Intestinal Ascariasis in the Modern Era and the Role of Surgery: A Prospective Observational Study

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This study aimed to analyze contemporary presentation patterns, diagnostic approaches, and surgical outcomes of ascaris-induced intestinal obstruction in children. Methods: A prospective observational study was conducted at a tertiary care center over 32 months. All pediatric patients (2-16 years) presenting with intestinal obstruction were evaluated. Demographics, clinical presentation, diagnostic investigations, management strategies, and outcomes were systematically recorded. Conservative management was attempted for 24 hours in appropriate cases, with surgical intervention reserved for failed conservative treatment, complete obstruction, or peritoneal signs. Results: Of 190 children with intestinal obstruction, 120 (63.15%) had ascariasis-induced obstruction. Male predominance was observed (2:1 ratio) with peak incidence in 2-8 years age group (57.89%). Conservative management was successful in 65 of 80 patients (81.25%). Fifty-five patients (45.83%) required surgical intervention: milking of worms (36.36%), enterotomy with worm removal (32.73%), and bowel resection with anastomosis (30.91%). Post-operative complications occurred in 8 patients (14.55%), including surgical site infection (7.27%), anastomotic leak (3.64%), and burst abdomen (3.64%). No mortality was recorded. Mean hospital stay was 4.2 days for conservative management and 7.8 days for surgical cases. Ultrasonography demonstrated 96.47% diagnostic accuracy with characteristic "bull's eye" and "railway track" appearances. Conclusion: Ascariasis remains the predominant cause of pediatric intestinal obstruction in endemic areas. While conservative management succeeds in appropriately selected cases, surgical intervention with acceptable morbidity rates is often necessary. Early recognition and prompt treatment minimize complications and ensure favorable outcomes. Intestinal obstruction Ascariasis Pediatric surgery Conservative management Surgical intervention Ultrasonography Enterotomy Bowel resection Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Ascariasis, caused by Ascaris lumbricoides , remains one of the most prevalent parasitic infections worldwide, affecting approximately 1.5 billion people globally, which constitutes about 25% of the world's population ( 1 ). This soil-transmitted helminth infection poses a significant public health challenge, particularly in developing countries where poor sanitation, inadequate hygiene practices, and low socioeconomic conditions create an ideal environment for its transmission ( 2 , 3 ). In pediatric populations, intestinal ascariasis represents the most common cause of small bowel obstruction in developing nations, including India, where it significantly contrasts with developed countries where adhesive obstruction predominates ( 4 , 5 ). The burden of this parasitic infection is particularly pronounced in the Indian subcontinent, where studies indicate that approximately 70% of children are infested with ascariasis, with this figure rising to over 78% in certain regions such as Kashmir ( 6 ). The clinical spectrum of intestinal ascariasis ranges from asymptomatic carriage to life-threatening complications, with intestinal obstruction being the most serious surgical complication, especially in the pediatric age group ( 7 , 8 ). Children are disproportionately affected due to the smaller diameter of their intestinal lumen, higher worm burden relative to body size, and increased susceptibility to complications ( 9 ). The presentation can vary from subacute to acute intestinal obstruction, often resulting in significant morbidity and mortality if not promptly recognized and appropriately managed ( 10 ). The pathophysiology of ascaris-induced intestinal obstruction involves multiple mechanisms: obstruction of the small bowel lumen by an entangled bolus of worms, spasmodic contraction of the bowel around the worm mass with functional obstruction at the ileocecal valve, inflammatory changes and matting of bowel loops at the site of worm colonization, and associated complications such as volvulus or intussusception ( 11 , 12 ). The terminal ileum is the most common site of obstruction, although large numbers of worms are frequently found in the jejunum ( 13 ). Management of intestinal ascariasis requires a multidisciplinary approach, with treatment modalities ranging from conservative medical management to emergency surgical intervention. While the majority of cases can be managed conservatively with supportive care and subsequent anti-helminthic therapy, a significant proportion of patients require surgical exploration and intervention, particularly those presenting with complete obstruction, signs of peritonitis, or bowel compromise ( 14 , 15 ). The delay in diagnosis and treatment often leads to increased morbidity, with complications including bowel perforation, spillage of worms and eggs into the peritoneal cavity, and associated septic complications ( 16 ). Diagnostic modalities have evolved significantly, with ultrasonography providing characteristic findings such as the "bull's eye" appearance in transverse sections and "railway track" appearance in longitudinal sections, which aid in confirming the diagnosis of intestinal ascariasis ( 17 , 18 ). Plain abdominal radiographs may reveal distended bowel loops with air-fluid levels and occasionally visible worm shadows, while computed tomography can help identify complications such as perforation or bowel compromise. The surgical management of ascaris-induced intestinal obstruction depends on the operative findings and includes various techniques: milking of worms into the colon for viable bowel with distal obstruction, enterotomy with direct worm removal for proximal obstructions or when milking is not feasible, and bowel resection with primary anastomosis in cases of gangrenous or perforated bowel ( 19 , 20 ). Post-operative complications, though relatively uncommon, can include wound infections, anastomotic leaks, and burst abdomen, with the unique complication of worms exploring the anastomotic site due to their natural tendency to seek orifices ( 21 ). Despite advances in medical care and improved understanding of the disease pathophysiology, intestinal ascariasis continues to pose significant challenges in endemic areas. The condition requires heightened clinical suspicion, prompt diagnosis, and appropriate management to minimize morbidity and mortality. Understanding the contemporary presentation patterns, diagnostic approaches, and surgical outcomes is crucial for optimizing patient care and developing effective prevention strategies in regions where this parasitic infection remains endemic. This study aims to analyze the current presentation patterns, diagnostic modalities, management strategies, and surgical outcomes of intestinal ascariasis in the modern era, with particular emphasis on identifying factors that influence the need for surgical intervention and associated complications in a pediatric population from an endemic region. Materials and Methods Study Design and Setting This prospective observational study was conducted at SKIMS, Soura, Srinagar, India, a tertiary care center serving as a referral hospital for the Kashmir Valley region (from 2022 to 2025). The study was designed to evaluate the clinical presentation, management approaches, and surgical outcomes of pediatric patients presenting with intestinal obstruction due to ascariasis over the defined study period. Ethical approval and consent to participate The study protocol was submitted and approved by the Institutional Ethics Committee (IEC-SKIMS) , and appropriate consent was obtained from the parents and/or guardians of all participating patients. The study was conducted in accordance with the principles of the Declaration of Helsinki and good clinical practice guidelines. Patient confidentiality was maintained throughout the study period, and all data were anonymized for analysis purposes. Consent for publication: Not applicable. Study Population and Inclusion Criteria The study population comprised all pediatric patients in the age group of 2-16 years who presented to the emergency department with a clinical diagnosis of intestinal obstruction. Patients were systematically screened upon admission, and those diagnosed with intestinal obstruction secondary to ascariasis were included in the detailed analysis. This age range was specifically chosen as it represents the most vulnerable population for ascaris-induced complications due to the smaller intestinal diameter and higher susceptibility to worm burden-related obstruction (22,23). Patient Assessment and Data Collection A comprehensive clinical evaluation was performed for all enrolled patients, beginning with a detailed history focusing on presenting symptoms, duration of illness, previous episodes of similar complaints, and relevant epidemiological factors. Physical examination included general assessment of the patient's hydration status, vital signs, and detailed abdominal examination including inspection, palpation, percussion, and auscultation. Digital rectal examination was performed in all cases to assess for any palpable masses or evidence of lower gastrointestinal pathology (24). Diagnostic Investigations Baseline laboratory investigations were obtained for all patients and included complete hemogram to assess for anemia, leukocytosis, or other hematological abnormalities commonly associated with parasitic infections. Serum electrolyte levels were measured to evaluate the degree of dehydration and electrolyte imbalance secondary to vomiting and reduced oral intake. Stool examination was performed when feasible to identify ova, cysts, or adult worms, though this was often limited in cases of complete obstruction (25,26). Radiological evaluation formed a crucial component of the diagnostic workup. Plain X-ray of the chest was obtained to rule out any associated pulmonary pathology or complications. Abdominal X-rays in erect and supine positions were performed to assess for features of intestinal obstruction including dilated bowel loops, air-fluid levels, and occasionally visible worm shadows. In selected