Worm accumulation

　　The accumulation of worms is often caused by unclean diet, eating food containing worm eggs or worms. The accumulation of worms, caused by intestinal parasites, is a common disease with abnormal diet, umbilical abdominal pain, yellowish complexion, emaciation, and facial worm spots as the main manifestations.

　　1, Biliary ascariasis (biliary ascariasis):When the intestinal environment or the host's overall condition changes, the worm can be stimulated to enter the bile duct and cause biliary ascariasis. This disease is one of the main complications of intestinal ascariasis, second only to appendicitis, cholecystitis, and perforated peritonitis, etc. It is more common in adults and children, especially among the young and middle-aged, and more common in women than in men. The most common location of the worm is the common bile duct, followed by the right and left hepatic ducts, and the least in the gallbladder.

　　(1) Clinical types can be divided into the following: ①Biliary colic type, the most common, caused by the worm钻入the ampulla of Vater in the wall of the duodenum leading to spasm of the bile duct orifice sphincter and common bile duct; ②Acute cholecystitis, the worm entering the gallbladder can cause gallbladder inflammation due to secondary bacterial infection or due to the worm entering the gallbladder causing obstruction of the cystic duct; ③Acute cholangitis, when the worm enters the bile duct, the abdominal pain does not subside, and chills and high fever appear, indicating secondary infection of the bile duct and concurrent acute cholangitis.

　　(2) Typical clinical manifestations of biliary ascariasis include: ① Acute onset, with the prominent symptom being intermittent severe pain in the upper abdomen, presenting as piercing or colicky pain, which can radiate to the back and shoulder, with the pain basically disappearing and a significant period of relief; ② Accompanied by severe nausea and vomiting, most patients can vomit bile and worms; ③ Symptoms and signs are not consistent, that is, when the pain is severe, there is no significant tenderness in the abdomen, nor is there obvious muscle tension; ④ A few patients may not relieve the pain, and secondary bacterial suppurative infection may occur in the later stage; ⑤ Jaundice is rare, and even if there is jaundice, it is relatively mild.

　　2. Parasitic intestinal obstruction (ascaris intestinal obstruction):Over ten Ascaris lumbricoides in the intestine can form a ball in the small intestine, causing mechanical intestinal obstruction. This disease is more common in children with severe infection, with more than 60% being under 10 years old, and the highest incidence rate in those under 2 years old. Parasitic intestinal obstruction is mostly incomplete intestinal obstruction, with the obstruction site mostly in the lower segment of the ileum. The typical manifestations of parasitic intestinal obstruction are abdominal pain, vomiting, abdominal distension, cessation of defecation and flatus, dehydration, acidosis, and electrolyte imbalance, which are similar to those of general intestinal obstruction. About 30% of patients can palpate an abdominal mass. Strangulated intestinal obstruction, secondary intestinal perforation, and peritonitis can be life-threatening.

　　3. Parasitic appendicitis:Incorrect deworming can cause Ascaris lumbricoides to penetrate the vermiform appendix, leading to obstruction of the appendiceal lumen. Due to the stimulation of the worm's movement and the toxins it secretes on the appendiceal mucosa, the appendiceal muscular layer and blood vessels contract, blood supply is obstructed, causing mucosal injury and acute appendicitis. If the appendiceal lumen obstruction worsens progressively, increasing the intraluminal pressure, it can lead to appendiceal perforation and secondary peritonitis. According to reports, the incidence of appendiceal perforation in parasitic appendicitis is 25% to 65%. Parasitic appendicitis ranks second only to biliary ascariasis and parasitic intestinal obstruction, and plays an important role in the etiology of pediatric appendicitis. The worms that penetrate the appendix are usually 1 to 3, with more than 30 in some cases. The clinical manifestations of this disease are similar to those of general appendicitis. Intermittent severe abdominal pain, cold sweat, pale complexion, nausea, vomiting, and abdominal distension may occur 3 to 6 hours after taking deworming medication, and there may be localized abdominal muscle tension.

