A Case of Anisakiasis Invading the Stomach and the Colon at the Same Time after Eating Anchovies
A 47-year-old male visited the hospital for abdominal pain lasting for 3 days. He was diagnosed with acute appendicitis 10 years ago and had an appendectomy operation. He did not have a medical history of hypertension or diabetes mellitus. He was an ex-smoker and social drinker. In the history taking, he was found to have eaten raw anchovies 4 days ago. Vital signs at admission were measured as blood pressure 120/70 mm Hg, pulse rate 68/min, respiration rate 16/min, and body temperature 37℃. There was no urticaria or no facial angioedema. There was no splenomegaly or palpable mass from abdominal palpitation. There was epigastric and periumbilical tenderness but no rebound tenderness. Digital rectal examination was negative. Complete blood count result showed hemoglobin 14.2 g/dL, white blood cell 10,350/mm3 (eosinophil 1.6%), platelet 221,000/mm3, and erythrocyte sedimentation rate 4 mm/hr. Blood chemistry was analyzed as total bilirubin 0.9 mg/dL, aspartate aminotransferase 29 IU/L, alanine aminotransferase 35 IU/L, gamma glutamyl transpeptidase 68 IU/L, alkaline phosphatase 138 IU/L, lactate dehydrogenase 351 IU/L, blood urea nitrogen 20.2 mg/dL, creatinine 1.0 mg/dL, Na 142 mmol/L, K 4.0 mmol/L, Cl 109 mmol/L, amylase 15 IU/L, lipase 32 IU/L, and C-reactive protein 0.34 mg/dL. Urinalysis was normal. Gastroscopy was performed for the suspected acute gastritis.\nThe gastroscopic finding showed that there was a marked mucosal swelling and one thread like living worm (about 1.0 to 1.2 cm) was found penetrating the gastric mucosa in the lesser curvature of the lower body (). It was withdrawn with biopsy forceps and biopsy was done (). For the mucosal swelling lesion, endoscopic ultrasonography was performed to rule out the possibility of a submucosal tumor. The endoscopic ultrasonographic finding showed that there was diffuse mucosal and submucosal swelling without mass (). The most affected layer was the submucosa. Its character was homogenous and relatively hypodense. The 5-layered wall structure was well preserved. After gastroscopy, patient's abdominal pain decreased but still remained. Colonoscopy was performed for the evaluation of the remaining symptom.\nThe colonoscopic finding showed that there was round erythematous mucosal swelling and one thread like living structure (about 1.0 to 1.1 cm) was found penetrating the colonic mucosa in the transverse colon area (). It was also withdrawn with biopsy forceps and biopsy was done (). The endoscopic ultrasonographic finding showed that there was diffuse submucosal swelling (). Thickened submucosal layer showed generally homogenous echo and was not easily distinguishable from other layers.\nAfter endoscopic extraction of the living worm, the patient's symptoms were relieved. In order to eradicate Anisakis larvae that might be in small intestine, we prescribed albendazole (400 mg) twice daily for 14 days. Two days later, a follow-up gastroscopy was performed. There was no living structure observed and the gastric mucosa swelling was markedly improved. The stomach biopsy result was gastritis with eosinophil infiltration without eosinophilic granuloma (). The colon biopsy result was colitis with eosinophil infiltration ().\nThe patient was discharged and now is followed up as an outpatient.