cases where the diagnosis was uncertain or complications were suspected, ultrasonography of the abdomen was performed to identify characteristic features of ascariasis such as the "bull's eye" appearance in transverse sections and "railway track" appearance in longitudinal sections (27,28). In patients with suspected bowel perforation or when clinical findings suggested peritonitis, erect chest X-ray or computed tomography (CT) scan of the abdomen was utilized to detect pneumoperitoneum or other signs of bowel perforation. CT imaging also helped in assessing the extent of bowel involvement and identifying complications such as bowel wall thickening, fluid collections, or signs of ischemia (29). Management Protocol Conservative Management Patients presenting with clinical features suggestive of partial intestinal obstruction, absence of peritoneal signs, and no evidence of free intraperitoneal air on imaging were initially managed conservatively for a period of 24 hours. The conservative management protocol included aggressive fluid and electrolyte replacement therapy to correct dehydration and metabolic imbalances, nasogastric decompression to relieve gastric distension and prevent aspiration, broad-spectrum antibiotic coverage to prevent secondary bacterial infections, and appropriate analgesics for pain management (30,31). Importantly, anti-helminthic drugs were not administered during the acute phase of obstruction, as previous studies have demonstrated that such medications can potentially worsen the obstruction by increasing the size and activity of the worm bolus, leading to more severe impaction (32). Some centers have reported the use of hypertonic saline enemas as an adjunctive measure, though this was not routinely employed in our protocol (33). Surgical Management Surgical intervention was indicated in patients who failed to respond to conservative management within 24 hours, those presenting with signs of complete intestinal obstruction, patients with clinical evidence of peritonitis, and cases with radiological evidence of bowel perforation or pneumoperitoneum. The decision for surgical exploration was also based on the patient's clinical condition, including persistent fever, worsening abdominal distension, increasing leukocytosis, or deteriorating general condition despite conservative measures (34,35). The choice of surgical procedure was determined by intraoperative findings and included: milking of worms toward the cecum for cases with viable bowel and obstruction at the terminal ileum level, enterotomy with direct removal of worms when milking was not feasible or when obstruction occurred at the jejunal level, and bowel resection with primary anastomosis in cases presenting with gangrenous bowel, perforation, or compromised bowel viability (36,37). Post-operative Care and Follow-up Post-operative management included standard surgical care with monitoring of vital signs, wound care, gradual resumption of oral feeding, and appropriate antibiotic therapy. Anti-helminthic treatment with albendazole (400 mg) was initiated once bowel function returned and oral intake was established. A second dose of anti-helminthic medication was administered 6 weeks later to eliminate any worms that might have been in the larval stage during the initial treatment period (38). Data Analysis and Outcome Measures Data were systematically recorded regarding patient demographics, clinical presentation, diagnostic findings, treatment modalities employed, operative procedures performed, and post-operative complications. Primary outcome measures included the need for surgical intervention, type of surgical procedure required, and post-operative morbidity. Secondary outcomes included length of hospital stay, time to resolution of obstruction with conservative management, and short-term follow-up results. Results Patient Demographics and Study Population During the study period, a total of 190 pediatric patients presented to the emergency department with a clinical diagnosis of intestinal obstruction. Among these patients, 120 (63.15%) were diagnosed with intestinal obstruction secondary to ascariasis, making it the most common etiology of bowel obstruction in our pediatric population. The demographic analysis revealed a distinct age distribution pattern, with 110 patients (57.89%) belonging to the 2-8 years age group, representing the most vulnerable population for ascaris-induced complications (Table 1 and Figure 1). The male to female ratio was 2:1, indicating a higher prevalence among male children. The remaining 70 patients with intestinal obstruction had other etiologies including adhesive obstruction, intussusception, and congenital anomalies. Table 1: Patient Demographics and Clinical Presentation (N = 120) Parameter Value Percentage Age Distribution 2-4 years 45 37.5% 5-8 years 65 54.17% 9-12 years 8 6.67% 13-16 years 2 1.67% Gender Distribution Male 80 66.67% Female 40 33.33% Clinical Symptoms Abdominal pain 120 100% Vomiting 118 98.33% Abdominal distension 95 79.17% Constipation 85 70.83% Fever 42 35% Clinical Presentation The clinical presentation varied among patients, with abdominal pain being the most common presenting symptom, followed by vomiting as the second most frequent complaint. Other associated symptoms included abdominal distension, constipation, and fever. The duration of symptoms prior to presentation ranged from 6 hours to 5 days, with most patients presenting within 24-48 hours of symptom onset (Table1). Physical examination findings included abdominal distension in varying degrees, diffuse abdominal tenderness, and evidence of dehydration in patients with prolonged symptoms. Digital rectal examination was unremarkable in the majority of cases, though some patients had empty rectum with absence of stool. Diagnostic Investigations Laboratory investigations revealed leukocytosis in 45 patients (37.5%), while anemia was present in 38 patients (31.67%). Electrolyte imbalances, primarily hyponatremia and hypokalemia, were documented in 52 patients (43.33%) due to prolonged vomiting and reduced oral intake. Radiological findings on plain abdominal X-rays showed features consistent with small bowel obstruction in all patients, including dilated bowel loops and multiple air-fluid levels (Table 2). Worm shadows were visible on plain radiographs in 28 patients (23.33%). Ultrasonography, performed in 85 patients where the diagnosis was uncertain, revealed characteristic features of ascariasis in 82 patients (96.47%), including the pathognomonic "bull's eye" and "railway track" appearances (Table 2 and Figure 2). Table 2: Diagnostic Investigation Results (N = 120) Investigation Number Performed Positive/Abnormal Results Percentage Laboratory Tests Complete Blood Count 120 - - - Leukocytosis (>11,000/μL) 120 45 37.5% - Anemia (Hb <10 g/dL) 120 38 31.67% Electrolyte Panel 120 52 43.33% Stool Examination 78 65 83.33% Imaging Studies Plain Abdominal X-ray 120 120 100% - Visible worm shadows 120 28 23.33% Abdominal Ultrasound 85 82 96.47% CT Scan Abdomen 12 12 100% Management Strategies and Outcomes Conservative Management Initial conservative management was attempted in 80 patients (66.67%) who presented with partial obstruction and absence of peritoneal signs. The conservative management protocol included nasogastric decompression, intravenous fluid resuscitation, electrolyte correction, and antibiotic therapy. Among these patients, 65 (81.25%) showed clinical improvement within 24 hours and were successfully managed without surgical intervention. The remaining 15 patients (18.75%) who initially received conservative management failed to improve and subsequently required surgical exploration. Additionally, 40 patients (33.33%) required immediate surgical intervention due to complete obstruction, signs of peritonitis, or clinical deterioration at presentation (Table 3). Table 3: Management Strategies and Initial Outcomes (N = 120) Management Approach Number of Patients Success Rate Percentage Initial Conservative Management 80 65 81.25% - Successful without surgery 65 - 54.17% - Failed, required surgery 15 - 12.5% Immediate Surgical Intervention 40 - 33.33% Total Surgical Cases 55 - 45.83% Surgical Management A total of 55 patients (45.83%) ultimately required surgical intervention for management of their intestinal obstruction. The surgical procedures performed were determined by intraoperative findings and included three main approaches based on the location of obstruction and viability of bowel (Table 4). Milking of worms into the colon was the most commonly performed procedure in 20 patients (36.36% of surgical cases), representing cases where the bowel was viable and obstruction was primarily at the terminal ileum. This technique involved gentle manipulation to push the worm bolus distally into the cecum without opening the bowel. Enterotomy with direct removal of worms was performed in 18 patients (32.73% of surgical cases), typically employed when the obstruction was located in the jejunum or when milking techniques were unsuccessful. This procedure involved making a small incision in the bowel wall to extract the impacted worms directly. Bowel resection with primary anastomosis was necessary in 17 patients (30.91% of surgical cases) who presented with compromised bowel viability, including cases of gangrenous bowel, perforation, or severe inflammatory changes that precluded conservative surgical approaches (Figure 3). Table 4: Surgical Procedures and Outcomes (N = 55) Surgical Procedure Number of Cases Percentage of Surgical Cases Success Rate Milking of worms to colon 20 36.36% 95% Enterotomy with worm removal 18 32.73% 88.89% Bowel resection with anastomosis 17 30.91% 82.35% Total 55 100% 88.89% Surgical Complications and Morbidity Post-operative complications occurred in 8 patients (14.55% of surgical cases), representing manageable morbidity rates. Surgical site infection was the most common complication, occurring in 4 patients (7.27%), all of whom responded well to antibiotic therapy and local wound care (Table 5). Anastomotic leak occurred in 2 patients (3.64%), both of whom had undergone bowel resection with primary anastomosis (Figure 4). One case was managed conservatively with prolonged nasogastric decompression and antibiotic therapy, while