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Introduction

Lower gastrointestinal haemorrhageis defined as intraluminal blood loss from asource distal to the ligament of Treitz. Typicalcauses include large bowel diverticular disease,anorectal pathologies, benign or malignantneoplasias,inflammatoryboweldisease,vascularmalformations, and angiodysplasias. Smallbowel haemorrhages account for 5% of lowergastrointestinalhaemorrhagesandoftenare thesource of obscure gastrointestinal haemorrhagewhen the diagnosis cannot be established byconventional upper and lower endoscopy. Wepresent a case of acute lower gastrointestinalhaemorrhage secondary to jejunal ascariasisanda literature searchon lowergastrointestinalhaemorrhage associated with jejunal infestationwithAscaris.

Case Report

A 65-year-old Indonesian woman wasreferred from a district hospital with a 1-dayhistory of passing a black, tarry stool. She hadno abdominal discomfort, no constitutionalsymptomsandnoalterationinappetiteorbowelhabits.Uponexamination,althoughshewasalertand not in distress, her conjunctiva was pale.Her vital signs were stable with no evidence ofhypovolaemicshock.Anabdominalexaminationwas unremarkable, and a digital rectalexamination revealed freshmelaena.Otherwise,herexaminationwasnormal.

Case Report

Submitted: 27May2011Accepted: 29Jun2011

Laboratory investigations revealed thather haemoglobin level was 4.8 g/dL and thather platelet count was 496000 U/L. Shehad no coagulopathy. An emergency uppergastrointestinal endoscopy performed uponadmission was normal. She was then admitted,underwentbloodtransfusion,andwasscheduledforcolonoscopythenextday.Colonoscopyresultshowed stale melaena along the entire lengthof her large bowel, with no identifiable sourceof bleeding. During admission, she continued to passfresh melaena and was transfused a total of9unitsofpackedcellsbecauseshewaspersistentlyanaemic. An emergency computed tomography(CT)angiogramidentifiedactivebleedingintothejejunumthatoriginatedfromoneofthebranchesof thesuperiormesentericartery.Interventionalembolisation was initiated, but the bleedingstoppedduringtheprocedure.Theprocedurewasabandonedastherewasnofurtherdemonstrableangiographic evidence of active bleeding fromeither the celiac or the superior mesenteryarteries. The following day, she began to bleedagainwhileintheward,andadecisiontoperformsurgerywasmade. A laparotomy did not show any grosspathologyofthestomach,smallbowels,orcolon.An enterotomy was performed at the jejunum(130 cm from the duodenojejunal [DJ] flexure)and was followed by an on-table enteroscopy.With a soft bowel clamp applied distally tothe enterotomy, the endoscope was advancedproximally, which revealed fresh blood

Acute Lower Gastrointestinal Haemorrhage Secondary to Small Bowel Ascariasis

Daphne Dewi Stephen, Sze Li Siow

Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia

Abstract Acutelowergastrointestinalhaemorrhagesecondarytosmallbowelascariasisisextremelyrare. A high level of suspicion should be maintained when dealing with acute gastrointestinalhaemorrhage inmigrants and travellers. Small bowel examination is warranted when carefullyrepeated upper and lower endoscopies have failed to elicit the source of bleeding. Appropriatetestselectionisdeterminedbytheavailabilityoflocalexpertise.Wepresentacaseofacutelowergastrointestinal haemorrhage secondary to jejunal ascariasis and a literature search on lowergastrointestinalhaemorrhageassociatedwithjejunalinfestationwithAscaris.

Keywords: ascariasis, aetiology, complications, diagnosis, gastrointestinal haemorrhage, jejunal diseases, melaena, parasitology

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oozing from mucosal erosions of the jejunumapproximately 120 cm from the DJ flexure.Further examination proximal to the mucosalerosions revealed a viable adult Ascaris overthe proximal jejunum (Figure 1). Enteroscopicexaminationdistaltotheenterotomytowardstheileocaecalvalveshowedhaematinstainsalongtheentirelengthofthedistaljejunumandileum.Theparasite was removed via a second enterotomy60 cm from the DJ flexure. A small bowelresection with end-to-end anastomosis wasperformed for the length of the jejunum thathad the bleeding erosions. Histopathologicalexamination of the resected jejunum showedanormalsmallbowelwithlymphoidhyperplasia. The patient recovered uneventfullywith nofurtherepisodesofgastrointestinalhaemorrhageandwaswell at dischargewith oral albendazole(400mg).ExaminationoftheparasiteconfirmedanadultAscaris lumbricoides.

