Caput Medusae due to portal hypertension in schistosomiasis mansoni.

A 62-year-old Brazilian man who lived in endemic areas of tropical diseases had an episode of hematemesis associated with portal hypertension. He used to swim in natural ponds during childhood and developed the hepatosplenic form of schistossomiasis with moderate ascites, in addition to the characteristic features of abdominal Caput Medusae. The aim of the report is highlight the role of chronic liver disease and schistossomiasis.

Pulmonary shunts in severe hepatosplenic schistosomiasis: Diagnosis by contrast echocardiography and their relationship with abdominal ultrasound findings.

BACKGROUND: Schistosomiasis is endemic to several parts of the world. Among the species that affect humans, Schistosoma mansoni is one of the most common causes of illness. In regions where schistosomiasis mansoni is endemic, reinfection is responsible for the emergence of hepatosplenic schistosomiasis (HSS) with portal hypertension in about 10% of infected individuals. Regardless of its etiology, portal hypertension may bring about the formation of arteriovenous fistulas and pulmonary vascular dilation, thus constituting a pulmonary shunt and its presence has been associated with the occurrence of neurological complications. The objective of this study was to identify pulmonary shunt using TTCE in patients with HSS and esophageal varices, and to compare the abdominal ultrasound and endoscopy findings among patients with and without pulmonary shunt. METHODOLOGY/PRINCIPAL FINDINGS: In this case series, a total of 461 patients with schistosomiasis mansoni were prospectively evaluated using abdominal ultrasound and endoscopy and 71 presented with HSS with esophageal varices. Fifty seven patients remained in the final analysis. The mean age of the patients was 55 ± 14 years, and 65% were female. Pulmonary shunts were observed in 19 (33.3%) patients. On comparing the groups with and without pulmonary shunt, no significant differences were observed in relation to the abdominal ultrasound and endoscopic findings. When comparing the two subgroups with pulmonary shunts (grade 1 vs grades 2 and 3), it was observed that the subgroup with shunt grades 2 and 3 presented with a significantly higher frequency of an enlarged splenic vein diameter (>0.9 cm), and an advanced pattern of periportal hepatic fibrosis (P = 0.041 and P = 0.005, respectively). None of the patients with pulmonary shunts had severe neurological complications. CONCLUSIONS/SIGNIFICANCE: Our findings suggest that in HSS with esophageal varices the pulmonary shunts may be present in higher grades and that in this condition it was associated with ultrasound findings compatible with advanced HSS.

Caput Medusae due to portal hypertension in schistosomiasis mansoni / Cabeza de Medusa debida a la hipertensión portal en esquistosomiasis mansoni

A 62-year-old Brazilian man who lived in endemic areas of tropical diseases had an episode of hematemesis associated with portal hypertension. He used to swim in natural ponds during childhood and developed the hepatosplenic form of schistossomiasis with moderate ascites, in addition to the characteristic features of abdominal Caput Medusae. The aim of the report is highlight the role of chronic liver disease and schistossomiasis

Un hombre natural de Brasil de 62 años de edad que vivía en zonas endémicas de enfermedades tropicales presentó un episodio de hematemesis asociada con hipertensión portal. Frecuentemente se bañaba en los estanques naturales durante la infancia y desarrolló la forma hepatosplénica de la esquistosomiasis con ascitis moderada, además de los rasgos abdominales característicos de la Cabeza de Medusa. El objetivo del informe es poner de relieve el papel de la enfermedad hepática crónica y de la esquistosomiasis

[Application of degree of portal systemic shunting in assessing upper gastrointestinal bleeding in patients with schistosomiasis cirrhosis].