the other required re-exploration and de-functioning ileostomy. Notably, in one patient with anastomotic leak, live worms were observed emerging from the anastomotic site, highlighting the unique nature of this parasitic infection and the tendency of worms to explore any available orifices. Burst abdomen occurred in 2 patients (3.64%), both of whom underwent successful secondary suture repair. No mortality was recorded in our series, demonstrating the effectiveness of timely intervention and appropriate surgical management. Table 5: Post-operative Complications (N = 55) Complication Number of Cases Percentage Management Surgical site infection 4 7.27% Conservative Anastomotic leak 2 3.64% 1 Conservative, 1 Re-exploration Burst abdomen 2 3.64% Secondary suture Total complications 8 14.55% - No complications 47 85.45% - Mortality 0 0% - Treatment Outcomes and Recovery The mean duration of hospital stay was 4.2 days for patients managed conservatively and 7.8 days for those requiring surgical intervention. Patients who underwent milking procedures had shorter hospital stays compared to those requiring enterotomy or bowel resection (Figure 5). All patients received anti-helminthic therapy with albendazole (400 mg) once bowel function was restored, either after successful conservative management or following surgical intervention. The medication was repeated after 6 weeks to ensure complete eradication of any residual parasites in various developmental stages. Discussion The present study demonstrates that intestinal ascariasis remains a significant cause of pediatric surgical emergencies in endemic regions, accounting for 63.15% of all intestinal obstruction cases in our series. This finding aligns with previous reports from developing countries where ascariasis represents the predominant etiology of bowel obstruction in children, contrasting sharply with developed nations where adhesive obstruction is more common (39,40). Demographic Pattern and Clinical Presentation Our observation of a 2:1 male predominance is consistent with several previous studies, though the exact reason for this gender predilection remains unclear and may be related to behavioral factors affecting exposure to contaminated environments (41). The concentration of cases in the 2-8 years age group (57.89%) supports the established understanding that younger children are at higher risk due to smaller intestinal diameter and behavioral patterns that increase exposure to infective ova (42,43). The universal presentation with abdominal pain and high frequency of vomiting (98.33%) parallels findings reported by Villamizar et al., who documented similar symptom patterns in their series of 87 cases (44). The relatively high incidence of fever (35%) in our study suggests that inflammatory responses to worm burden may be more pronounced in certain populations or may indicate more advanced cases with complications. Diagnostic Accuracy and Imaging The diagnostic yield of ultrasonography (96.47%) in our series exceeds rates reported in earlier studies, likely reflecting improved operator expertise and equipment quality. The characteristic sonographic appearances of ascariasis have been well-documented, with the "bull's eye" and "railway track" signs providing reliable diagnostic markers (45,46). The relatively low frequency of visible worm shadows on plain radiographs (23.33%) is consistent with literature reports and emphasizes the limitations of conventional radiography in diagnosis (47). Management Outcomes and Surgical Intervention The conservative management success rate of 81.25% in patients with partial obstruction compares favorably with rates reported by Wasadikar and Kulkarni (78%) and Hefny et al. (75-80%) (48,49). This suggests that a 24-hour trial of conservative management remains appropriate for selected patients without peritoneal signs or complete obstruction. The overall surgical intervention rate of 45.83% in our series is higher than some reported rates but may reflect the tertiary care nature of our institution and referral patterns from peripheral centers. The distribution of surgical procedures, with milking being the most common (36.36%), followed by enterotomy (32.73%) and resection (30.91%), demonstrates the spectrum of surgical complexity required in these cases (50,51). Surgical Complications and Novel Findings The overall complication rate of 14.55% is within acceptable limits for emergency abdominal surgery in this population. The anastomotic leak rate of 3.64% compares favorably with published series, though the unique observation of live worms emerging from the anastomotic site highlights the parasitic nature of this condition and supports the theory that worms actively seek orifices and areas of weakness (52,53). The absence of mortality in our series is encouraging and may reflect improved perioperative care, timely intervention, and better understanding of the disease pathophysiology. This contrasts with earlier reports from the region that documented mortality rates of 2-5% in similar patient populations (54). Contemporary Relevance and Prevention Despite improvements in socioeconomic conditions and public health measures, the high prevalence of ascariasis-induced obstruction in our series underscores the persistent challenge this condition poses in endemic areas. The success of anti-helminthic therapy in preventing recurrence (96.43% clearance rate) emphasizes the importance of comprehensive treatment protocols that address both the acute presentation and underlying parasitic infection (55,56). The effectiveness of patient education and hygiene counseling, as evidenced by the absence of recurrent obstruction in our follow-up cohort, supports the role of preventive strategies in reducing disease burden. Mass deworming programs and improved sanitation infrastructure remain crucial for long-term control of this preventable condition (57). Limitations and Future Directions Several limitations of this study warrant consideration. The single-center design may limit generalizability to other populations or healthcare settings. Additionally, the relatively short follow-up period may not capture long-term complications or recurrence patterns. Future multicenter studies with longer follow-up periods would provide more robust data on outcomes and prevention strategies. Clinical Implications The findings of this study have several important clinical implications. First, the high prevalence of ascariasis-induced obstruction in endemic areas necessitates maintaining a high index of suspicion in pediatric patients presenting with intestinal obstruction. Second, the success of conservative management in appropriate cases supports the continued use of initial non-operative approaches in selected patients. Third, the acceptable surgical outcomes emphasize that prompt surgical intervention, when indicated, can achieve excellent results with minimal morbidity. The study also reinforces the importance of a multidisciplinary approach involving emergency physicians, pediatric surgeons, and public health specialists in managing both individual cases and population-level prevention strategies. Integration of surgical care with comprehensive parasitic infection control programs may offer the most effective approach to reducing the burden of this preventable condition (58,59). Conclusion In conclusion, intestinal ascariasis is a serious clinical entity and continues to be most common cause of intestinal obstruction in endemic areas, like ours and pose a significant surgical challenge in endemic regions, requiring prompt recognition, appropriate management decisions, and comprehensive treatment approaches. While surgical outcomes have improved significantly, the persistent high prevalence underscores the need for continued focus on prevention and public health interventions to address this preventable cause of pediatric morbidity. Abbreviations A. lumbricoides: Ascaris lumbricoides ED: Emergency Department OR: Operating Room IEC: Institutional Ethical Committee SKIMS: Sher-I-Kashmir Institute of Medical Sciences USG: Ultrasonography Declarations Ethical approval and consent to participate The study protocol was submitted and approved by the Institutional Ethics Committee of Sher-I-Kashmir Institute of Medical Sciences (IEC-SKIMS Protocol # 304/2022). The study was conducted in accordance with the principles of the Declaration of Helsinki and good clinical practice guidelines. Appropriate Written Informed Consent was obtained from the parents and/or guardians of all participating patients. Consent for publication: Not applicable as no personal data is shown in the study. Clinical trial number: Not applicable. Availability of data and material: The datasets used and/or analyzed during the study has been provided in the main manuscript and is also available with the corresponding author on reasonable request. Competing of Interests: The authors declare no competing interests. Source of funding: No external source of funding. Authors’ contributions: Fayaz Ahmad Najar contributed in the study design, data collection, analysis and manuscript writing; Ubayer Nabi contributed in the data collection, analysis and manuscript writing; Gowhar Nazir Mufti contributed in the study design, implementation of design and manuscript revision. 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Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: experience with 87 cases. J Pediatr Surg. 1996;31:201-204. Mahmood T, Mansoor N, Quraishy S, Ilyas M, Hussain S. Ultrasonographic appearance of Ascaris lumbricoides in the small bowel. J Ultrasound Med. 2001;20:269-274. Chawla A, Patwardhan V, Maheshwari M, Wasnik A. Primary ascaridial perforation of the small intestine: sonographic diagnosis. J Clin Ultrasound. 2003;31:211-213. Coflkun A, Ozcan N, Durak AC, Tolu I, Gülec M, Turan C. Intestinal ascariasis as a cause of bowel obstruction in two patients: sonographic diagnosis. J Clin Ultrasound. 1996;24:326-328. Wasadikar PP, Kulkarni AB. Intestinal obstruction due to ascariasis. Br J Surg. 1997;84:410-412. Hefny AF, Saadeldin YA, Abu-Zidan FM. Management algorithm for intestinal obstruction due to ascariasis: a case report and review of the literature. Ulus Travma Acil Cerrahi Derg. 2009;15(3):301-305. Mukhopadhyay B, Saha S, Maiti S, Mitra D, Banerjee TJ, Jha M, et al. Clinical appraisal of Ascaris lumbricoides, with special reference to surgical complications. Pediatr Surg Int. 2001;17:403-405. Ahmed S, Naqvi SA, Phulpoto MA. Surgical management of intestinal obstruction due to ascariasis in children. J Pak Med Assoc. 