Answer
1) X ray finding consistent with classical finding of worm bolus
Worms could be seen outlined against intestinal gas; the interface between worm bolus and adjacent gas shadows was irregular. Gas trapped within the worm bolus had irregular outlines. There were also fine linear radiolucent shadows and small bubbles. Fluid levels were sometimes distorted by a projecting worm bolus, resulting in a hump eftect. Some of the radlolucencies were within the worms.[Brian A ellman et al]
2) Provisional diagnosis is Acute intestinal obstruction secondary to worm bolus.
Round worm obstruction should be considered as the first differential diagnosis in any patient of intestinal obstruction in an endemic area [Aejaz Ahsan Baba et al]
Ascaridial intestinal obstruction may be acute or subacute, or can be due to ascaris-induced volvulus,intussusception, and may lead to gangrene of the small gut [Imtiaz Wani et al]
Abdominal pain was a leading symptom in 357 patients (99%) with the pain in periumbilical area present in 215 patients (60%). In 227 patients (63%) abdominal distension was seen and was the commonest physical finding. [Imtiaz Wani et al]
3) Management to this patient includes
a) Admit to pediatric ward
b) Fluid resuscitation.
c) Oxygen 3L/min via nasal prong
d) Hourly vital sign monitoring
e) Monitoring of urine output (0.5 ml/kg/hr)
f) Antibiotic coverage (IV cefobid & IV flagyl)
g) Analgesic (IV fentanyl)
h) Pre- op preparation for emergency laparotomy.
Reference:
1) Aejaz Ahsan Baba, Syed Mudasir Ahmad & Khursheed Ahmad Sheikh, "Intestinal ascariasis: the commonest cause of bowel obstruction in children at a tertiary care center in Kashmir", Pediatr Surg Int (2009) 25:1099–1102
2) Brian A. Ellman, J. Michael Wynne & Arthur Freeman, " Intestinal Ascariasis: New Plain Film Features", AJR 135:37-42, July 1980
3) Imtiaz Wani, Muddasir Rather, Ghulam Naikoo et al, "Intestinal Ascariasis in Children", World J Surg (2010) 34:963–968