OBJECTIVE: To discuss the application of the degree of portal systemic shunting in assessing the upper gastrointestinal bleeding in patients with hepatic schistosomiasis. METHODS: Thirty-three patients with upper gastrointestinal bleeding caused by hepatic schistosomiasis (a bleeding group) and 29 schistosomiasis cirrhosis patients without bleeding (a non-bleeding group) were enrolled as investigation subjects in Jinshan Hospital. The subjects were scanned by the 128 abdominal slice spiral CT. The portal systemic shunting vessels were reconstructed by using thin slab maximum intensity projection (TSMIP) and multiplanar reconstruction (MPR). The degrees of the shunting vessels of the subjects were evaluated and compared, and the relationship between upper gastrointestinal bleeding and the degree of the shunting was analyzed. RESULTS: In the bleeding group, the occurrence rates of the shunting vessels were found as follows: 86.4% in left gastric varices, 68.2% in short gastric varices, 50.0% in esophageal varices, 50.0% in para-esophageal varices, 37.9% in gastric varices, 69.7% in gastric-renal varices, 51.5% in spleen-renal varices, 25.8% in abdominal wall varices, 15.2% in omentum varices, 63.6% in para-splenic varices, 34.8% in umbilical varices, 40.9% in retroperitoneal-paravertebral varices, and 36.4% in mesenteric varices. In the bleeding group, the occurrence rates and the degree of shunt were significantly higher than those in the non-bleeding group in esophageal varices, esophageal vein, left gastric vein and gastric varices (all P < 0.05). CONCLUSIONS: CT portal vein reconstruction can accurately display the location, degree and walking of all kinds of shunting vessels. Esophageal varices, esophageal vein, left gastric vein and gastric varices can accurately predict the risk of upper gastrointestinal bleeding in patients with hepatic schistosomiasis. The patents with higher degree of the shunting vessels have a higher risk of gastrointestinal bleeding.

Schistosomal portal hypertension: Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy.

UNLABELLED:  Background. Upper gastrointestinal bleeding is a major cause of morbidity and mortality in patients with portal hypertension secondary to schistosomiasis mansoni. AIM: To evaluate the efficacy of combined surgery and sclerotherapy versus endoscopic treatment alone in the prophylaxis of esophageal variceal rebleeding due to portal hypertension in schistosomiasis. MATERIAL AND METHODS: During a two-years period consecutive patients with schistosomiasis and a recent bleeding history were evaluated for prospective randomization. Absolute exclusion criteria were alcoholism or other liver diseases, whereas platelet count < 50,000/mm3, INR > 1.5 or presence of gastric varices were relative exclusion criteria. By random allocation 25 (group A) have received endoscopic sclerotherapy for esophageal varices alone and 22 (group B) combined treatment: esophagogastric devascularization with splenectomy followed by sclerotherapy. Interim analysis at 24 months has shown significant statistical differences between the groups and the randomization was halted. RESULTS: Mean age was 38.9 ± 15.4 years and 58.46% were male. Mean follow-up was 38.6 ± 20.1 months. Endoscopic comparison of the size of esophageal varices before and after treatment did not show significant differences among the two groups. Treatment efficacy was assessed by the rate of recurrent esophageal variceal bleeding, that was more common in group A- 9/25 patients (36.0%) vs. 2/22 (9.0%) in group B (p = 0.029). Other complications were odynophagia, dysphagia and esophageal ulcer in group A and ascites and portal vein thrombosis in the surgical group. CONCLUSION: In portal hypertension due to schistosomiasis, combined surgical and endoscopic treatment was more effective for the prevention of recurrent esophageal variceal bleeding.

Ratio of platelet count/spleen diameter predicted the presence of esophageal varices in patients with schistosomiasis liver cirrhosis.