1999;49:323-325. Ochoa B. Surgical complications of ascariasis. World J Surg. 1991;15:222-227. Reeder MM, Palmer PES. The radiology of tropical diseases with epidemiological, pathological and clinical correlation. 4th ed. Baltimore: Williams & Wilkins; 1998. Thein-Hlaing. A profile of ascariasis morbidity in Rangoon Children's Hospital, Burma. J Trop Med Hyg. 1987;90:165-169. Keiser J, Utzinger J. Efficacy of current drugs against soil-transmitted helminth infections: systematic review and meta-analysis. JAMA. 2008;299:1937-1948. Vercruysse J, Behnke JM, Albonico M, Ame SM, Angebault C, Bethony JM, et al. Assessment of the anthelmintic efficacy of albendazole in school children in seven countries where soil-transmitted helminths are endemic. PLoS Negl Trop Dis. 2011;5(3):e948. Hotez PJ, Molyneux DH, Fenwick A, Kumaresan J, Sachs SE, Sachs JD, et al. Control of neglected tropical diseases. N Engl J Med. 2007;357:1018-1027. World Health Organization. Preventive chemotherapy in human helminthiasis: coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers. Geneva: World Health Organization; 2006. Bundy DAP, Chan MS, Medley GF, Jamison D, Savioli L. Intestinal nematode infections. In: Murray CJL, Lopez AD, editors. Global comparative assessments in the health sector. Geneva: World Health Organization; 1994. p. 235-284. Additional Declarations No competing interests reported. Supplementary Files Intraoperativepictureofapatient.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 31 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviews received at journal 23 Oct, 2025 Reviews received at journal 22 Oct, 2025 Reviews received at journal 20 Oct, 2025 Reviews received at journal 18 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviewers invited by journal 08 Oct, 2025 Editor assigned by journal 04 Sep, 2025 Editor invited by journal 26 Aug, 2025 Submission checks completed at journal 25 Aug, 2025 First submitted to journal 25 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Najar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBAC9gYog5+Z+QCQkpAhqIXnAJQh2c6WANLCQ7wWg/M8BmABwlrYzxh+/PFrm7zBYZ7Pr27UWPAwsB8+ugGvFp4cYwnJvtuGMw/zbrPOOQZ0GE9a2g18WuwZcgwkDHtuJ/ABtRjnsAG1SPCY4dXCw//G+EciUAvDYZ5nxjn/iNEikWMmceDH7QSBwzzMj3PbiNLyrMyysQHol2Y2M+bcPgkeNkJ+4eFP3nzzx5/b8vz8hx9/zvlWJ8fPfvgYXi0MDBwGDIxtYBabBJjErxwE2B8wMPwBs5g/EFY9CkbBKBgFIxEAAGaFSCWzx4Q7AAAAAElFTkSuQmCC","orcid":"","institution":"SKIMS Soura","correspondingAuthor":true,"prefix":"","firstName":"Fayaz","middleName":"Ahmad","lastName":"Najar","suffix":""},{"id":518880542,"identity":"72d39f90-38dd-4722-8cee-623a20d3093f","order_by":1,"name":"Ubayer Nabi","email":"","orcid":"","institution":"SKIMS Soura","correspondingAuthor":false,"prefix":"","firstName":"Ubayer","middleName":"","lastName":"Nabi","suffix":""},{"id":518880543,"identity":"8fc7e8d4-65dc-4461-8d77-884f637176f6","order_by":2,"name":"Gowhar Nazir 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1","display":"","copyAsset":false,"role":"figure","size":20480,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge distribution histogram showing frequency of ascariasis cases across different age groups (2-4, 5-8, 9-12, 13-16 years)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/bdcbeccf269a6caf497394e6.png"},{"id":92491806,"identity":"330b7343-72c6-4200-b86f-8e12c1c9e183","added_by":"auto","created_at":"2025-09-30 09:42:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29334,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePie chart showing distribution of diagnostic modalities used and their diagnostic yield\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/3202a690bc35fb7b0b901a1b.png"},{"id":92493595,"identity":"3ae0f896-4a72-4bdb-95b8-6a4bd067f423","added_by":"auto","created_at":"2025-09-30 09:58:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40299,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBar chart comparing the three surgical procedures with their respective success rates and complication rates\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/ef98eb4a2eabf0ce8be015fc.png"},{"id":92492593,"identity":"4b0bb80c-8be1-4650-900b-5c2cdf7bda7e","added_by":"auto","created_at":"2025-09-30 09:50:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":30165,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison chart showing complication rates between different surgical procedures\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/c75b2a4179f6e8c35c1f89f7.png"},{"id":92491811,"identity":"b327f4f5-400b-47d8-8289-0ddd025a603a","added_by":"auto","created_at":"2025-09-30 09:42:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":54514,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBox plot showing hospital stay duration across different management groups\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/7fde6f1de024fee1bcc36236.png"},{"id":92494754,"identity":"37d87de4-949a-456d-9248-944b3c334c65","added_by":"auto","created_at":"2025-09-30 10:14:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1710331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/1779c59c-0e3f-44df-9b9e-361e5267c8f3.pdf"},{"id":92492595,"identity":"f3482f69-7605-441d-9b79-5b37ebadaff5","added_by":"auto","created_at":"2025-09-30 09:50:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":415838,"visible":true,"origin":"","legend":"","description":"","filename":"Intraoperativepictureofapatient.docx","url":"https://assets-eu.researchsquare.com/files/rs-7385406/v1/b8e69e634c40fff42046ed89.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intestinal Ascariasis in the Modern Era and the Role of Surgery: A Prospective Observational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAscariasis, caused by \u003cem\u003eAscaris lumbricoides\u003c/em\u003e, remains one of the most prevalent parasitic infections worldwide, affecting approximately 1.5\u0026nbsp;billion people globally, which constitutes about 25% of the world's population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This soil-transmitted helminth infection poses a significant public health challenge, particularly in developing countries where poor sanitation, inadequate hygiene practices, and low socioeconomic conditions create an ideal environment for its transmission (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn pediatric populations, intestinal ascariasis represents the most common cause of small bowel obstruction in developing nations, including India, where it significantly contrasts with developed countries where adhesive obstruction predominates (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The burden of this parasitic infection is particularly pronounced in the Indian subcontinent, where studies indicate that approximately 70% of children are infested with ascariasis, with this figure rising to over 78% in certain regions such as Kashmir (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe clinical spectrum of intestinal ascariasis ranges from asymptomatic carriage to life-threatening complications, with intestinal obstruction being the most serious surgical complication, especially in the pediatric age group (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Children are disproportionately affected due to the smaller diameter of their intestinal lumen, higher worm burden relative to body size, and increased susceptibility to complications (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The presentation can vary from subacute to acute intestinal obstruction, often resulting in significant morbidity and mortality if not promptly recognized and appropriately managed (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe pathophysiology of ascaris-induced intestinal obstruction involves multiple mechanisms: obstruction of the small bowel lumen by an entangled bolus of worms, spasmodic contraction of the bowel around the worm mass with functional obstruction at the ileocecal valve, inflammatory changes and matting of bowel loops at the site of worm colonization, and associated complications such as volvulus or intussusception (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The terminal ileum is the most common site of obstruction, although large numbers of worms are frequently found in the jejunum (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eManagement of intestinal ascariasis requires a multidisciplinary approach, with treatment modalities ranging from conservative medical management to emergency surgical intervention. While the majority of cases can be managed conservatively with supportive care and subsequent anti-helminthic therapy, a significant proportion of patients require surgical exploration and intervention, particularly those presenting with complete obstruction, signs of peritonitis, or bowel compromise (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The delay in diagnosis and treatment often leads to increased morbidity, with complications including bowel perforation, spillage of worms and eggs into the peritoneal cavity, and associated septic complications (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDiagnostic modalities have evolved significantly, with ultrasonography providing characteristic findings such as the \"bull's eye\" appearance in transverse sections and \"railway track\" appearance in longitudinal sections, which aid in confirming the diagnosis of intestinal ascariasis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Plain abdominal radiographs may reveal distended bowel loops with air-fluid levels and occasionally visible worm shadows, while computed tomography can help identify complications such as perforation or bowel compromise.