Discussion

TheWorldHealthOrganization(1)estimatedthatmorethan1billionoftheworld’spopulationisinfectedwithoneormoreofthesoiltransmittedhelminths, particularly Ascaris lumbricoides, Trichuris trichiura, and Necator americanus or Ancylostoma duodenale. These infections,together with schistosomiasis, represent morethan 40% of the disease burden caused by alltropicaldiseases,excludingmalaria(2).

Ascariasisisacommoninfectioninchildrenoftropicalcountriesduetopoorsanitation.Itis,however,rareinadults.Infectionisacquiredviafaecal-oraltransmissionthroughingestionoffood,water, or soil contaminated with embryonatedeggs (3). Upon ingestion, the eggs hatch in thestomach and duodenum and release the larvaeinto the duodenum. The larvae then penetratetheintestinalwalltoentertheportalcirculation.Fromthere,thelarvaefollowthevenousandthelymphatic systems to enter the right side of theheart, the pulmonary circulation and, finally,thepulmonarycapillaries.Inthelung,thelarvaepenetrate throughthecapillaries into thealveoliandtravelupthetracheaintothepharynx,wherethey return to the small intestine through theswallowing of bronchial secretions. The larvaematureintoadultroundwormswithinthelumenof the small intestine, especially the jejunum,and reach a size of 15–35 cm in approximately2months.Adultwormscansurviveintheintestinefor6–18months.Aftermating,thefemalesbeginegg production 2–3 months after the initialinfection.Theadultfemaleascaridsaresomewhatlarger than the males, measuring 22–35 cm inlengthand3–6mminwidth,whereasthemalesare15–31cminlengthand2–4mminwidth.Theadultwormsarefusiformandcylindricalinshapeandwhiteorcreamy-pinkincolour.Theanteriorendoftheascaridisblunt,whereastheposteriorendispointedand,inthemale,coiled(4). Ascaris lumbricoides can cause a myriadof surgical complications in the abdomen. Themost common complication of ascariasis isintestinal obstruction caused by a worm bolus,which may present as an acute or subacuteintestinal obstruction or alternatively asintussusceptions, perforation and gangrene ofthe small bowel (5). Other areas where adultworms could lodge are in the appendix, causingacuteappendicitisandappendicularperforation,or in the biliary and pancreatic ducts, causinghepato¬pancreatic ascariasis. In addition, acuteupperairwayobstructionduetoroundwormshasbeendocumented. Gastrointestinal bleeding appears to beuncommon with ascariasis. Typically, ascariasismay present with chronic occult bleeding andanaemia, but rarely with acute gastrointestinalbleeding.Theclinicaldiseaseislargelyrestrictedto individualswith ahighworm load. Intestinalmucosal ulceration is thought to be due to themechanical traumafromtheworm’sattachmentto the intestinal lining and tomucosal chemicalirritationcausedbytheworm’ssecretions(6).Figure 1: On-table enteroscopic finding of an

Ascaris.

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Malays J Med Sci. Apr-Jun 2012; 19(2): 92-95

