Oftentimes general surgeons working in poorly resourced communities carry out emergency abdominal surgery in patients with acute abdomen with no definitive preoperative diagnosis. The definitive diagnosis is made at laparotomy. Perforated small bowel obstruction secondary to heavy Infestation with Ascaris lumbricoides brings a number of intraoperative challenges requiring correct intraoperative surgical management decisions. We present a case of a 17 year-old patient who was admitted with a diagnosis of small bowel obstruction that at laparotomy was found to have perforated gangrenous small bowel volvulus with heavy worm load visible through the bowel wall. Because of fecal peritoneal contamination and hemodynamic instability she underwent a two staged procedure with good outcome.