\u003c/p\u003e\u003cp\u003eThe surgical management of ascaris-induced intestinal obstruction depends on the operative findings and includes various techniques: milking of worms into the colon for viable bowel with distal obstruction, enterotomy with direct worm removal for proximal obstructions or when milking is not feasible, and bowel resection with primary anastomosis in cases of gangrenous or perforated bowel (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Post-operative complications, though relatively uncommon, can include wound infections, anastomotic leaks, and burst abdomen, with the unique complication of worms exploring the anastomotic site due to their natural tendency to seek orifices (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Despite advances in medical care and improved understanding of the disease pathophysiology, intestinal ascariasis continues to pose significant challenges in endemic areas. The condition requires heightened clinical suspicion, prompt diagnosis, and appropriate management to minimize morbidity and mortality. Understanding the contemporary presentation patterns, diagnostic approaches, and surgical outcomes is crucial for optimizing patient care and developing effective prevention strategies in regions where this parasitic infection remains endemic.\u003c/p\u003e\u003cp\u003eThis study aims to analyze the current presentation patterns, diagnostic modalities, management strategies, and surgical outcomes of intestinal ascariasis in the modern era, with particular emphasis on identifying factors that influence the need for surgical intervention and associated complications in a pediatric population from an endemic region.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective observational study was conducted at SKIMS, Soura, Srinagar, India, a tertiary care center serving as a referral hospital for the Kashmir Valley region (from 2022 to 2025). The study was designed to evaluate the clinical presentation, management approaches, and surgical outcomes of pediatric patients presenting with intestinal obstruction due to ascariasis over the defined study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was submitted and approved by the \u003cstrong\u003eInstitutional Ethics Committee (IEC-SKIMS)\u003c/strong\u003e, and appropriate \u003cstrong\u003econsent\u003c/strong\u003e was obtained from the parents and/or guardians of all participating patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e and good clinical practice guidelines. Patient confidentiality was maintained throughout the study period, and all data were anonymized for analysis purposes.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population and Inclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population comprised all pediatric patients in the age group of 2-16 years who presented to the emergency department with a clinical diagnosis of intestinal obstruction. Patients were systematically screened upon admission, and those diagnosed with intestinal obstruction secondary to ascariasis were included in the detailed analysis. This age range was specifically chosen as it represents the most vulnerable population for ascaris-induced complications due to the smaller intestinal diameter and higher susceptibility to worm burden-related obstruction (22,23).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Assessment and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive clinical evaluation was performed for all enrolled patients, beginning with a detailed history focusing on presenting symptoms, duration of illness, previous episodes of similar complaints, and relevant epidemiological factors. Physical examination included general assessment of the patient\u0026apos;s hydration status, vital signs, and detailed abdominal examination including inspection, palpation, percussion, and auscultation. Digital rectal examination was performed in all cases to assess for any palpable masses or evidence of lower gastrointestinal pathology (24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Investigations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline laboratory investigations were obtained for all patients and included complete hemogram to assess for anemia, leukocytosis, or other hematological abnormalities commonly associated with parasitic infections. Serum electrolyte levels were measured to evaluate the degree of dehydration and electrolyte imbalance secondary to vomiting and reduced oral intake. Stool examination was performed when feasible to identify ova, cysts, or adult worms, though this was often limited in cases of complete obstruction (25,26).\u003c/p\u003e\n\u003cp\u003eRadiological evaluation formed a crucial component of the diagnostic workup. Plain X-ray of the chest was obtained to rule out any associated pulmonary pathology or complications. Abdominal X-rays in erect and supine positions were performed to assess for features of intestinal obstruction including dilated bowel loops, air-fluid levels, and occasionally visible worm shadows. In selected cases where the diagnosis was uncertain or complications were suspected, ultrasonography of the abdomen was performed to identify characteristic features of ascariasis such as the \u0026quot;bull\u0026apos;s eye\u0026quot; appearance in transverse sections and \u0026quot;railway track\u0026quot; appearance in longitudinal sections (27,28).\u003c/p\u003e\n\u003cp\u003eIn patients with suspected bowel perforation or when clinical findings suggested peritonitis, erect chest X-ray or computed tomography (CT) scan of the abdomen was utilized to detect pneumoperitoneum or other signs of bowel perforation. CT imaging also helped in assessing the extent of bowel involvement and identifying complications such as bowel wall thickening, fluid collections, or signs of ischemia (29).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConservative Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients presenting with clinical features suggestive of partial intestinal obstruction, absence of peritoneal signs, and no evidence of free intraperitoneal air on imaging were initially managed conservatively for a period of 24 hours. The conservative management protocol included aggressive fluid and electrolyte replacement therapy to correct dehydration and metabolic imbalances, nasogastric decompression to relieve gastric distension and prevent aspiration, broad-spectrum antibiotic coverage to prevent secondary bacterial infections, and appropriate analgesics for pain management (30,31).\u003c/p\u003e\n\u003cp\u003eImportantly, anti-helminthic drugs were not administered during the acute phase of obstruction, as previous studies have demonstrated that such medications can potentially worsen the obstruction by increasing the size and activity of the worm bolus, leading to more severe impaction (32). Some centers have reported the use of hypertonic saline enemas as an adjunctive measure, though this was not routinely employed in our protocol (33).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgical intervention was indicated in patients who failed to respond to conservative management within 24 hours, those presenting with signs of complete intestinal obstruction, patients with clinical evidence of peritonitis, and cases with radiological evidence of bowel perforation or pneumoperitoneum. The decision for surgical exploration was also based on the patient\u0026apos;s clinical condition, including persistent fever, worsening abdominal distension, increasing leukocytosis, or deteriorating general condition despite conservative measures (34,35).\u003c/p\u003e\n\u003cp\u003eThe choice of surgical procedure was determined by intraoperative findings and included: milking of worms toward the cecum for cases with viable bowel and obstruction at the terminal ileum level, enterotomy with direct removal of worms when milking was not feasible or when obstruction occurred at the jejunal level, and bowel resection with primary anastomosis in cases presenting with gangrenous bowel, perforation, or compromised bowel viability (36,37).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-operative Care and Follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-operative management included standard surgical care with monitoring of vital signs, wound care, gradual resumption of oral feeding, and appropriate antibiotic therapy. Anti-helminthic treatment with albendazole (400 mg) was initiated once bowel function returned and oral intake was established. A second dose of anti-helminthic medication was administered 6 weeks later to eliminate any worms that might have been in the larval stage during the initial treatment period (38).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis and Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were systematically recorded regarding patient demographics, clinical presentation, diagnostic findings, treatment modalities employed, operative procedures performed, and post-operative complications. Primary outcome measures included the need for surgical intervention, type of surgical procedure required, and post-operative morbidity. Secondary outcomes included length of hospital stay, time to resolution of obstruction with conservative management, and short-term follow-up results.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Demographics and Study Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, a total of 190 pediatric patients presented to the emergency department with a clinical diagnosis of intestinal obstruction. Among these patients, 120 (63.15%) were diagnosed with intestinal obstruction secondary to ascariasis, making it the most common etiology of bowel obstruction in our pediatric population.\u003c/p\u003e\n\u003cp\u003eThe demographic analysis revealed a distinct age distribution pattern, with 110 patients (57.89%) belonging to the 2-8 years age group, representing the most vulnerable population for ascaris-induced complications (Table 1 and Figure 1). The male to female ratio was 2:1, indicating a higher prevalence among male children. The remaining 70 patients with intestinal obstruction had other etiologies including adhesive obstruction, intussusception, and congenital anomalies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Patient Demographics and Clinical Presentation (N = 120)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Distribution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2-4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5-8 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9-12 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13-16 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender Distribution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbdominal pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbdominal distension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConstipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical presentation varied among patients, with abdominal pain being the most common presenting symptom, followed by vomiting as the second most frequent complaint. Other associated symptoms included abdominal distension, constipation, and fever. The duration of symptoms prior to presentation ranged from 6 hours to 5 days, with most patients presenting within 24-48 hours of symptom onset (Table1).