causing serious medical and social problems, mainly in developing countries, because here unhygienic disposal of human excreta is common.[1] [2] Globally, more than 1.4 billion people are infected with AL, out of which an estimated 1.2 to 2 million such cases with 20,000 deaths per year occur in mostly endemic areas.[1]

AL might be a cause of intestinal infection in children with a peak age between 2 and 10 years[3] and cause about 60,000 deaths per year.[4] The mortality rate from intestinal infection caused by AL is 5.7% for those below the age of 10 years.[5] Most cases of AL are asymptomatic; however, symptoms may appear depending on the intensity of the infection, the host's nutritional and immunological status, and the possible complications that may arise.

The main sites of involvement are the lungs during larval migration and the intestine after the parasite reaches full maturity. Invasion of the biliary ducts and the liver parenchyma may occur.[6] [7] The adult worm has also been reported in the pleural cavity, airway, pancreas, peritoneal cavity, lacrimal duct, middle ear, and femoral artery.[8] [9]

Intestinal obstruction due to AL is a serious disease with high morbidity and mortality, especially postoperatively.[10] [11] Even though a lot of complications were reported from AL infestations worldwide.[12] Hence, reporting such findings with their intervention will help policymakers to mitigate the challenges in the health care system and also help as a piece of baseline evidence for future researchers on the issue of interest.

Case Presentation

A 14-year-old boy from a rural locality in North India presented in the emergency room with a chief complaint of fever for 10 days, followed by abdominal pain associated with multiple episodes of nonbilious vomiting and abdominal distention. He also had obstipation for the past 3 days. No history of cough and chest pain. On general examination, the child appeared ill, was febrile, and had moderate dehydration. On per-abdominal examination, there was abdominal distention with diffuse tenderness, guarding, and rigidity. Bowel sounds were absent. Digital rectal examination was unremarkable. The patient was initially resuscitated in the emergency room, and imaging studies were performed once the patient was stable. A plain radiograph of the chest and abdomen was taken in the erect position, which was suggestive of pneumoperitoneum, while the bilateral lung fields were normal ([Fig. 1]).

Fig. 1 X-ray chest shows gas under the right hemidiaphragm (bowel perforation caused by Ascaris lumbricoides).

Ultrasonography of the abdomen was suggestive of a collection (approximately 150 mL) in the right subdiaphragmatic space and right paracolic gutter containing low-level echoes and air foci. Multiple tubular hyperechoic structures were also noted in the ileal loops in the periumbilical and left lumbar region, suggestive of intestinal ascariasis and intestinal perforation ([Fig. 2]). Due to confirmation of diagnosis via clinical signs and symptoms, chest X-ray, ultrasound of abdomen, and emergency due to peritonitis, no further investigations like computed tomography abdomen were done.

Fig. 2 Ultrasonography of intestinal Ascaris lumbricoides.

All routine investigation including hemoglobin - 8.6 g/dL, eosinophil count - 550 count/μL, platelets count - normal, leucocyte count - 14000/μL, liver and kidney function tests, as well as serum electrolytes were within normal range. Widal and malaria parasite tests were negative.

On performing an exploratory laparotomy, we found Ascaris in the peritoneal cavity and a perforation of 2*2 cm in the prepyloric region of the stomach. The stomach, small intestine, and large intestine were loaded with Ascaris ([Fig. 3]).

Fig. 3 Intraoperatively: Ascaris present in the lumen as well as the peritoneal cavity.

Peritoneal lavage was done, and ascarids were removed from the stomach. The whole small bowel, large bowel, stomach, liver and gallbladder, urinary bladder, spleen, and other adjacent organs were examined. The entire small bowel was found to be edematous and inflamed, but there were no signs of impending perforation. The other organs showed no evidence of worm infection. The perforation was primarily repaired with Graham's omental patch. Enterotomy was done in the distal ileum, worms were removed from the small bowel by simply squeezing, and distal loop washes were given to empty the large intestine ([Fig. 4]).

Fig. 4 Worm retrieved from the lumen and peritoneal cavity.