AIM: To examine the platelet count (PC)/spleen diameter (SD) ratio in predicting the presence of esophageal varices (EV) in patients with schistosomiasis liver cirrhosis. MATERIALS AND METHODS: A total of 95 consecutive patients with EV induced by schistosomiasis liver cirrhosis were enrolled in this trial. A total of 141 schistosomiasis liver cirrhosis patients without EV were enrolled as controls. All patients were diagnosed by endoscopy. Demographic, laboratory, and Doppler ultrasound parameters were collected and analyzed. Binary logistic regression analysis was carried out to identify independent risk factors associated with EV occurrence. Receiver operating curves were generated to obtain the PC/SD ratio cutoff values for the optimal sensitivity and specificity with respect to EV. RESULTS: The accuracy was increased in diagnosing for EV using the ratio of PC/SD compared with the SD alone [area under the curve: 0.891 95% confidence interval (CI): 0.844-0.928 vs. 0.764 95% CI: 0.705-0.817; P<0.01]. The optimal cutoff value was 1004, with a 77.1% (95% CI: 67.9-84.8%) positive-predictive value and an 89.3% (95% CI: 82.7-94.0%) negative-predictive value. Using a cutoff of 1004, it was determined that 117/141 (83.0%) patients without EV could avoid undergoing unnecessary endoscopy, whereas 14/95 (14.7%) patients with EV would be misdiagnosed. In contrast, when the ratio was set at 909, the positive-predictive and negative-predictive values were 79.5% (95% CI: 69.5-87.4%) and 83.1% (95% CI: 76.1-88.8%), respectively. A ratio of 909 would accurately predict the absence of EV in 123/141 (87.2%) patients; however, 24/95 (25.3%) patients with EV would miss the necessary screening endoscopy. CONCLUSION: The ratio of PC/SD was a useful marker in predicting the presence of EV in patients with schistosomiasis liver cirrhosis.

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension.

AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension. METHODS: Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30(th) postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings. RESULTS: There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion. CONCLUSION: Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.

Improvement of schistosomal portal hypertensive colopathy after surgical treatment.

CONTEXT: Data on vascular alterations in patients with hepatosplenic schistosomiasis and portal hypertensive colopathy and changes in these after surgery to decrease portal hypertension are limited. OBJECTIVE: The purpose of this study was to analyse the alterations of portal hypertensive colopathy previously and 6-12 months after splenectomy and gastric devascularization. METHODS: Twelve patients with hepatosplenic schistosomiasis who also had upper gastrointestinal bleeding were studied prospectively. Their endoscopic findings before and 6-12 months after the surgery were analysed. In addition, mucosal biopsies from ascending colon, sigmoid colon and rectum at these time points were subjected to histological and histomorphometric assessment. It was used a control group due to lack of normal pattern of the histomorphometric measures of vessels in individuals without portal hypertension. The critical level of significance adopted in all tests was of a maximum probability error of 5%. RESULTS: Surgery did not lead to significant improvement in histological and endoscopic findings. However, on histomorphometry, there was a significant decrease in the area, diameter and thickness of the vessels in mucosa at all colonic sites. CONCLUSION: Surgery for decompression of schistosomal portal hypertension has a beneficial effect on the associated colopathy, being best indicated in patients with gastrointestinal bleeding and esophageal varices.

[Endoscopic variceal ligation in prevention from esophageal variceal hemorrhage of advanced schistosomiasis patients].

OBJECTIVE: To evaluate the effect of the endoscopic esophageal variceal ligation on the prevention from recurrence of esophageal varices and variceal hemorrhage. METHODS: Forty-two advanced schistosomiasis patients with variceal hemorrhage in the treatment group received the endoscopic esophageal variceal ligation, and 30 patients in the control group did not, and all of them had oral propranolol, spironolactone and 5 single-isosorbide dinitrate etc. in hospital for the same period and had these drugs for 3-6 months after discharge. The re-examinations of endoscopy were performed once 3 to 6 months. RESULTS: The time of follow-up was from 2 to 3 years and the average was 29 months. In the treatment group, the rate of recurrence of esophageal varices was 19.0% (8/42) and the average time was 30 months; the incidence of esophageal variceal bleeding was 11.9% (5/42) and 2 patients died. In the control group, the rate of recurrence of esophageal varices was 43.3% (13/30) and the average time was 18 months; the incidence of esophageal variceal bleeding was 36.7% (11/30) and 7 patients died. The therapeutic efficacy of the treatment group was much superior to that of the control group. CONCLUSION: The endoscopic esophageal variceal ligation is effective and safe, and can become one of the preferred methods in the prevention from variceal hemorrhage.

Evolutional profile of the esophageal varices after splenectomy associated with ligation of the left gastric vein and sclerotherapy in schistosomal portal hypertension.

