Pediatric Ascariasis Treatment & Management

Updated: Jan 05, 2015
  • Author: William H Shoff, MD, DTM&H; Chief Editor: Russell W Steele, MD  more...
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Treatment

Medical Care

Pulmonary disease

Most cases are asymptomatic.

Most symptomatic cases are mild and self-limited (days) and do not require therapy.

Bronchospasm can be managed with conventional therapy.

Severe cases can be managed with systemic steroids and oxygen supplementation.

Partial small bowel obstruction

In the absence of signs of toxicity (eg, fever, tachycardia, protracted vomiting, peritoneal signs), persisting abdominal pain, or a palpable mass in the same site for more than 24 hours, several conservative management strategies, including supportive care, have proven efficacious. Some of these strategies are as follows:

Intravenous fluids and nasogastric tube with or without an antispasmodic (antimuscarinic)

Intravenous fluids, nasogastric tube, and antibiotics (eg, metronidazole, aminoglycoside, penicillin) with or without an antihelminthic after resolution of symptoms

Saline enema with or without an antispasmodic: Saline enemas are effective in children because 80% have an incompetent ileal-cecal sphincter.

Racine or mineral oil (15-30 mL via nasogastric tube) in conjunction with an antihelminthic: A low dose is used to allow worm death over few days. Several reports note that administration of antihelminthics in patients with partial bowel obstruction can precipitate complete obstruction.

Gastrografin (15-30 mL) via nasogastric tube: The hyperosmolar action results in increased fluid around worms, which favors their separation.

In the presence bowel obstruction, persisting or worsening abdominal pain, or sepsis, surgical intervention is warranted (see Surgical Care).

Hepatobiliary and pancreatic ascariasis

This typically manifests as biliary colic, acalculous cholecystitis, ascending cholangitis, pancreatitis, or hepatic abscess. Ascariasis is a common cause of these conditions in endemic countries.

Aggressive antibiotic therapy for suspected infection and early ERCP to remove the worms are highly efficacious together in the treatment of HPA. During ERCP, worms are sometimes observed to be moving into and out of the duct orifices. Worms are directly removed; when they are out of reach, they can be flushed out with rapid injection of 5-10 mL of diluted dye (eg, 10% Urograffin) into the duct. The entire worm must be removed because fragments lead to infection, granulomas, or stone formation.

After abdominal symptoms improve, antihelminthics can be administered. In one series, the ERCP complication (cholangitis, hypotension) rate was 6%. [14]

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Surgical Care

In endemic regions, ascariasis is a major etiology for conditions that require acute surgical intervention, including the following:

  • Intestinal obstruction
  • Appendicitis
  • Volvulus
  • Intussusception
  • Ischemic bowel
  • Hepatobiliary obstruction (if ERCP has failed or is unavailable)
  • Failure of conservative management of partial bowel obstruction
  • Severe abdominal pain or tenderness with signs of toxicity
  • Persisting or worsening abdominal pain
  • Severe abdominal pain with a palpable mass in the same site for longer than 24 hours

Surgical procedures used in the management of the bowel obstruction secondary to ascariasis include the following:

Milking the worms through the ileo-cecal valve: This is recommended for a worm bolus in the distal ileum. Milking proximal boluses may cause damage to the bowel. This process has been facilitated by oral administration of mineral oil (15-30 mL).

Enterotomy to remove the bolus if milking is unsuccessful

Segmental resection of damaged bowel with or without temporary ostomy, as needed: Anastomosis should be 2-layers and end-to-end to prevent residual worms from migrating through the anastomosis into the peritoneal cavity, which has been reported.

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Consultations

Surgeon

Any patient with acute abdominal pain and tenderness suggestive of an acute surgical process warrants a surgical consultation. If a double-contrast (ie, oral and intravenous dye) CT scan can be performed and the patient is not toxic or septic, the consultation may be deferred until the results of the scan are available. If the patient is toxic or septic, the surgical consultation should take place immediately.

Critical care specialist

Any patient who appears to be septic may qualify for early goal-directed therapy.

GI specialist

Any patient who is diagnosed with HPA or in whom a high index of suspicion for this diagnosis is noted warrants an immediate GI consultation for emergent ERCP. This procedure is often both diagnostic and therapeutic, with removal of the offending worm and relief of the obstruction.

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Diet

Advise patients with known ascariasis to avoid peppery and spicy foods because they induce increased worm migration.

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