Ascaris lumbricoides: an unusual aetiology of gastric perforation
A 48-year-old male patient presented to the emergency room with severe upper abdominal pain along with vomiting for 2 days. There was no history of any drug intake, alcoholism or dyspepsia. He gave a history of occasional passage of round worms with stool. On examination, the patient was febrile with a pulse rate of 130/min and a blood pressure of 110/70 mm Hg. He was severely dehydrated with a low urine output. An abdominal examination revealed evidence of peritonitis. A straight X-ray abdomen showed free gas under both domes of diaphragm. His white blood cell count was 11000/µl, serum urea was 24.1 mmol/l, creatinine was 0.141 mmol/l, sodium was 120 mmol/l and potassium level was 3.1 mmol/l. After adequate resuscitation, an exploratory laparotomy was carried out. On opening the abdomen, air came out and around 1.2 l of bilious fluid was drained. A 1 cm × 1 cm perforation was found in the prepyloric region of stomach and two live Ascaris were seen protruding through the perforation (Figs and ). There was no scarring or induration around the perforation to suggest a long-standing peptic ulcer disease. A bundle of worms could be palpated within the small bowel. A biopsy from the margin of the perforation was taken. A rapid urease test of the biopsy specimen was negative. The perforation was repaired with Graham's omental patch after extracting the worm protruding through the perforation. Thorough peritoneal lavage was done and the abdomen was closed after placing a drain in the pelvis. The postoperative period was uneventful apart from wound infection which was treated conservatively. The patient was discharged on postoperative day 8 on anthelmentics. A histopathology report of the biopsy from the margin of perforation showed evidence of a focal acute inflammatory reaction. An upper GI endoscopy performed 1 month later did not show any evidence of peptic ulcer disease. These findings helped us in ruling out peptic ulcer disease as an aetiology for the prepyloric ulcer.