Gastric ascariasis presenting as recurrent massive upper gastrointestinal bleeding

Abstract

Ascaris lumbricoides is a parasitic nematode that, in its adult phase, lives in the human gastrointestinal tract. Ascaris lumbriciodes infects approxiamately one-fourth of the world's population. Most persons infected have minimal symptoms. Less commonly, weight loss, pneumonia and gastrointestinal/biliary obstruction can occur. We present a patient with recurrent massive gastrointestinal bleeding found to have Ascaris lunbricoides. A 63 year-old Bangladeshi female presented to the medical center with symptoms of weakness, fatigue, dark stools and coffee ground emesis. One year prior, she had been hospitalized elsewhere with an upper gastrointestinal bleed. The etiology was unclear. The patient reported that the physicians found a small hole in the stomach which was not amenable to endoscopic therapy. She was treated medically and sent home on an H2 blockers. Past medical history was significant for end stage renal disease requiring dialysis, hypertension, prior cerebrovascular accident and Chronic hepatitis C. Medications included amlodipine and famotidine. There was no aspirin or NSAID use. On admission, blood pressure 160/60, pulse 70 per minute, respirations 15 per minute. Physical exam was significant for anicteric sclera, dry mucosa, poor dentition, a III/IV systolic murmur and an arteriovenous fistula in the left arm. Abdominal exam revealed a non-distended abdomen with active bowel sounds, mild epigastric tenderness, no masses. Rectal exam showed guiac positive loose black stool. Laboratory analysis was significant for a hematocrit of 24. Although the patient had not eaten since the previous day, upper endoscopy, in the emergency room, was limited by food in the stomach. The patient was kept NPO; pantoprazole was begun intravenously. On subsequent endoscopy, there were linear ulcerations in the body of the stomach and mild gastritis. An actively bleeding duodenal ulcer was appreciated. An Ascaris worm was found in the blood and piercing the mucosa. The worm was removed by snare. The bleeding duodenal ulcer was injected with epinephrine. Hemostasis was completed with heater probe cauterization. Subsequent staining of pre-pyloric gastric biopsies failed to identify H. pylori. The patient was treated with albendazole and discharged home. This case report represents the first description of recurrent massive GI bleeding caused by Ascariasis.