ThefirstreportpublishedinEnglishmedicalliterature on acute massive jejunal bleedingcaused by ascariasis was by Sharma et al. (6)in2000.The authorsdescribed theuse of pushenteroscopy todiagnose thepresenceofAscarisand reported the presence of multiple roundedorovalerosions,2–4mminsize,associatedwithfreshbloodoozingfromerosions.Sincethen,fewreportshaveemergedtodescribethepresenceofAscaris lumbricoides during capsule endoscopicexaminations for obscure gastrointestinalhaemorrhage(7,8). Asageneralrule,melaenaoccurswhenthesourceofbleedingisproximaltotheligamentofTreitz.Thetimerequiredforbloodtobebrokendown in the intestinal lumen is approximately14hours.Therefore,theexplanationforwhythispatient hadmelaena rather than haematochesiaisthatthebleedingwasslowandthetransittimewasgreaterthan14hours. Inpatientswithovertobscuregastrointestinalbleeding with negative upper endoscopy andcolonoscopy, further investigations of the smallbowel should be performed early. Variousapproacheshavebeenused inthediagnosisandtreatmentofsmallbowelbleeding.Theseincluderadiographic approaches, such as small-bowelfollow-through and enteroclysis; various formsof enteroscopy, such as push, double or singleballoon, and spiral; radionuclide red blood cellscans; angiography; capsule endoscopy; andintra-operativeenteroscopy.Nosingletechniquehasemergedasthemostefficientwaytoevaluatesmallbowelbleeding,and theprocedurechosenshould be tailored to the clinical scenario,availability,andlocalexpertise(9). Angiographymaybehelpfulinpatientswithactive bleeding greater than 0.5mL/minutes inwhomhighlyvascularnon-bleeding lesionssuchasangiodysplasiaandneoplasmscanbeidentified(9). In our case, CT angiography was able tolocalisethesiteofthehaemorrhageandpromptedustoplanforembolisation.However,therepeatangiography did not demonstrate any activeextravasationintothelumenofthebowelduetothefactthatthebleedingmayhavestopped. Intra-operative enteroscopy duringlaparotomy was used as a last resort in ourpatient as she continued to bleed, requiringblood transfusions. However, this techniquehas a moderate therapeutic efficacy because itonlyidentifiesthesiteofoccultbleedinginupto40%ofundiagnosedcasesandallowsexaminationof just 50% to 80% of the small bowel (10). Inour case, its diagnostic accuracy was aided bypre-operativeCTangiographiclocalisation.

In summary, acute lower gastrointestinalhaemorrhagesecondarytoascariasisisextremelyrare.Ahighlevelofclinicalsuspicionisrequiredwhen dealing with acute gastrointestinalhaemorrhage inmigrants and travellers.. In thenear future, less invasive formsof investigation,such as capsule and balloon enteroscopy, maybe available to identify obscure gastrointestinalbleeding. Otherwise, laparotomy and intra-operative enteroscopy are often used as a lastresorttoidentifythesourceofbleeding.

Acknowledgement

We wish to thank the Director General ofHealth,Malaysia, for the permission to publishthispaper.

Authors’ Contributions

Conceptionanddesign,provisionofpatient,criticalrevisionandfinalapprovalofthearticle:SLSCollectionandassemblyofdata,draftingofthearticle:DDS

Correspondence

DrSiowSzeLiMBBS(Monash),MRCS(Ire),MRCS(Edin),MSurg(UM),DiplomainLaparoscopicSurgery(France),FellowshipinAdvancedLaparoscopicandBariatricSurgery(France)DepartmentofSurgerySarawakGeneralHospitalJalanHospital93586KuchingSarawak,MalaysiaTel:+608-2276428Fax:+608-2419495Email:szeli18@yahoo.com

References

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2. Al-MekhlafiMS,AtiyaAS,LimYA,MahdyAK,AriffinWA, Abdullah HC, et al. An unceasing problem:Soil-transmitted helminthases in rural Malaysiancommunities. Southeast Asian J Trop Med Pub Health.2007;38(6):998–1007.

3. GaashB.Ascaris lumbricoides. Indian J Practising Doctor.2004;1(3):11–12.

4. Palmer PES, Reeder MM. The imaging of tropical diseases: With epidemiological, pathological and clinical correlation: Volume 1. 2nd ed. Maryland:Springer;2001.

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5. RefeidiA.LiveAscaris lumbricoidesintheperitonealcavity.Ann Saudi Med.2007;27(2):118–121.

6. SharmaBC,BhasinDK,BhattiHS,DasG,SinghK.Gastrointestinal bleeding due to worm infestation,with negative upper gastrointestinal endoscopyfindings: Impact of enteroscopy. Endoscopy.2000;32(4):314–316.

7. Floro L, Pak G, Sreter L, Tulassay Z. Wirelesscapsuleendoscopyinthediagnosisofhelminthiasis.Gastrointest Endosc.2007;65(7):1078–1079.

8. Balachandran P, Prasad VG. Intestinal parasitesseen on capsule endoscopy. Gastrointest Endosc.2006;64(4):651.

9. Leighton JA, Goldstein J, Hirota W, JacobsonBC, Johanson JF, Mallery JS, et al. Obscuregastrointestinal bleeding. Gastrointest Endosc.2003;58(5):650–655.

10. MitchellSH,SchaeferDC,DubaguntaS.Anewviewof occult and obscure gastrointestinal bleeding.Am Fam Physician.2004;69(4):875–878.