IJCRR - 6(22), November, 2014
Pages: 22-24
Date of Publication: 21-Nov-2014
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AN EXTREMELY RARE REPORT OF FINDING MULTIPLE HOOKWORMS IN THE JEJUNAL PART OF GASTROJEJUNOSTOMY STOMA INSTEAD OF ITS USUAL SITE IN DUODENUM WHILE DOING UPPER GASTRO INTESTINAL ENDOSCOPY
Author: Govindarajalu Ganesan
Category: Healthcare
Abstract:While doing upper gastro intestinal endoscopy hookworms are most commonly found in duodenum and very rarely in stomach. But interestingly multiple hookworms were seen in the jejunal part of gastrojejunostomy stoma while doing upper gastro intestinal endoscopy in a 45 year old female patient who had undergone Truncal Vagotomy and gastrojejunostomy. Such endoscopic finding has not been reported so far. The patient underwent upper gastro intestinal endoscopy since she had dyspepsia for the last few months. But infection with multiple hookworms was found to be the cause of her dyspepsia after endoscopy. Hence upper gastro intestinal endoscopy is a very useful investigation to diagnose hookworm infection of duodenum, stomach and even the jejunal part of gastrojejunostomy stoma.
Keywords: Hookworm, Upper gastro intestinal endoscopy, Jejunal part of gastrojejunostomy stoma
Full Text:
INTRODUCTION
There has been many reports of finding hookworms in duodenum while doing upper gastro intestinal endoscopy (1to10). Rarely hookworm is also reported to occur in stomach while doing upper gastro intestinal endoscopy (10to13). But there has been no reports of finding hookworms in the jejunal part of gastrojejunostomy stoma while doing upper gastro intestinal endoscopy. Hence an extremely rare report of finding multiple hookworms in the jejunal part of gastrojejunostomy stoma while doing upper gastro intestinal endoscopy is given here.
CASE REPORT
A 45 year old female patient who had undergone Truncal Vagotomy and gastrojejunostomy before six years and having dyspepsia for the last few months was subjected to upper gastro intestinal endoscopy. But very interestingly multiple hookworms were found actively moving in the jejunal part of gastrojejunostomy stoma (Fig 1,2). The head and the mouth of the hookworm is bent backward dorsally like a hook (Fig3) giving the name hookworm to it. It is S-shaped due to its dorsal bend at the head end (Fig3,4). Locomotion is by longitudinal muscles on one side contracting, while the other side expands, deforming the body into S-shaped curves (Fig 2,3,4). Two hookworms lying extremely close to one another (Fig 1) were retrieved out using biopsy forceps and immediately sent for microbiological examiniation. By microbilogical examiniation the two hookworms were identified as male and female hookworms and were also identified as Ancylostoma duodenale. The patient was treated with a single dose of 400mg of albendazole and her symptoms resolved.
DISCUSSION There are two human-specific hookworms, namely Ancylostoma duodenale and Necator americanus (4). Usually, the diagnosis of hookworm infection is made by the characteristic egg shape appearance on faecal examination (4). However, misdiagnosis is due to the absence of eggs of the parasites in stools (4). In such situation upper gastro intestinal endoscopy becomes an extremely useful investigation to diagnose hookworm infection (4). Hookworm is an elongated, unsegmented round worm belonging to the the Phylum Nematoda. When a round worm is found during upper gastrointestinal endoscopy, differential diagnosis is important to determine the diagnosis for the appropriate treatment (4). This can be achieved according to the morphology of the worms under microscopy and their location in the gastro intestinal tract (4). The common intestinal worms include Ascaris lumbricoides, Trichuris trichiura (whipworm), Enterobius vermicularis (pinworm), Strongyloides stercoralis and Anisakis simplex in addition to hookworms (Ancylostoma duodenale and Necator americanus) (4). Ascaris is a large roundworm (15-40cm in length) and inhabits the small intestine (4). Whipworm is 30-50mm in length and inhabits the large intestine (especially around caecum ) (4). Pinworm (10mm in length) also inhabits the same areas as the whipworm (4). Therefore, both the parasites are very rarely observed during upper gastrointestinal endoscopy (4). Strongyloides stercoralis inhabits the mucosa of duodenum or upper jejunum and is pretty small (2-3 mm in length) and relatively rare (4). The larva of anisakis simplex is found usually in the stomach of human beings and measures 2cm in length. Hookworms usually reside in the upper portion of the small intestine (4). In our study also multiple hookworms were found in the jejunal part of gastrojejunostomy stoma. Hence in our study also, hookworms were found to reside in the upper portion of the small intestine. Hookworm is identified by its characteristic bent head giving it a hook like appearance (Fig3,4). Hookworm is also Sshaped due to its bend at the head end (Fig3,4). Locomotion is by longitudinal muscles on one side contracting, while the other side expands, deforming the body into Sshaped curves (Fig 2,3,4). By all these features the round worm seen in this patient was identified as hook worm. The worms were also retrieved out using biopsy forceps and by microscopic examiniation were also confirmed as Ancylostoma duodenale. This patient presented with dyspepsia and upper gastro intestinal endoscopy was carried out in this patient due to her dyspepsia. But infection with multiple hookworms was found to be the cause of her dyspepsia after upper gastro intestinal endoscopy. Thus hookworm infection can present with dyspepsia and upper gastro intestinal endoscopy is a very useful investigation to diagnose hookworm infection.
CONCLUSION
Hence upper gastro intestinal endoscopy is very useful to diagnose the presence of hookworms in duodenum, stomach and even in the jejunal part of gastrojejunostomy stoma. Hence upper gastro intestinal endoscopy is a very useful investigation to diagnose hookworm infection of the entire gastro intestinal tract.
ACKNOWLEDGEMENT
The author sincerely thanks G. Kumaresan, computer engineer, for his immense help in labeling the figures of this article. The author acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. The author is extremely grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
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