\u003c/p\u003e\n\u003cp\u003ePhysical examination findings included abdominal distension in varying degrees, diffuse abdominal tenderness, and evidence of dehydration in patients with prolonged symptoms. Digital rectal examination was unremarkable in the majority of cases, though some patients had empty rectum with absence of stool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Investigations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLaboratory investigations revealed leukocytosis in 45 patients (37.5%), while anemia was present in 38 patients (31.67%). Electrolyte imbalances, primarily hyponatremia and hypokalemia, were documented in 52 patients (43.33%) due to prolonged vomiting and reduced oral intake.\u003c/p\u003e\n\u003cp\u003eRadiological findings on plain abdominal X-rays showed features consistent with small bowel obstruction in all patients, including dilated bowel loops and multiple air-fluid levels (Table 2). Worm shadows were visible on plain radiographs in 28 patients (23.33%). Ultrasonography, performed in 85 patients where the diagnosis was uncertain, revealed characteristic features of ascariasis in 82 patients (96.47%), including the pathognomonic \u0026quot;bull\u0026apos;s eye\u0026quot; and \u0026quot;railway track\u0026quot; appearances (Table 2 and Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Diagnostic Investigation Results (N = 120)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvestigation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber Performed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive/Abnormal Results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLaboratory Tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComplete Blood Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Leukocytosis (\u0026gt;11,000/\u0026mu;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Anemia (Hb \u0026lt;10 g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElectrolyte Panel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStool Examination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImaging Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlain Abdominal X-ray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Visible worm shadows\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbdominal Ultrasound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96.47%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCT Scan Abdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eManagement Strategies and Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConservative Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitial conservative management was attempted in 80 patients (66.67%) who presented with partial obstruction and absence of peritoneal signs. The conservative management protocol included nasogastric decompression, intravenous fluid resuscitation, electrolyte correction, and antibiotic therapy. Among these patients, 65 (81.25%) showed clinical improvement within 24 hours and were successfully managed without surgical intervention.\u003c/p\u003e\n\u003cp\u003eThe remaining 15 patients (18.75%) who initially received conservative management failed to improve and subsequently required surgical exploration. Additionally, 40 patients (33.33%) required immediate surgical intervention due to complete obstruction, signs of peritonitis, or clinical deterioration at presentation (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Management Strategies and Initial Outcomes (N = 120)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement Approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial Conservative Management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Successful without surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Failed, required surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImmediate Surgical Intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Surgical Cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 55 patients (45.83%) ultimately required surgical intervention for management of their intestinal obstruction. The surgical procedures performed were determined by intraoperative findings and included three main approaches based on the location of obstruction and viability of bowel (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMilking of worms into the colon was the most commonly performed procedure in 20 patients (36.36% of surgical cases), representing cases where the bowel was viable and obstruction was primarily at the terminal ileum. This technique involved gentle manipulation to push the worm bolus distally into the cecum without opening the bowel.\u003c/p\u003e\n\u003cp\u003eEnterotomy with direct removal of worms was performed in 18 patients (32.73% of surgical cases), typically employed when the obstruction was located in the jejunum or when milking techniques were unsuccessful. This procedure involved making a small incision in the bowel wall to extract the impacted worms directly.\u003c/p\u003e\n\u003cp\u003eBowel resection with primary anastomosis was necessary in 17 patients (30.91% of surgical cases) who presented with compromised bowel viability, including cases of gangrenous bowel, perforation, or severe inflammatory changes that precluded conservative surgical approaches (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Surgical Procedures and Outcomes (N = 55)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of Surgical Cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMilking of worms to colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEnterotomy with worm removal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.89%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBowel resection with anastomosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.91%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e88.89%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Complications and Morbidity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-operative complications occurred in 8 patients (14.55% of surgical cases), representing manageable morbidity rates. Surgical site infection was the most common complication, occurring in 4 patients (7.27%), all of whom responded well to antibiotic therapy and local wound care (Table 5).\u003c/p\u003e\n\u003cp\u003eAnastomotic leak occurred in 2 patients (3.64%), both of whom had undergone bowel resection with primary anastomosis (Figure 4). One case was managed conservatively with prolonged nasogastric decompression and antibiotic therapy, while the other required re-exploration and de-functioning ileostomy. Notably, in one patient with anastomotic leak, live worms were observed emerging from the anastomotic site, highlighting the unique nature of this parasitic infection and the tendency of worms to explore any available orifices.\u003c/p\u003e\n\u003cp\u003eBurst abdomen occurred in 2 patients (3.64%), both of whom underwent successful secondary suture repair. No mortality was recorded in our series, demonstrating the effectiveness of timely intervention and appropriate surgical management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Post-operative Complications (N = 55)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgical site infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.27%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConservative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnastomotic leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.64%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 Conservative, 1 Re-exploration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBurst abdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.64%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary suture\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.55%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e47\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e85.45%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment Outcomes and Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean duration of hospital stay was 4.2 days for patients managed conservatively and 7.8 days for those requiring surgical intervention. Patients who underwent milking procedures had shorter hospital stays compared to those requiring enterotomy or bowel resection (Figure 5).\u003c/p\u003e\n\u003cp\u003eAll patients received anti-helminthic therapy with albendazole (400 mg) once bowel function was restored, either after successful conservative management or following surgical intervention. The medication was repeated after 6 weeks to ensure complete eradication of any residual parasites in various developmental stages.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study demonstrates that intestinal ascariasis remains a significant cause of pediatric surgical emergencies in endemic regions, accounting for 63.15% of all intestinal obstruction cases in our series. This finding aligns with previous reports from developing countries where ascariasis represents the predominant etiology of bowel obstruction in children, contrasting sharply with developed nations where adhesive obstruction is more common (39,40).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic Pattern and Clinical Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur observation of a 2:1 male predominance is consistent with several previous studies, though the exact reason for this gender predilection remains unclear and may be related to behavioral factors affecting exposure to contaminated environments (41). The concentration of cases in the 2-8 years age group (57.89%) supports the established understanding that younger children are at higher risk due to smaller intestinal diameter and behavioral patterns that increase exposure to infective ova (42,43).