A loop ileostomy was performed in view of an overwhelming worm load. Both proximal and distal washes were given through the ileostomy and per-rectal washes were also given. Small bowels were heavily loaded with worms, which were found to be impacted proximal to the ileocecal junction; thus, an ileostomy was appropriate.

In the initial 3 to 4 days postoperatively, the stoma output was watery, averaging 800 to 1000 mL per day, due to inflammatory fluid. The output also showed the passage of worms. Gradually, the output became more semisolid. A nasogastric tube that was placed preoperatively was maintained for 5 days to facilitate healing of the gastric perforation. Postoperatively, the patient received intravenous pantoprazole twice daily for acid suppression, along with intravenous albumin, micronutrients, and total intralipid. Intravenous fluids were administered in higher volumes than usual to compensate for fluid losses through the stoma. For distal bowel clearance, distal loop stoma washes were given with normal saline for 3 days.

Postoperatively, the patient was allowed oral intake from the 6th postoperative day. He was advised to take fluids rich in electrolytes and to follow a high-protein diet. For acid suppression, tablet pantoprazole 40 mg twice daily was prescribed for 5 days. Antihelminthic treatment was initiated, which consisted of a single 400 mg dose of albendazole, 6 mg of ivermectin once daily on an empty stomach, and 50 mg of nitazoxanide twice daily for 3 days. The patient was successfully discharged on the eighth postoperative day without any complications.

The patient was advised to follow a high-protein and high-fat semisolid diet to promote prompt healing and compensate for the losses due to steatorrhea. The patient and caregivers were counseled and taught about stoma care, using a stoma bag with colostomy paste and adhesive powder to prevent peristomal skin excoriation.

Upon follow-up after 7 days, the patient reported no complaints regarding bowel habits, pain, or food tolerance. Mild peristomal excoriation was present on examination, which was initially managed with zinc oxide-based ointment. Excoriation continued to worsen, necessitating the application of silver paint. The caretakers were reeducated on the proper use of the stoma bag with adhesive paste and were advised to continue a semisolid, high-protein diet and fluids rich in electrolytes. Ultrasonography of the abdomen and chest was performed to look for any persistent worms in the abdomen as well as to rule out lung involvement. Patient is now on regular follow-up with a healthy wound and a healthy functioning stoma.

Discussion

AL is one of the most prevalent soil-transmitted helminths and a neglected tropical parasite, primarily affecting people in developing countries with tropical climates. These regions have warm and humid climates, which favor the growth and development of the parasite. Additionally, poor sanitation, inadequate hygiene practices, and limited access to medication and health facilities further increase the disease burden.[13] [14] [15]

Ascaris enters the human body through the ingestion of embryonated eggs, typically via contaminated raw vegetables, fruits, and water. The adult worms inhabit the lumen of the small intestine (jejunum or ileum). Intestinal ascariasis is rarely detected and is usually an incidental finding.[16] The infections are mostly asymptomatic or may present with mild, nonspecific gastrointestinal symptoms. However, in heavy worm loads, it can also cause intestinal obstruction, perforation, and gastrointestinal bleeding.[17] [18]

Approximately 10 to 14 days after infection, AL larvae may migrate through the lungs, leading to eosinophilic pneumonia (Löffler's syndrome)—a self-limiting inflammatory response characterized by pulmonary infiltration and eosinophilia. Adult Ascaris can cause a variety of gastrointestinal complications, such as small bowel obstruction, upper gastrointestinal bleeding, intussusception, volvulus, intestinal perforation, and gastric ascariasis. Extraintestinal involvement can present as acute cholangitis, hepatic abscess, biliary colic, and acute pancreatitis. Transabdominal ultrasound, using a high-frequency linear transducer, is a highly sensitive diagnostic modality, especially when performed by expert hands. Due to the risk of residual worms, which might lead to a worm bolus and spastic paralysis, anthelmintic therapy should be administered for 3 to 5 days postoperatively once the bowel movements are established.[19] [20] [21]

The bowel has a remarkable capacity for dilatation and can accommodate up to 5,000 worms without producing any symptoms.[22] [23] However, the most common complication is intestinal obstruction, which may be acute or subacute, and depends upon the worm load, especially in children. Further gangrene and perforation may also occur due to pressure necrosis caused by worms.[24] The cause of perforation remains controversial, but in the tropics, patients often have associated diseases such as typhoid enteritis, tuberculosis, and amebiasis, which can also cause intestinal ulcerations. The worm may escape into the peritoneal cavity through perforations at these sites of ulceration.[25] Another possible explanation is that the large worm bolus can lead to pressure necrosis and gangrene.[7] Intussusceptions due to Ascaris have also been reported.[26] [27] [28] Involvement of the appendix can lead to appendicular perforation. A perforation of Meckel's diverticulum has also been found.