　　4. Parasitic pancreatitis:The invasion of Ascaris lumbricoides into the pancreatic duct can lead to partial obstruction of the duct. Due to mechanical injury by the worm body, egg deposition and stimulation, secondary bacterial infection, toxin effect, and bile reflux, pancreatic enzymes can be activated, leading to acute pancreatitis. The clinical manifestations of parasitic pancreatitis are similar to those of general acute pancreatitis. Sudden onset of intermittent upper abdominal pain, nausea, and vomiting is common; followed by persistent abdominal pain with intermittent exacerbation, chills, and fever; upper abdominal tenderness, and increased abdominal muscle tension. Elevated levels of blood and urine amylase activity. In cases of hemorrhagic necrotizing pancreatitis, symptoms such as high fever, rapid pulse, decreased blood pressure, abdominal distension, and mobile dullness in the abdomen may occur. If not diagnosed and treated promptly, it can be life-threatening to the patient.

　　5、蛔虫性肝病：少数胆道蛔虫病患者可因蛔虫进入肝脏带入细菌，继发感染形成细菌性肝脓肿。脓肿以肝右叶最常见，左叶较少，可为单发或多发性，其大小不一。脓液中可找到蛔虫和虫卵；脓肿壁上可查虫卵和虫体所引起的异物反应。蛔虫性肝脓肿与一般肝脓肿表现相似。但合并症较多，临床经过极为严重。容易引起肝功能损害，甚至出现急性肝功能衰竭。还可出现胆管炎、胆道出血、脓毒败血症、脓胸、膈下脓肿等，病死率可达80％左右。

　　6、蛔虫卵性：肉芽肿蛔虫卵性肉芽肿多位于腹腔脏器的表面，表现为发热、腹部隐痛、腹部包块。临床较少见，因无特征性表现，诊断较困难。文献报道的病例均为手术活检确诊。本病容易误诊为肠系膜淋巴结炎、肠结核、结核性腹膜炎及腹腔肿瘤等。

　　7、蛔虫性腹膜炎：蛔虫可经小肠或阑尾等腹腔脏器穿孔进入腹膜腔，由于肠内容物流入腹腔引起化学性刺激和细菌感染，导致腹膜炎。有报道肠蛔虫病所致外科合并症中腹膜炎占12.75％。其表现与其他原因所致的化脓性腹膜炎相同，主要为持续性剧烈腹痛、腹胀，发热，呼吸急促，脉搏加快，腹部压痛、反跳痛，肝浊音界缩小或消失等。

　　8、蛔虫性脑病：本病主要见于幼儿患者。蛔虫分泌的脂肪醛、抗凝素及溶血素等物质，吸收后作用于神经系统，引起的神经功能失调称为蛔虫中毒性脑病或蛔虫性脑病。出现头痛、兴奋性增高、精神不振、失眠，还可有智力发育障碍等。严重时可出现癫痫、脑膜刺激征、昏迷及瞳孔散大等。蚴虫若经血循环进入脑组织可形成脑栓塞及脑局部病变，驱虫治疗后症状可迅速减轻。

　　9、其他蛔虫性疾病：蛔虫受到刺激后，可窜入各种孔道而致病。文献报道，蛔虫可引起渗出性胸膜炎，少量胸腔积液，或继发性脓胸；钻入气管造成呼吸道阻塞而窒息；经耳咽管钻入中耳道；钻入小肠憩室引起憩室炎，还有蛔虫使梅克尔憩室（Meckel’sdiverticulum）穿孔而从尿道排出蛔虫的病例报道；经膀胱直肠瘘进入膀胱、输尿管，或经肾盂结肠瘘进入泌尿系统，可从尿道排出蛔虫。蛔虫偶可进入血流引起转移性蛔虫病，若经血流至右心达肺动脉，可形成血栓引起栓塞性肺动脉阻塞，这也是胆道蛔虫病及肝脏蛔虫病的罕见并发症，常经尸解方可确诊。

　　The main symptoms are yellowish dark complexion, or with white spots, emaciated body, umbilical abdominal pain, intermittent pain, severe pain in the morning or empty stomach, pain decreases after eating, fondness for eating foreign objects, grinding teeth at night, restless sleep, irritability and crying, constipation or diarrhea, or passing Ascaris in the stool. Severe cases may have clear saliva, cold extremities, pale complexion. After a long time, abdominal distension, hard abdomen, and visible blue veins may appear.