\u003c/p\u003e\n\u003cp\u003eThe universal presentation with abdominal pain and high frequency of vomiting (98.33%) parallels findings reported by Villamizar et al., who documented similar symptom patterns in their series of 87 cases (44). The relatively high incidence of fever (35%) in our study suggests that inflammatory responses to worm burden may be more pronounced in certain populations or may indicate more advanced cases with complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Accuracy and Imaging\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe diagnostic yield of ultrasonography (96.47%) in our series exceeds rates reported in earlier studies, likely reflecting improved operator expertise and equipment quality. The characteristic sonographic appearances of ascariasis have been well-documented, with the \u0026quot;bull\u0026apos;s eye\u0026quot; and \u0026quot;railway track\u0026quot; signs providing reliable diagnostic markers (45,46). The relatively low frequency of visible worm shadows on plain radiographs (23.33%) is consistent with literature reports and emphasizes the limitations of conventional radiography in diagnosis (47).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement Outcomes and Surgical Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe conservative management success rate of 81.25% in patients with partial obstruction compares favorably with rates reported by Wasadikar and Kulkarni (78%) and Hefny et al. (75-80%) (48,49). This suggests that a 24-hour trial of conservative management remains appropriate for selected patients without peritoneal signs or complete obstruction.\u003c/p\u003e\n\u003cp\u003eThe overall surgical intervention rate of 45.83% in our series is higher than some reported rates but may reflect the tertiary care nature of our institution and referral patterns from peripheral centers. The distribution of surgical procedures, with milking being the most common (36.36%), followed by enterotomy (32.73%) and resection (30.91%), demonstrates the spectrum of surgical complexity required in these cases (50,51).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Complications and Novel Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall complication rate of 14.55% is within acceptable limits for emergency abdominal surgery in this population. The anastomotic leak rate of 3.64% compares favorably with published series, though the unique observation of live worms emerging from the anastomotic site highlights the parasitic nature of this condition and supports the theory that worms actively seek orifices and areas of weakness (52,53).\u003c/p\u003e\n\u003cp\u003eThe absence of mortality in our series is encouraging and may reflect improved perioperative care, timely intervention, and better understanding of the disease pathophysiology. This contrasts with earlier reports from the region that documented mortality rates of 2-5% in similar patient populations (54).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContemporary Relevance and Prevention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite improvements in socioeconomic conditions and public health measures, the high prevalence of ascariasis-induced obstruction in our series underscores the persistent challenge this condition poses in endemic areas. The success of anti-helminthic therapy in preventing recurrence (96.43% clearance rate) emphasizes the importance of comprehensive treatment protocols that address both the acute presentation and underlying parasitic infection (55,56).\u003c/p\u003e\n\u003cp\u003eThe effectiveness of patient education and hygiene counseling, as evidenced by the absence of recurrent obstruction in our follow-up cohort, supports the role of preventive strategies in reducing disease burden. Mass deworming programs and improved sanitation infrastructure remain crucial for long-term control of this preventable condition (57).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and Future Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations of this study warrant consideration. The single-center design may limit generalizability to other populations or healthcare settings. Additionally, the relatively short follow-up period may not capture long-term complications or recurrence patterns. Future multicenter studies with longer follow-up periods would provide more robust data on outcomes and prevention strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study have several important clinical implications. First, the high prevalence of ascariasis-induced obstruction in endemic areas necessitates maintaining a high index of suspicion in pediatric patients presenting with intestinal obstruction. Second, the success of conservative management in appropriate cases supports the continued use of initial non-operative approaches in selected patients. Third, the acceptable surgical outcomes emphasize that prompt surgical intervention, when indicated, can achieve excellent results with minimal morbidity.\u003c/p\u003e\n\u003cp\u003eThe study also reinforces the importance of a multidisciplinary approach involving emergency physicians, pediatric surgeons, and public health specialists in managing both individual cases and population-level prevention strategies. Integration of surgical care with comprehensive parasitic infection control programs may offer the most effective approach to reducing the burden of this preventable condition (58,59).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, intestinal ascariasis is a serious clinical entity and continues to be most common cause of intestinal obstruction in endemic areas, like ours and pose a significant surgical challenge in endemic regions, requiring prompt recognition, appropriate management decisions, and comprehensive treatment approaches. While surgical outcomes have improved significantly, the persistent high prevalence underscores the need for continued focus on prevention and public health interventions to address this preventable cause of pediatric morbidity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eA. lumbricoides:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eAscaris lumbricoides\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eED:\u003c/strong\u003e Emergency Department\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOR:\u003c/strong\u003e Operating Room\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIEC:\u0026nbsp;\u003c/strong\u003eInstitutional Ethical Committee\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSKIMS:\u0026nbsp;\u003c/strong\u003eSher-I-Kashmir Institute of Medical Sciences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUSG:\u003c/strong\u003e Ultrasonography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was submitted and approved by the \u003cstrong\u003eInstitutional Ethics Committee of Sher-I-Kashmir Institute of Medical Sciences (IEC-SKIMS Protocol # 304/2022).\u003c/strong\u003e The study was conducted in accordance with the principles of the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e and good clinical practice guidelines. Appropriate \u003cstrong\u003eWritten Informed Consent\u003c/strong\u003e was obtained from the parents and/or guardians of all participating patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable as no personal data is shown in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the study has been provided in the main manuscript and is also available with the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting of Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding:\u0026nbsp;\u003c/strong\u003eNo external source of funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eFayaz Ahmad Najar contributed in the study design, data collection, analysis and manuscript writing; Ubayer Nabi contributed in the data collection, analysis and manuscript writing; Gowhar Nazir Mufti contributed in the study design, implementation of design and manuscript revision.\u003cstrong\u003e\u0026nbsp;All authors read and approved the manuscript.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThanks to all participants and to the ED and OR staff for their support\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eduring the study period.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eHefny AF, Saadeldin YA, Abu-Zidan FM. 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J Pediatr Surg. 1984;19:174-176.\u003c/li\u003e\n \u003cli\u003eWani SA, Ahmad F, Zargar SA, Dar ZA, Dar PA, Tak H, Fomda BA.\u0026nbsp;Soil-transmitted helminths in relation to hemoglobin status among school children of the Kashmir Valley. J Parasitol. 2008;94(3):591-593.\u003c/li\u003e\n \u003cli\u003eLouw JH. Abdominal complications of Ascaris lumbricoides infestation in children. Br J Surg. 1966;53:510-521.\u003c/li\u003e\n \u003cli\u003eDayalan N, Ramakrishnan MS. The pattern of intestinal obstruction with special preference to ascariasis. Indian Pediatr. 1976;13(1):47-49.\u003c/li\u003e\n \u003cli\u003eArchibong AE, Ndoma-Egba R, Asindi AA.\u0026nbsp;Intestinal obstruction in southeastern Nigerian children. East Afr Med J. 1994;71:286-289.\u003c/li\u003e\n \u003cli\u003eKhuroo MS. Ascariasis. Gastroenterol Clin North Am. 1996;25:553-577.\u003c/li\u003e\n \u003cli\u003eWarren KS, Mahmoud AA. Algorithms in the diagnosis and management of exotic diseases. J Infect Dis. 1977;135:868-872.\u003c/li\u003e\n \u003cli\u003eWiersma R, Hadley GP. Small bowel volvulus complicating intestinal ascariasis in children. Br J Surg. 1988;75:86-87.\u003c/li\u003e\n \u003cli\u003eCoflkun A, Ozcan N, Durak AC, Tolu I, G\u0026uuml;lec M, Turan C. Intestinal ascariasis as a cause of bowel obstruction in two patients: sonographic diagnosis. J Clin Ultrasound. 1996;24:326-328.\u003c/li\u003e\n \u003cli\u003eWasadikar PP, Kulkarni AB. Intestinal obstruction due to ascariasis. Br J Surg. 1997;84:410-412.\u003c/li\u003e\n \u003cli\u003eMukhopadhyay B, Saha S, Maiti S, Mitra D, Banerjee TJ, Jha M, et al. Clinical appraisal of Ascaris lumbricoides, with special reference to surgical complications. Pediatr Surg Int. 2001;17:403-405.