BACKGROUND: The schistosomiasis affects 200 million people in 70 countries worldwide. It is estimated that 10% of those infected will develop hepatosplenic status and of these, 30% will progress to portal hypertension and esophagogastric varices, whose expression is through gastrointestinal bleeding with significant mortality in the first bleeding episode. Multiple surgical techniques have been developed to prevent re-bleeding. AIM: To evaluate the evolutional profile of esophageal varices after splenectomy + ligation of the left gastric vein associated with endoscopic sclerotherapy in schistosomal portal hypertension. METHODS: Prospective and observational study including schistosomiasis patients with previous history of upper digestive hemorrhage and underwent to splenectomy + ligation of the left gastric vein and sclerotherapy. The variables were: evolutional profile of esophageal varices before and after surgery and re-bleeding rate. RESULTS: The sample included 30 patients, 15 patients for each gender. The age ranged from 19 to 74 years (median = 43 years). There was a reduction in the degree, caliber and red spots in all patients (p< 0.05). The eradication of varices with sclerotherapy was achieved in 86.7% and with surgery alone in 15.4%. The mean follow-up was 28 months, ranging from two to 76 months. Were carried from one to seven sessions of sclerotherapy and the average was three per patient to eradicate varices. Four (13.3%) did not complete the follow-up. The re-bleeding rate was 16.7%. CONCLUSION: There was a reduction of the degree, caliber and red spots of esophageal varices in all patients.

Improvement of cchistosomal portal hypertensive colopathy after surgical treatment

Context Data on vascular alterations in patients with hepatosplenic schistosomiasis and portal hypertensive colopathy and changes in these after surgery to decrease portal hypertension are limited. Objective The purpose of this study was to analyse the alterations of portal hypertensive colopathy previously and 6-12 months after splenectomy and gastric devascularization. Methods Twelve patients with hepatosplenic schistosomiasis who also had upper gastrointestinal bleeding were studied prospectively. Their endoscopic findings before and 6-12 months after the surgery were analysed. In addition, mucosal biopsies from ascending colon, sigmoid colon and rectum at these time points were subjected to histological and histomorphometric assessment. It was used a control group due to lack of normal pattern of the histomorphometric measures of vessels in individuals without portal hypertension. The critical level of significance adopted in all tests was of a maximum probability error of 5%. Results Surgery did not lead to significant improvement in histological and endoscopic findings. However, on histomorphometry, there was a significant decrease in the area, diameter and thickness of the vessels in mucosa at all colonic sites. Conclusion Surgery for decompression of schistosomal portal hypertension has a beneficial effect on the associated colopathy, being best indicated in patients with gastrointestinal bleeding and esophageal varices. .

Contexto Dados em relação às alterações vasculares em pacientes com esquistossomose hepatoesplênica e colopatia hipertensiva portal e suas modificações após cirurgia para atenuação da hipertensão portal são restritos. Objetivo Analisar as alterações da colopatia hipertensiva portal antes e seis a 12 meses após a esplenectomia e desvascularização gástrica. Métodos Foram estudados prospectivamente 12 pacientes com esquistossomose hepatoesplênica e antecedente de hemorragia digestiva alta. Os achados colonoscópicos antes e após 6 a 12 meses após a cirurgia foram analisados. Nesses períodos, biopsias da mucosa do cólon ascendente, sigmóide e reto foram encaminhadas para análise histológica e histomorfométrica. Foi utilizado um grupo controle pela falta de padrão de normalidade das medidas histomorfométricas das vênulas do cólon e reto em indivíduos sem hipertensão portal. O nível de significância crítica adotado em todos os testes foi de probabilidade máxima de erro de 5%. Resultados Não foram encontradas diferenças significantes na intensidade das alterações endoscópicas e histológicas nos vasos da mucosa do cólon e reto após a cirurgia. Entretanto, houve decréscimo estatisticamente significante nas áreas, diâmetros e espessuras dos vasos estudados através da histomorfometria. Conclusão Cirurgia para descompressão da hipertensão portal esquistossomótica tem efeito benéfico na colopatia associada, sendo bem indicada nos pacientes com hemorragia digestive alta e varizes esofágicas. .

