Ascariasis during corrective Roux-en-Y hepaticojejunostomy.

Authors:
Cristina Botero Fonnegra, Kedar Sukharamwala, Prashant Sukharamwala, Samarth Patel, Subhasis Misra

Body of Abstract:
Background

Ascaris spp. is a parasitic nematode whose eggs can remain viable in the environment for extended periods. Ascariasis, the infection caused by Ascaris spp., occurs when individuals ingest these eggs. Over 1 billion people are affected worldwide. In developed nations, however, sporadic cases are often linked to individuals who have traveled to regions where the infection is endemic. The infection can be asymptomatic or present with gastrointestinal symptoms, bowel obstruction, or biliary disorders due to the migration of the parasite through the small bowel. The number of cases in the United States has been increasing, particularly in southeastern regions, due to travel, immigration, and climate conditions that favor the survival of the parasite.

Case presentation

The patient was a 22-year-old woman who initially presented with symptomatic cholelithiasis at an outside institution, where she underwent a laparoscopic cholecystectomy. Her medical history was significant for recent immigration from Polynesia. She was subsequently discharged but re-presented with abdominal pain 7 days later. A CT scan revealed a biliary leak, and an ERCP identified a bile duct injury, with no other significant imaging findings. She was transferred to our tertiary care facility for corrective Roux-en-Y hepaticojejunostomy. During intraoperative inspection of her small bowel, numerous cord-like structures were palpated, suggesting a parasitic infection.
Given the clinical suspicion of an intestinal helminth infection, a decision was made to perform an enterotomy to extract the parasites, which were milked from the ligament of Treitz to the terminal ileum (Figure 1). Gross examination, along with subsequent microbiological and pathological analysis, confirmed the presence of Ascaris lumbricoides. The patient was treated with albendazole during her stay, and a follow-up stool antigen test was negative, confirming the eradication of the infection. The patient recovered well postoperatively.

Conclusion
This case presents an unexpected and significant intraoperative finding that was not evident preoperatively, despite the use of preoperative imaging. The successful identification and management of this patient underscores the importance of heightened clinical vigilance for parasitic infections in patients with a history of travel to high-endemic areas.