Ascariasis-related surgical complications still occur in India. Ascariasis usually manifests as diarrhoea, abdominal pain, and anaemia. Bowel obstruction is a frequent cause of emergency presentations related to ascariasis in developing countries. However, bowel perforation is relatively rare. Here, we described a rare cause of perforation peritonitis due to ascariasis in a young adult with wandering live worms in the peritoneum.

A young adult male (25 years) presented in our emergency department with acute onset severe pain abdomen for 48 hours without any radiation or relief with symptomatic medications. He denied any past history suggestive of gastric or duodenal ulcer. There was also no history of analgesic abuse or any trauma. He gave a history of passages of worms in faeces a few days back. The patient was febrile on admission with tachycardia, hypotension, and low urine output. The abdomen was tender with guarding and rebound tenderness. On admission, the white blood cell count was 16600/ml. His blood urea nitrogen and creatinine were 58.1 mg/dl and 1.1 mg/dl, respectively. Abdominal X-ray revealed gas under the dome of the diaphragm. After fluid resuscitation, a laparotomy was performed. A perforation was found in the ileum (30 cm proximal to the ileocaecal junction) and a live motile worm was seen coming out through the perforation site (Figure 1) and wandering free intothe peritoneum. Few live worms could be palpated within the adjacent unhealthy ileum. He underwent ileal resection with end ileostomy with extraction of worms (Figure 2). He recovered uneventfully except for surgical site infection which was managed conservatively. The histopathology report showed non-specific inflammation without any evidence of a granuloma. He was started on anti-helminthic drugs. Ileostomy was closed after 3 months and he is symptom-free at 3 years follow-up.

Ascariasis is still prevalent in some countries and it causes about 10,00,000 new cases and 60,000 deaths in a year worldwide.^2,3 Adult worms stay in the lumen of the small bowel and usually cause chronic symptoms like vague abdominal pain, nausea, diarrhoea, and malnutrition/anaemia. However, surgical complications are not uncommon, especially in developing countries. Surgical complications like intestinal obstruction are more common in paediatric and young adults. The cause may be a narrower bowel lumen in children that gets occluded by a worm bolus more easily than an adult with a wider circumference of the bowel. In endemic areas, it has been shown that between 5-35% of cases of bowel obstruction are due to ascariasis.¹ There are a few steps involved in the development of ascariasis-induced bowel obstruction. Firstly, worms form a large bolus that can cause mechanical intestinal obstruction. Secondly, intussusception may be caused by a worm bolus. Thirdly, worm-loaded bowel may get twisted and cause volvulus, sometimes leading to bowel ischemia and perforation. Lastly, the inflammatory response against worm-related toxins may cause bowel obstruction.

In conclusion, ascariasis-related obstruction and perforation should be taken into consideration as an alternate diagnosis of surgical acute abdomen especially in paediatric population and young adults in endemic areas. Early diagnosis and prompt treatment can reduce surgical complications and morbidity.