Pediatric ascaris intestinal obstruction

　　1. Etiology:Ascariasis infection and parasitism in the intestinal tract. When the host's environment and the function of the intestinal tract are disordered, such as fever, vomiting, diarrhea, unclean diet, excessive consumption of cold and刺激性 foods, insufficient dosage of vermifuge and medication, the ascaris body is stimulated, its excitability increases, it becomes more active in the intestinal tract, and it twists into clumps with each other, blocking the intestinal lumen and causing intestinal obstruction.

　　2. Pathogenesis:Under normal circumstances, the ascaris does not form into clumps, and it often resides in the jejunum and ileum, living on the intestinal chyme. It remains calm and scattered within the intestinal lumen, parallel to the longitudinal axis of the intestinal tract. When certain factors stimulate the ascaris, increasing its activity and causing it to twist into clumps within the intestines, the intestinal contents can still pass around the ascaris body, hence it is mostly an incomplete intestinal obstruction. If the obstruction persists for too long, the clump of worms does not disperse, and the continued spasm of the intestinal tract can lead to a complete intestinal obstruction. The lip teeth of the ascaris head can directly damage the intestinal mucosa, causing congestion and edema, while the toxic metabolites stimulate the intestinal wall, leading to reflex spasm of the intestinal tract and increasing the obstruction. This is most common at the distal ileum. On the basis of incomplete intestinal obstruction caused by ascaris aggregation in a segment of the intestine, the vigorous peristalsis of the proximal intestinal tract can induce volvulus of the intestinal loop, resulting in ascaris intestinal volvulus. Additionally, intestinal spasm induced by ascaris or its toxins can trigger intussusception, exacerbating the obstruction and causing strangulation. Long-term compression of the intestinal wall by the worm clump can lead to pinpoint necrosis and perforation, causing localized or diffuse peritonitis. Sometimes, a segment of the intestinal loop filled with ascaris can suddenly twist due to its weight, leading to rapid necrosis of the intestinal tract and a rapid deterioration of the condition.

　　What complications are easy to occur in pediatric ascaris intestinal obstruction?

　　1, Dehydration and acidosis often occur, which can lead to intestinal necrosis, perforation, and peritonitis, as well as infectious shock.

　　Typical symptoms include episodic abdominal pain and vomiting, which can include vomiting of ascaris:

　　1, Abdominal Pain

　　Most initial abdominal pain is episodic and mild, with a lack of activity and a desire to eat. The child can clearly state that the pain is around the umbilicus. As the disease progresses, the abdominal pain becomes persistent, with poor spirits, a grayish face, restlessness, and some children may cry loudly.

　　2, Vomiting

　　After abdominal pain, most patients have vomiting, with vomiting contents mainly gastric juice and bile, some even vomit ascaris, and a few may also have fecal vomiting, but there is usually no coffee-like substance or blood in the vomiting contents.

　　3, Constipation

　　Most patients have constipation, while a few have only a small amount of stool or a small amount of ascaris at the initial stage. Some severe intestinal obstruction can lead to ischemia, necrosis, bleeding, and the passage of a small amount of bloody stools. If the age is under 2 years, it needs to be differentiated from primary intussusception. After the disease progresses, complete cessation of排气 and defecation occurs, and abdominal distension is marked.

　　4, Abdominal Mass

　　The abdomen is slightly distended and soft. The disease often presents with multiple active thin cord-like masses that can change shape, move to different locations, or split into several, which needs to be differentiated from intussusception, intestinal cysts, abdominal tuberculosis, etc. This has certain differential diagnostic significance from the masses in pediatric intussusception. Early diagnosis is usually not difficult, but diagnosis is more difficult when abdominal distension is severe in the later stage. When the ascaris mass does not disperse for a long time or the worms have died, the toxins secreted by the ascaris stimulate the intestinal wall, causing intestinal spasm. The intestines become completely obstructed and distended, ischemic, necrotic, and even perforated, leading to diffuse peritonitis. Or due to the heavy weight of the intestinal ascaris mass, the intestinal tract hangs on the mesentery, causing torsion due to peristalsis disorder, leading to绞窄性肠梗阻. At this time, in addition to the exacerbation of the above symptoms, there are systemic symptoms of poisoning, such as fever, elevated blood count, dehydration, acidosis, and even shock.

　　5, Intestinal Obstruction

　　Ascaris lumbricoides can cause acute绞窄性肠梗阻 symptoms when the worm mass twists around the intestine, leading to sudden severe abdominal pain, vomiting, and occasionally bloody stools, but the amount of blood is usually not excessive. The child's condition often deteriorates rapidly, with symptoms of poisoning, high fever, dehydration, abdominal distension with tenderness and muscle tension, occasionally palpable masses, and the condition is often very serious. An X-ray of the abdomen shows partial mechanical bowel obstruction, with the obstruction site often showing the shadow of the twisted worms (coiled into a mass resembling a 'coarse woolen ball' shadow), presenting as complete low intestinal obstruction. There may be signs of strangulation or suspected strangulation on X-ray, and some patients with partial bowel obstruction may still be able to pass gas through the anus.