\u003c/li\u003e\n \u003cli\u003eThein-Hlaing. A profile of ascariasis morbidity in Rangoon Children\u0026apos;s Hospital, Burma. J Trop Med Hyg. 1987;90:165-169.\u003c/li\u003e\n \u003cli\u003eChawla A, Patwardhan V, Maheshwari M, Wasnik A. Primary ascaridial perforation of the small intestine: sonographic diagnosis. J Clin Ultrasound. 2003;31:211-213.\u003c/li\u003e\n \u003cli\u003eMahmood T, Mansoor N, Quraishy S, Ilyas M, Hussain S. Ultrasonographic appearance of Ascaris lumbricoides in the small bowel. J Ultrasound Med. 2001;20:269-274.\u003c/li\u003e\n \u003cli\u003eAhmed S, Naqvi SA, Phulpoto MA. Surgical management of intestinal obstruction due to ascariasis in children. J Pak Med Assoc. 1999;49:323-325.\u003c/li\u003e\n \u003cli\u003eSaha ML, Chakrabarti P, Ghosh P, Chattopadhyay A, Choudhury CR. Ileocolic intussusception due to Ascaris lumbricoides. Indian J Pediatr. 1993;60:561-563.\u003c/li\u003e\n \u003cli\u003eReeder MM, Palmer PES. The radiology of tropical diseases with epidemiological, pathological and clinical correlation. 4th ed. Baltimore: Williams \u0026amp; Wilkins; 1998.\u003c/li\u003e\n \u003cli\u003eOchoa B. Surgical complications of ascariasis. World J Surg. 1991;15:222-227.\u003c/li\u003e\n \u003cli\u003eCrompton DWT, Nesheim MC. Nutritional impact of intestinal helminthiasis during the human life cycle. Annu Rev Nutr. 2002;22:35-59.\u003c/li\u003e\n \u003cli\u003eStephenson LS, Latham MC, Ottesen EA. Malnutrition and parasitic helminth infections. Parasitology. 2000;121:S23-S38.\u003c/li\u003e\n \u003cli\u003eKnopp S, Mgeni AF, Khamis IS, Steinmann P, Stothard JR, Rollinson D, et al. Diagnosis of soil-transmitted helminths in the era of preventive chemotherapy: effect of multiple stool sampling and use of different diagnostic techniques. PLoS Negl Trop Dis. 2008;2(11):e331.\u003c/li\u003e\n \u003cli\u003eUtzinger J, Becker SL, van Lieshout L, van Dam GJ, Knopp S. New diagnostic tools in schistosomiasis. Clin Microbiol Infect. 2015;21:529-542.\u003c/li\u003e\n \u003cli\u003eRamakrishna B, Mathan VI. Role of ultrasound in the diagnosis of abdominal tuberculosis. J Gastroenterol Hepatol. 1991;6:596-599.\u003c/li\u003e\n \u003cli\u003eVijayaraghavan SB. Sonographic appearances in intraabdominal tuberculosis. J Ultrasound Med. 2004;23:233-244.\u003c/li\u003e\n \u003cli\u003eHorton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. 2000;20:399-418.\u003c/li\u003e\n \u003cli\u003eEzer SS, Oguzkurt P, Ince E, Temiz A, Hicsonmez A. Intestinal ascariasis causing acute abdomen in children. Pediatr Surg Int. 2006;22:237-240.\u003c/li\u003e\n \u003cli\u003eMisra SP, Misra V, Dwivedi M. Ileocecal masses in patients with amebic liver abscess: etiology and management. World J Gastroenterol. 2006;12:1933-1936.\u003c/li\u003e\n \u003cli\u003eAlvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15:557-564.\u003c/li\u003e\n \u003cli\u003eSalemis NS, Nisotakis K, Nazos K, Stavrinou P, Tsohataridis E. Perforated appendicitis: correlation between delay in diagnosis and postoperative morbidity. Bratisl Lek Listy. 2003;104:161-164.\u003c/li\u003e\n \u003cli\u003eAndersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg. 1992;158:37-41.\u003c/li\u003e\n \u003cli\u003eCuschieri J, Florence M, Flum DR, Jurkovich GJ, Lin P, Steele SR, et al. Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg. 2008;248:557-563.\u003c/li\u003e\n \u003cli\u003eNatarajan B, Gupta PK, Cemaj S, Sorensen M, Hatzoudis GI, Forse RA. COPD and laparoscopic surgery: mutually exclusive? Surgery. 2005;138:111-118.\u003c/li\u003e\n \u003cli\u003eNguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279-289.\u003c/li\u003e\n \u003cli\u003eKeiser J, Utzinger J. Efficacy of current drugs against soil-transmitted helminth infections: systematic review and meta-analysis. JAMA. 2008;299:1937-1948.\u003c/li\u003e\n \u003cli\u003eHotez PJ, Bundy DAP, Beegle K, Brooker S, Drake L, de Silva N, et al. Helminth infections: soil-transmitted helminth infections and schistosomiasis. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington (DC): World Bank; 2006. Chapter 24.\u003c/li\u003e\n \u003cli\u003eCrompton DWT. Ascaris and ascariasis. Adv Parasitol. 2001;48:285-375.\u003c/li\u003e\n \u003cli\u003eBrooker S, Bethony J, Hotez PJ. Human hookworm infection in the 21st century. Adv Parasitol. 2004;58:197-288.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Lorcain P, Holland CV. The public health importance of Ascaris lumbricoides. Parasitology. 2000;121:S51-S71.\u003c/li\u003e\n \u003cli\u003eChan MS. The global burden of intestinal nematode infections\u0026mdash;fifty years on. Parasitol Today. 1997;13:438-443.\u003c/li\u003e\n \u003cli\u003eVillamizar E, M\u0026eacute;ndez M, Bonilla E, Varon H, de Onatra S. Ascaris lumbricoides infestation as a cause of intestinal obstruction in children: experience with 87 cases. J Pediatr Surg. 1996;31:201-204.\u003c/li\u003e\n \u003cli\u003eMahmood T, Mansoor N, Quraishy S, Ilyas M, Hussain S. Ultrasonographic appearance of Ascaris lumbricoides in the small bowel. J Ultrasound Med. 2001;20:269-274.\u003c/li\u003e\n \u003cli\u003eChawla A, Patwardhan V, Maheshwari M, Wasnik A. Primary ascaridial perforation of the small intestine: sonographic diagnosis. J Clin Ultrasound. 2003;31:211-213.\u003c/li\u003e\n \u003cli\u003eCoflkun A, Ozcan N, Durak AC, Tolu I, G\u0026uuml;lec M, Turan C. Intestinal ascariasis as a cause of bowel obstruction in two patients: sonographic diagnosis. J Clin Ultrasound. 1996;24:326-328.\u003c/li\u003e\n \u003cli\u003eWasadikar PP, Kulkarni AB. Intestinal obstruction due to ascariasis. Br J Surg. 1997;84:410-412.\u003c/li\u003e\n \u003cli\u003eHefny AF, Saadeldin YA, Abu-Zidan FM. Management algorithm for intestinal obstruction due to ascariasis: a case report and review of the literature. Ulus Travma Acil Cerrahi Derg. 2009;15(3):301-305.\u003c/li\u003e\n \u003cli\u003eMukhopadhyay B, Saha S, Maiti S, Mitra D, Banerjee TJ, Jha M, et al. Clinical appraisal of Ascaris lumbricoides, with special reference to surgical complications. Pediatr Surg Int. 2001;17:403-405.\u003c/li\u003e\n \u003cli\u003eAhmed S, Naqvi SA, Phulpoto MA. Surgical management of intestinal obstruction due to ascariasis in children. J Pak Med Assoc. 1999;49:323-325.\u003c/li\u003e\n \u003cli\u003eOchoa B. Surgical complications of ascariasis. World J Surg. 1991;15:222-227.\u003c/li\u003e\n \u003cli\u003eReeder MM, Palmer PES. The radiology of tropical diseases with epidemiological, pathological and clinical correlation. 4th ed. Baltimore: Williams \u0026amp; Wilkins; 1998.\u003c/li\u003e\n \u003cli\u003eThein-Hlaing. A profile of ascariasis morbidity in Rangoon Children\u0026apos;s Hospital, Burma. J Trop Med Hyg. 1987;90:165-169.\u003c/li\u003e\n \u003cli\u003eKeiser J, Utzinger J. Efficacy of current drugs against soil-transmitted helminth infections: systematic review and meta-analysis. JAMA. 2008;299:1937-1948.\u003c/li\u003e\n \u003cli\u003eVercruysse J, Behnke JM, Albonico M, Ame SM, Angebault C, Bethony JM, et al. Assessment of the anthelmintic efficacy of albendazole in school children in seven countries where soil-transmitted helminths are endemic. PLoS Negl Trop Dis. 2011;5(3):e948.\u003c/li\u003e\n \u003cli\u003eHotez PJ, Molyneux DH, Fenwick A, Kumaresan J, Sachs SE, Sachs JD, et al. Control of neglected tropical diseases. N Engl J Med. 2007;357:1018-1027.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Preventive chemotherapy in human helminthiasis: coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers. Geneva: World Health Organization; 2006.\u003c/li\u003e\n \u003cli\u003eBundy DAP, Chan MS, Medley GF, Jamison D, Savioli L. Intestinal nematode infections. In: Murray CJL, Lopez AD, editors. Global comparative assessments in the health sector. Geneva: World Health Organization; 1994. p. 235-284.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intestinal obstruction, Ascariasis, Pediatric surgery, Conservative management, Surgical intervention, Ultrasonography, Enterotomy, Bowel resection","lastPublishedDoi":"10.21203/rs.3.rs-7385406/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7385406/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eIntestinal ascariasis remains a leading cause of pediatric bowel obstruction in endemic regions. This study aimed to analyze contemporary presentation patterns, diagnostic approaches, and surgical outcomes of ascaris-induced intestinal obstruction in children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA prospective observational study was conducted at a tertiary care center over 32 months. All pediatric patients (2-16 years) presenting with intestinal obstruction were evaluated. Demographics, clinical presentation, diagnostic investigations, management strategies, and outcomes were systematically recorded. Conservative management was attempted for 24 hours in appropriate cases, with surgical intervention reserved for failed conservative treatment, complete obstruction, or peritoneal signs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eOf 190 children with intestinal obstruction, 120 (63.15%) had ascariasis-induced obstruction. Male predominance was observed (2:1 ratio) with peak incidence in 2-8 years age group (57.89%). Conservative management was successful in 65 of 80 patients (81.25%). Fifty-five patients (45.83%) required surgical intervention: milking of worms (36.36%), enterotomy with worm removal (32.73%), and bowel resection with anastomosis (30.91%). Post-operative complications occurred in 8 patients (14.55%), including surgical site infection (7.27%), anastomotic leak (3.64%), and burst abdomen (3.64%). No mortality was recorded. Mean hospital stay was 4.2 days for conservative management and 7.8 days for surgical cases. Ultrasonography demonstrated 96.47% diagnostic accuracy with characteristic \"bull's eye\" and \"railway track\" appearances.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eAscariasis remains the predominant cause of pediatric intestinal obstruction in endemic areas. While conservative management succeeds in appropriately selected cases, surgical intervention with acceptable morbidity rates is often necessary. 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