　　1. Controlling the source of infection:Eliminating Ascaris in the human intestinal tract is an important measure to control the source of infection. It is necessary to actively discover and treat patients with intestinal ascariasis, and regularly investigate and treat susceptible individuals. Especially for kindergartens, primary schools, and rural residents, when the infection rate exceeds half of the sample survey, general treatment can be carried out. Two to three months after the peak of infection (such as winter or autumn), collective medication can be taken. The expelled worms and feces should be disposed of in time to avoid environmental pollution.

　　2. Pay attention to personal hygiene:Develop good personal hygiene habits, wash hands before and after meals; do not drink unboiled water, do not eat unclean fruits and vegetables; frequently trim nails; do not defecate on the ground, etc. For restaurants and catering shops, etc., regular health standardization inspections should be carried out, and the production of drinks with unboiled water should be prohibited.

　　3. Strengthening feces management:Improve the environmental sanitation, carry out harmless treatment of feces, do not use raw feces for fertilization, do not graze pigs, etc. Using harmless human feces as fertilizer is an important measure to cut off the transmission route of ascariasis. In areas where water feces are used as fertilizer, the five-grid three-pool storage method can be adopted to make most of the eggs settle at the bottom of the pool. Due to the action of free ammonia in feces and anaerobic fermentation, eggs can be killed, and at the same time, it will also increase the fertilizer efficiency. Utilizing biogas pool fermentation can not only solve the problem of farmers' lighting and cooking; it is also beneficial to the harmless treatment of feces. The feces residue can be cleared once every half a year. At this time, most of the eggs have lost the ability to infect. In areas where feces are used as fertilizer, the mud-sealed composting method can be adopted. After three days, the temperature inside the feces pile can rise to 52℃ or higher, which can kill ascaris eggs.

　　1. Routine blood test

　　The white blood cell count is usually normal. During the early stage of acute massive infection and the migration period of larvae, white blood cells and eosinophils increase; it is reported that in acute ascariasis pneumonia, eosinophils can reach 40% to 80%. When ascariasis in the bile duct is accompanied by concurrent bacterial infection, the white blood cell count and neutrophil count are often significantly increased.

　　2. Pathogen examination

　　The direct smear method for feces is simple, with a high detection rate of Ascaris eggs, and it is currently the main method for diagnosing intestinal ascariasis. The positive rate of the three-slice method exceeds 90%. For those with negative direct smears, the sedimentation egg collection method, saturated salt water floating method, or improved Kato method can improve the detection rate of eggs, but the method is more complex. When pulmonary ascariasis or Ascaris larvae cause allergic pneumonia, Ascaris larvae can be detected in sputum.

　　3. Immunological examination

　　The positive rate of the adult worm antigen skin test can reach more than 80%. A positive result can suggest early ascaris infection or the presence of male worms, which is helpful for epidemiological investigation. Serum immunoglobulin detection shows that IgG and IgE are at high levels, but there is no specificity.

　　4. B-ultrasound examination

　　Abdominal ultrasound in patients with biliary ascariasis can show ascaris located in the dilated common bile duct, but the positive rate is not high.

　　5. X-ray examination

　　X-ray barium meal examination in patients with gastric ascaris disease shows variable round-shaped shadows similar in size to ascaris in the stomach; if multiple ascaris are parallelly aggregated, the shadows resemble 'rice grains'; the cross-sectional projection of the worm body presents as 'bean-shaped' or 'bead-like' images; after compression, the worm body spreads out, and the above images also change accordingly. X-ray examination in patients with duodenal ascaris disease shows arc-shaped, ring-shaped, 'spring-shaped', or '8' shaped images.

　　6. Fiberoptic retrograde cholangiopancreatography

　　It can be found that there are ascaris in the duodenum and bile ducts, and removing the worm body that has entered the ampulla of Vater can quickly relieve biliary colic and can reduce pressure and drain the bile duct obstruction.

　　Therapeutic diet for worm infestation:

　　1. Sangji: Two to three liang of whole scallion (Liang Qing Cong. The roots and stems are pounded into a paste, strained, and the juice taken). One liang of rapeseed oil (Liang You. If there is no rapeseed oil, sesame oil can be used as a substitute).

　　2. Modified Sini Powder, with Radix Bupleuri, Fructus Aurantii, Radix Curcumae, Rhizoma Cyperi, Radix Paeoniae Alba, Cortex Moutan, Poria, Medulla Trichosanthis, Herba Epimedii, Pericarpium Citri Reticulatae, and Radix Glycyrrhizae. Decocted, one dose per day, divided into three servings.