　　Collective children's institutions can carry out collective deworming regularly, actively treat carriers, and eliminate the source of infection. Deworming in autumn and winter, re-examination after 3 months, and deworming again if the egg is positive. Good feces management, high-temperature composting, and reducing ground pollution. Eliminate flies, cockroaches, and other vectors, improve the environmental hygiene, do not defecate on the ground. Develop good habits such as washing hands before meals and after defecation, often trimming nails, and washing and boiling raw fruits and vegetables. Overcome bad habits such as sucking fingers and biting nails.

　　In addition to the three major routine tests, it is necessary to perform routine blood sodium, potassium, chloride, calcium, and blood pH tests. The blood routine examination shows that the total white blood cell count reaches about 15×109/L, and the eosinophil count can reach more than 10%. Under the microscope, ascaris eggs can be found in the stool.

　　1. X-ray examination

　　The abdominal plain film shows signs of partial mechanical intestinal obstruction, which may have signs of strangulation or suspected strangulation X-ray signs. An upright position can see multiple liquid levels, and at the same time, the shadow of the ascaris coiled in the intestinal lumen can be seen, which is like a rough yarn-like cord or spot-like twisted ascaris shadow.

　　2. B-ultrasound examination

　　It also has certain help for diagnosis.

　　1. Diet should be light.

　　2. Pay attention to the proportion of sugar, fat, and protein in food, and pay attention to the content of vitamins and other essential nutrients for the body.

　　3. Avoid unclean diet: Gastroenteritis patients should pay special attention to dietary hygiene, especially in summer. Wash raw fruits and vegetables before eating and do not eat spoiled food. Foods stored in the refrigerator must be cooked thoroughly before eating. If spoilage is found, it should be discarded immediately and not consumed.

　　4. Avoid cold, hot, and hard foods: such as, cold or hot food and beverages.

　　5. Avoid spicy foods, such as chili, mustard, pepper, strong tea, coffee, cocoa, and other food or beverages.

　　Incomplete or early complete intestinal obstruction can be treated conservatively in patients with good general condition. The main treatment principles are antispasmodic, analgesic, and vermifuge. Vermifuge can be given with piperazine and other drugs. Antispasmodic and analgesic drugs such as atropine can be used. 1% warm saline enema can stimulate peristalsis and help expel loose ascaris quickly. If after conservative treatment, the worm clumps do not disperse for a long time, the clumps are large and firm with tenderness or abdominal distension, the whole abdomen is tense and painful, there is a suspicion of intestinal perforation, intestinal necrosis, and intestinal volvulus, surgical treatment should be adopted. Preoperative preparation is required to be active, correcting dehydration and shock, and then proceed with surgical treatment. According to the findings of the surgery, the methods of worm clump dispersion, intestinal resection and anastomosis, etc., should be performed:

　　First, non-surgical treatment

　　Incomplete or early complete obstruction, with good general condition. Conservative medical treatment can be used first.

　　1. Antispasmodic: Atropine taken orally or intramuscularly to relax the intestines, facilitating the spread of worms and alleviating obstruction.

　　1. Castor oil or peanut oil: 80-150ml (60ml for children) orally, which can relax the ascaris mass, alleviate symptoms, and deworm 1-2 days after the symptoms disappear.

　　2. Deworming: Avoid using stimulatory deworming drugs, and choose drugs that paralyze the worms: piperazine (deworming agent) 100-150mg/kg per day, with a maximum dose not exceeding 3g, taken once a day, for 2-3 days. Oxygen deworming can also relax the worms. Oxygen deworming should be performed in the morning with fasting, administered through a gastric tube, with the oxygen volume calculated at 100-150ml/age, injected at a moderate speed, and completed in 20-30 minutes. Observe the worm excretion situation; if there is no worm excretion, repeat oxygen administration 2-3 times.

　　4. Others: fasting, gastrointestinal decompression, fluid replacement, antibiotic anti-inflammatory therapy, and other symptomatic and supportive treatments.

　　Second, surgical treatment

　　1. Presence of peritonitis symptoms, positive abdominal puncture.

　　2. Abdominal pain changes from intermittent to continuous and progressively severe, with frequent vomiting.

　　3. Severe abdominal distension, dehydration, acidosis, and even shock, without improvement after treatment for 4 to 8 hours.

　　4. Hematochezia.

　　5. Sudden rise in body temperature and significant increase in blood white cell count.

　　6. X-ray examination shows complete obstruction or pneumoperitoneum.

　　7. Abdominal mass is hard, large, and numerous, and it is estimated that the mass cannot disperse spontaneously. In patients with severe clinical symptoms.

　　8. Once diagnosed with ascaris intestinal volvulus, surgical treatment should be performed immediately.