A 26-year-old Indian national presented with a one day history of acute colicky right sided loin to groin pain consistent with ureteric colic. However, on physical examination there was tenderness and guarding in the right iliac fossa (RIF) and no loin tenderness on palpation. A full blood count revealed haemoglobin of 14.4 g/dL, total white count of 9.53 × 10(9)/L and platelet count 257 × 10(9)/L with neutrophilia of 80.8% and an eosinophil count within normal range. Plain chest and abdominal radiographs were unremarkable. A CT of the abdomen and pelvis was performed to rule out appendicitis. This showed a tiny 2 mm stone at the right vesicoureteral junction with resultant mild hydronephrosis, and a normal appendix. Unexpectedly, several linear tubular and coiled structures were also seen in the sigmoid colon which were likely adult Ascaris Lumbricoides. (Figures 1a–b).
Oral mebendazole 100 mg BD was started, but despite passing the stone, the patient had persistent dull right-sided abdominal discomfort. A colonoscopy was performed to rule out concomitant colonic pathology. This revealed small worms in the transverse colon and a large worm in the caecum (approximately 8 cm long) (Figures 2a–b) which was removed via hot biopsy forcep.
Post colonoscopy, the patient reported improvement in his symptoms and was discharged. At subsequent follow-up 2 weeks post-discharge, he remained well.
Ascaris Lumbricoides infestation is uncommon in developed countries. This patient started work in Singapore only 6 months prior to presentation. A variety of gastrointestinal complications have been associated with ascaris infestation including intestinal obstruction, perforation, volvulus, intussusception, appendicitis, cholecystitis, biliary colic, cholangitis, hepatic abscess, pancreatitis, depending on the site and severity of infestation.
We postulate that in this case, the large worm in the patient's caecum contributed at least partially to his symptoms. The fact that his symptoms improved after endoscopic intervention is consistent with this. Indeed, on further questioning, he reported experiencing an intermittent, dull ache in the RIF for several months prior to his presentation with acute pain.
The diagnosis of ascaris infestation is usually made through a combination of blood counts showing marked leucocystosis and eosinophilia, stool studies and radiographic imaging. Antihelminthic therapy alone usually suffices, but patients who develop surgical complications as mentioned above should have further imaging and intervention as required.