Perfil evolutivo das varizes esofágicas pós esplenectomia associada à ligadura da veia gástrica esquerda e escleroterapia na hipertensão portal esquistossomótica / Evolutional profile of the esophageal varices after splenectomy associated with ligation of the left gastric vein and sclerotherapy in schistosomal portal hypertension

RACIONAL: A esquistossomose mansônica afeta 200 milhões de pessoas em 70 países do mundo. Estima-se que 10% dos infectados evoluirão para a forma hepatoesplênica e, destes, 30% progredirão para hipertensão portal e varizes esofagogástricas, cuja expressão será através de hemorragia digestiva com mortalidade relevante no primeiro episódio hemorrágico. Múltiplas técnicas cirúrgicas foram desenvolvidas para prevenir o ressangramento. OBJETIVO: Avaliar o perfil evolutivo das varizes esofágicas após esplenectomia + ligadura da veia gástrica esquerda associada à escleroterapia endoscópica na hipertensão portal esquistossomótica. MÉTODO: Estudo prospectivo, observacional, de pacientes esquistossomóticos com antecedentes de hemorragia digestiva alta, submetidos à esplenectomia + ligadura da veia gástrica esquerda e escleroterapia. As variáveis estudadas foram perfil evolutivo das varizes esofágicas antes e após a operação e índice de recidiva hemorrágica. RESULTADOS: Amostra foi constituída por 30 pacientes distribuídos, quanto ao gênero, em 15 doentes para cada sexo. A idade variou de 19 a 74 anos (mediana=43 anos). Houve redução do grau, calibre e red spots em todos os pacientes (p<0,05). A erradicação das varizes com escleroterapia foi alcançada em 86,7% e exclusivamente com a operação em 15,4% dos pacientes.O tempo de seguimento médio foi de 28 meses, variando de dois a 76 meses. Foram realizadas de uma a sete sessões de escleroterapia e média de três por paciente para erradicar as varizes. Quatro pacientes (13,3%) não completaram o seguimento. A recidiva hemorrágica foi de 16,7%. CONCLUSÃO: Houve redução do grau, calibre e dos red spots das varizes esofágicas em todos os pacientes.

BACKGROUND: The schistosomiasis affects 200 million people in 70 countries worldwide. It is estimated that 10% of those infected will develop hepatosplenic status and of these, 30% will progress to portal hypertension and esophagogastric varices, whose expression is through gastrointestinal bleeding with significant mortality in the first bleeding episode. Multiple surgical techniques have been developed to prevent re-bleeding. AIM: To evaluate the evolutional profile of esophageal varices after splenectomy + ligation of the left gastric vein associated with endoscopic sclerotherapy in schistosomal portal hypertension. METHODS: Prospective and observational study including schistosomiasis patients with previous history of upper digestive hemorrhage and underwent to splenectomy + ligation of the left gastric vein and sclerotherapy. The variables were: evolutional profile of esophageal varices before and after surgery and re-bleeding rate. RESULTS: The sample included 30 patients, 15 patients for each gender. The age ranged from 19 to 74 years (median = 43 years). There was a reduction in the degree, caliber and red spots in all patients (p< 0.05). The eradication of varices with sclerotherapy was achieved in 86.7% and with surgery alone in 15.4%. The mean follow-up was 28 months, ranging from two to 76 months. Were carried from one to seven sessions of sclerotherapy and the average was three per patient to eradicate varices. Four (13.3%) did not complete the follow-up. The re-bleeding rate was 16.7%. CONCLUSION: There was a reduction of the degree, caliber and red spots of esophageal varices in all patients.

Splenic hydatic cyst as a cause of sinistral portal hypertension and isolated gastric variceal bleeding.

A 60-year-old male, living in a rural area, presented with recurrent upper gastrointestinal bleeding. Isolated fundal varices were seen on endoscopy. A lesion similar to cyst hydatid was seen in the spleen on abdominal ultrasonography and computerized tomography scanning. Also, sinistral (left-sided) portal hypertension and collaterals were seen due to the compression of the splenic vein by the cyst. Indirect hemagglutination antibody test for Echinococcus granulosus was positive. By screening, no other cyst was found in any other site of the body. The patient underwent open abdominal surgery, and the anterior wall of the cyst was resected partially; within it were multiple daughter cysts and hydatid fluid. After decontamination of the daughter cysts and hydatid fluid, germinative membrane omentoplasty was performed with a part of the omentum. However, the patient suffered from recurrent gastrointestinal bleeding postoperatively and he was re-evaluated. Later, splenectomy was performed in order to relieve left-sided portal hypertension. The patient did not experience further bleeding and gastric varices disappeared following splenectomy.

