When asked what has been the most unusual thing he has treated in his life, gastroenterologist Alexánder Cordero Jiménez is very clear: with the help of his team at the Tony Facio Hospital in Limón, had to remove an unusual number of intestinal worms of a size that his eyes had never seen in all the years of his career and service in the hospital: up to 25 cm.
The parasite he faced was already known, but not in those dimensions, never in that size or quantity.
“One sees little ones, little ones in a regular colonoscopy, but this size, this amount of parasites that produced this type of obstruction, we see in books, in legal medicine books, because, unfortunately, most of these patients die. Sometimes these adult worms migrate to the lung and tend to obstruct it, they migrate to other organs and can wreak havoc”, the specialist emphasized.
However, in this case the story was different. The 44-year-old patient’s recovery was almost immediate when they “hunted” the worms.
“The day before yesterday (Tuesday) he was here, I spoke with him. He told me that he does remember seeing the first worm, because at that time he was awake, we had not sedated him. He told me to give him the photos to show them to his wife, because she sees him so well that she doesn’t believe him,” he commented.
The enemy
The team was dealing with a type of roundworm called Ascaris lumbricoides. It is the most common type of roundworm, but the size and number took this patient to another level of risk.
How does someone get infected like this?
“It is a parasite that is acquired in the form of eggs through a contaminated surface,” he said.
These infections are almost always related to the handling of faeces, since the organism must have already gone through a certain part of its life cycle to have the possibility of infecting. So, Cordero explained, this infectious stage is lived in another human being.
How is this? The first infected person leaves the infection in their feces and with it contaminates the water or soil. There are also families that use feces as fertilizer on crops and contaminate the soil. If the person consumes those eggs, it is where the Ascaris it takes strength to grow and “travel” through almost the entire human body.
Once consumed, the eggs hatch and release larvae within the small intestine. Within a few days, these larvae migrate through the bloodstream to the lungs. They then travel up through the large airways of the lungs and are swallowed back into the stomach and small intestine.
“In rural areas there is talk of poor hygiene when consuming food or drinks,” he said. Also, not all people who work on crops take safety measures, such as wearing gloves. For people who work in this type of work, he does recommend using dewormers.
“In adults it is not generally recommended, it is not necessary, but in those who have this type of work that works the land, I would recommend every six months,” he said.
The story of an unusual procedure
That morning his colleagues from the Emergency Service came looking for him to ask him to check on a neighboring Limonense from a rural area who had unbearable stomach pains. He also had nausea and vomiting. At that time, the medical staff had already done blood, urine and ultrasound tests and they might not find the answer. His liver and kidney function had also been explored. The only clue they had was acute pancreatitis, that is, inflammation of the pancreas.
“This inflammation can be fatal in a few hours or compromise the patient’s life in a short time,” the specialist recalled.
The patient improved with part of the interventions, but the pain did not go away and rather increased. They had to resort to drugs as strong as morphine and they did not get relief.
The results of the tests made Cordero suspect that there was an obstruction of the bile duct. This is a very important conduit, as it allows drainage between the liver, the gallbladder and the small intestine. The pancreas also drains that pathway.
The specialist then requested a CAT scan, and there was something obstructing, but he mightn’t see what it was. So he ordered a gastroscopy.
“With the ‘gastro’ I reached the second portion of the small intestine and found some huge worms, between 15 and 25 centimeters, they were thick and highly mobile,” he recalled.
It was then that, together with the emergency team, they made the decision to sedate the patient, change his position and perform another procedure to position himself in front of the bile duct. There they performed another test called a duodenoscopy, which has a side view. There they saw two huge worms and they knew they had to get them out.
The duodenoscopy itself allowed them to enter with minimally invasive instruments and “lasso” them, as is done in a rodeo, and remove each worm.
First they removed the two that were blocking the road, and there all the liquids began to drain as if a dam had opened. They managed to contain that, but there were more left, and if they weren’t removed within a couple of hours they would clog the duct once more.
“The second one broke in two, I did it with a lot of force. There I said ‘calm’, we are working. Afterwards it was easier, ”she pointed out.
At that moment they began to take them out one by one. In all, they counted 12.
“For the size and maturity of these parasites, this infection should have occurred months ago. He never had symptoms, until it was already an emergency, “said the doctor.
Cordero highlights the value that a regional hospital, such as the one in Limon, would have every supply that would allow him to carry out the procedure. If he had had to go to the Calderón Guardia Hospital in San José, it would have been a four or five hour trip that would have complicated things.
“We saw the case of a 44-year-old man who was already fine six hours following the procedure and today he already has normal tests. That shows us that it can be done”, he concluded.