　　The following anthelmintic drugs are commonly used:

　　1. Albendazole:It is one of the broad-spectrum, high-efficiency, and low-toxic benzimidazole anthelmintic drugs. Its mechanism of action is mainly to block the uptake of glucose by the worm body, leading to depletion of glycogen and reduced production of adenosine triphosphate, causing paralysis of the worm body. The anthelmintic effect is relatively slow, and ascaris is usually excreted in feces 2 to 4 days after administration. Severe infections require multiple treatments for cure. Concurrent biliary ascariasis may occur during treatment due to worm restlessness. Albendazole has a killing effect on adult worms, larvae, and eggs. The dosage for adults and children over 2 years of age is 400mg/200mg per tablet, taken all at once, or divided into 2 doses within 1 day. The drug can be repeated once after 10 days of deworming. The incidence of adverse reactions is 6% to 10%, and symptoms such as dizziness, insomnia, nausea, vomiting, dry mouth, decreased appetite, and fatigue may appear 2 to 3 days after taking the medicine, which can disappear spontaneously within 48 hours. Caution should be exercised in patients with a history of epilepsy, and the drug is contraindicated in pregnant women, lactating women, and children under 2 years of age.

　　2. Tegumentum:This product is a broad-spectrum anthelmintic with good efficacy against ascaris. Its mechanism of action is similar to that of albendazole. The dosage is 200mg, taken all at once, with an egg-negative rate of up to 80%; or 100mg per dose, 3 times a day, for 3 consecutive days, with an egg-negative rate of more than 95%. Adverse reactions are rare, and only a few patients may experience dizziness and mild gastrointestinal reactions, which can disappear spontaneously without treatment. It is contraindicated in pregnant women and children under 2 years of age.

　　This product is a composite preparation of mebendazole and levamisole, also known as Albenza/levamisole, rapid intestinal anthelmintic preparation. Each tablet contains 100mg of mebendazole and 25mg of levamisole. Adults take 2 tablets at once, which can enhance efficacy and reduce adverse reactions.

　　3. Thiabendazole bis-naphthohydroxamic acid thiabendazole:This drug is a broad-spectrum anthelmintic, which can inhibit nerve muscle conduction, causing spastic contraction of ascaris and paralysis, safe excretion from the body, and fast anthelmintic effect. The dosage is 500mg, the pediatric dosage is 10mg/kg body weight, taken all at once, with an egg-negative rate over 90%. Adverse reactions are mild.

　　4. Piperazine:It has anticholinergic effects, which can block the nerve conduction of ascaris muscle. It has characteristics such as low toxicity, good efficacy, and a wide safety range. The dosage is 3g per time, once a day, taken for 2 or 3 days consecutively; for children, 80-150mg/kg·d, taken in two doses, or taken all at once at night, taken for 2 days. The rate of excretion after taking the medicine is over 90%. For severe infections, the medicine can be taken for 3 or 4 days consecutively, and the treatment can be repeated after 1 week. Adverse reactions are mild, and a few patients may experience dizziness, dizziness, nausea, vomiting, or diarrhea, which often do not require treatment and disappear spontaneously in a short period of time. Overdose may cause muscle weakness, or stiffness of the limbs, allergic purpura, serum disease, and severe adverse reactions such as nervous and mental symptoms. It is not suitable for patients with impaired liver and kidney function.

　　5. Levamisole:Levamisole can inhibit the activity of succinate dehydrogenase in the muscle of ascaris, leading to a decrease in muscle energy production, causing paralysis of the worm body and excretion from the body. The dosage is 150-200mg, for children 2.5mg/kg body weight, taken all at once. There may be toxic encephalopathy occasionally after taking this drug, so it should be used with caution.

　　6. Ivermectin:This is an antibiotic produced by Streptomyces avermitilis, belonging to the macrolide structure, which can inhibit the nerve muscle information transmission of ascaris, causing paralysis of the worm body and thus having an anthelmintic effect. It is well absorbed orally, with a half-life of 12h, and its metabolites are excreted in the feces within 2 weeks. The dosage is 100μg/kg·d, taken for 2 days, with a cure rate of nearly 100%. Adverse reactions are rare.