[Case report: Budd-Chiari syndrome and esophageal variceal bleeding due to alveolar echinococcosis]. / Olgu sunumu: alveoler ekinokoka bagli budd-chiari sendromu ve özofagus varis kanamasi

Alveolar echinococcosis of the liver is a rare larval cestode disease which is due to the intrahepatic growth of the tapeworm Echinococcus multilocularis. This cestode naturally evolves as a larval stage within cysts in the body of carnivores. Humans are accidental intermediate hosts and become infected, either by eating food contaminated with carnivore-originated eggs or by touching foxes. It behaves as malignant liver tumour and rarely causes Budd-Chiari syndrome and variceal bleeding. Budd-Chiari syndrome is a hepatic venous outflow tract obstruction and may be present abdominal pain, hepatomegaly and ascites. Parasitic cysts may cause compression and thrombosis of the hepatic venous outflow tract. It may present as portal hypertension and variceal upper gastrointestinal bleeding. We here in report a 47-year-old woman without a prior history of liver disease presented with Budd-Chiari syndrome and variceal bleeding due to Alveolar echinococcosis. The course of this rare disease is demonstrated by means of the most important laboratory, serologic and radiologic parameters.

Propranolol reduces variceal pressure and wall tension in schistosomiasis presinusoidal portal hypertension.

BACKGROUND AND AIM: Although prophylaxis with beta-blockers has been shown to decrease variceal pressure and wall tension in cirrhotic patients, this has not been demonstrated in non-cirrhotic portal hypertension caused by Schistosoma mansoni infection. METHODS: Thirteen patients without history of previous gastrointestinal bleeding were included. All of them had high-risk esophageal varices at endoscopy. An endoscopic gauge and a high-frequency endoscopic ultrasonography miniprobe were used to assess transmural variceal pressure and wall tension before and after achieving beta-blockade with propranolol. RESULTS: Baseline variceal pressure decreased from 13.3 +/- 3.5 to 8.2 +/- 2.0 mmHg (P < 0.0001) and wall tension from 500.2 +/- 279.8 to 274.0 +/- 108.3 mg.mm(-1). The overall effect of propranolol on decreasing variceal pressure and wall tension expressed in percentage change in relation to baseline values was 35.7 +/- 18.4% and 35.9 +/- 26.7%, respectively (P = 0.9993). CONCLUSION: Propranolol significantly reduced variceal pressure and wall tension in schistosomiasis.

Duplex sonography study in schistosomiasis portal hypertension: characterization of patients with and without a history of variceal bleeding.

BACKGROUND: Presinusoidal portal hypertension with frequent episodes of upper gastrointestinal variceal bleeding are hallmarks of hepatosplenic Mansons schistosomiasis; a clinical form that affects about 5% of Brazilians who are infected by Schistosoma mansoni. AIMS: To evaluate duplex sonography findings in patients with hepatosplenic Mansons schistosomiasis with and without upper gastrointestinal variceal hemorrhage. METHODS: A cross-sectional study was performed whereby 27 consecutive patients with hepatosplenic Mansons schistosomiasis were divided into two groups: group I (six men and six women; mean age 48.7 years) with a past history of bleeding and group II (four men and eight women; mean age 44.7 years) without a past history of upper gastrointestinal bleeding, underwent duplex sonography examination. All patients underwent the same upper gastrointestinal endoscopy and laboratory examinations. Those with signs of mixed chronic liver disease or portal vein thrombosis (three cases) were excluded. RESULTS: Group I showed significantly higher mean portal vein flow velocity than group II (26.36 cm/s vs 17.15 cm/sec). Although, as a whole it was not significant in all forms of collateral vessels (83% vs 100%), there was a significantly higher frequency of splenorenal collateral circulation type in group II compared with group I (17% vs 67%). The congestion index of the portal vein was significantly lower in group I than in group II (0.057 cm vs 0.073 cm/sec). CONCLUSION: Our duplex sonography findings in hepatosplenic Mansons schistosomiasis support the idea that schistosomotic portal hypertension is strongly influenced by overflow status, and that collateral circulation seems to play an important role in hemodynamic behavior.