Granulomatous peritonitis in ascariasis is reported to be due to the presence of dead adult worms in the peritoneal cavity or by an inflammatory reaction to the eggs in the peritoneum.[17] There are only two reports in the literature on duodenal perforation possibly caused by ascariasis presenting as an acute abdomen.[17] [18] In a report by Louw,[23] a bleeding duodenal ulcer with ascariasis adherent to the ulcer site was found on endoscopy. A gastric outlet obstruction due to an Ascaris worm bolus has also been reported.[24] An extensive literature search revealed only one report[23] from Nigeria on the possible occurrence of gastric perforation caused by Ascaris. Very few case reports have been published previously, especially in pediatric patients ([Table 1]).

Table 1 Review cases

Study	Year	Age/sex	Symptoms	Durations	Intraoperative findings	Management	Outcomes	Complications
Gupta et al[1]	2012	48 y/m	Abdominal pain and vomiting	2 d	Gastric perforation	Graham's omental patch repair	Discharged	Discharge on anthelminthics
Refeidi[17]	2007	35 y/m	Epigastric pain with nausea, anorexia, constipation, and vomiting	6 d	Giant duodenal perforation with worm at peritoneal cavity	Graham's omental patch repair	Discharged	Ventilatory support, metabolic acidosis, wound infection
Anand et al[2]	2014	27 y/f	Pain in abdomen, vomiting	3 d	Ileal perforation	Primary repair	Discharged	Discharge on anthelminthics
Darlington and Anitha[16]	2018	4 y/m	Peritonitis features	4 d	Ileal perforation with volvulus	Ileostomy	Discharged	Discharge on anthelminthics
Molla et al[29]	2023	2 y/f	Vomiting, abdominal distension, and loss of appetite	6 d	Ileal perforation	Primary repair	Discharged	Discharge on anthelminthics
Sarmast et al[18]	2011	35 y/f	Epigastric pain with nausea	3 d	Peptic perforation	Graham's omental patch repair	Discharged	Discharge on anthelminthics
Xie et al[30]	2025	61 y/m	Epigastric pain, nausea, and vomiting	1 mo	Gastric perforation	Graham's omental patch repair	Discharged	Discharge on anthelminthics
Agrawal et al[31]	2017	5 y/f	Abdominal pain and vomiting of worms	4 d	Gangrenous small bowel with intraperitoneal worms, duodenal perforation	Graham's omental patch repair with resection and anastomosis	Discharged	Discharge on anthelminthics
Tejareddy et al[32]	2017	20 y/m	Abdominal pain and vomiting, blood in stool	7 d	Jejunal perforation	Primary repair	Discharged	Discharge on anthelminthics

Abbreviations: f, female; m, male.

In our case, we found that the stomach was distended, and small and large bowels were highly loaded with Ascaris, which caused obstruction at the distal ileum, which was decompressed surgically by enterotomy. More often, recurrent infestations lead to malnutrition and growth retardation in children in endemic areas. Surgical complications due to ascariasis are rare in adults.[23] Improvements in sanitation, hygiene, and health education, along with adequate therapy, are used to control and reduce the intensity of infection.

Infestation with roundworms is widespread in developing countries, and although the majority of intestinal obstructions can be treated conservatively, in some cases, surgery may be required. Patients with complete obstruction and bowel perforation are candidates for explorative laparotomy after initial resuscitation. Postoperative follow-up and further plans for deworming are recommended to ensure patient safety.

Conflict of Interest

None declared.

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Publication History

Received: 23 February 2025

Accepted: 28 September 2025

Article published online:
19 November 2025