Duplex sonography study in schistosomiasis portal hypertension: characterization of patients with and without a history of variceal bleeding

BACKGROUND: Presinusoidal portal hypertension with frequent episodes of upper gastrointestinal variceal bleeding are hallmarks of hepatosplenic Manson’s schistosomiasis; a clinical form that affects about 5 percent of Brazilians who are infected by Schistosoma mansoni. AIMS: To evaluate duplex sonography findings in patients with hepatosplenic Manson’s schistosomiasis with and without upper gastrointestinal variceal hemorrhage. METHODS: A cross-sectional study was performed whereby 27 consecutive patients with hepatosplenic Manson’s schistosomiasis were divided into two groups: group I (six men and six women; mean age 48.7 years) with a past history of bleeding and group II (four men and eight women; mean age 44.7 years) without a past history of upper gastrointestinal bleeding, underwent duplex sonography examination. All patients underwent the same upper gastrointestinal endoscopy and laboratory examinations. Those with signs of mixed chronic liver disease or portal vein thrombosis (three cases) were excluded. RESULTS: Group I showed significantly higher mean portal vein flow velocity than group II (26.36 cm/s vs 17.15 cm/sec). Although, as a whole it was not significant in all forms of collateral vessels (83 percent vs 100 percent), there was a significantly higher frequency of splenorenal collateral circulation type in group II compared with group I (17 percent vs 67 percent). The congestion index of the portal vein was significantly lower in group I than in group II (0.057 cm vs 0.073 cm/sec). CONCLUSION: Our duplex sonography findings in hepatosplenic Manson’s schistosomiasis support the idea that schistosomotic portal hypertension is strongly influenced by overflow status, and that collateral circulation seems to play an important role in hemodynamic behavior.

RACIONAL: Hipertensão portal pré-sinusoidal com freqüentes episódios de hemorragia digestiva alta são aspectos característicos da esquistossomose hepatoesplênica, forma clínica que acomete cerca de 5 por cento dos brasileiros com esquistossomose mansônica. OBJETIVO: Avaliar parâmetros ultra-sonográficos (modo-B e Doppler) nos hepatoesplênicos com e sem antecedentes de hemorragia digestiva. MÉTODOS: Estudo descritivo-transversal com 27 pacientes consecutivos com esquistossomose hepatoesplênica: 12 com passado de hemorragia digestiva alta (média de idade de 48,7 anos - grupo I) e 12 sem antecedentes de hemorragia digestiva alta (média de idade de 44,7 anos - grupo II). Todos foram igualmente submetidos a testes laboratoriais e endoscopia digestiva alta. Foram excluídos os doentes com hepatopatia mista e/ou trombose (três casos) ou transformação cavernosa da veia porta. RESULTADOS: O grupo I apresentou aumento significante da média de velocidade de fluxo na veia porta que o grupo II (26.36 cm/s vs 17.15 cm/s). Embora estatisticamente não significante considerando todos os tipos (100 por cento vs 83 por cento), houve maior freqüência de circulação colateral do tipo esplenorenal no grupo II (67 por cento vs 17 por cento), assim como o índice de congestão portal foi significantemente menor (0.057 vs 0.073 cm x sec) no grupo I que no grupo II. CONCLUSÃO: Os achados de dopplerfluxometria em esquistossomose hepatoesplênica sugerem que a hipertensão portal esquistossomótica é fortemente influenciada pelo hiperfluxo e a circulação colateral secundária exerce importante papel no equilíbrio hemodinâmico nestes pacientes.

Death related to albendazole-induced pancytopenia: case report and review.

Albendazole is a benzimidazole with wide spectrum coverage as an antiparasitic drug. Reported side effects have been minimal. We report the case of a patient who died with severe prolonged pancytopenia beginning during the third week of therapy for a pulmonary echinococcal cyst. This case was a 68-year-old man who presented with a large cystic lung mass. His medical history was significant for Child-Pugh class B cirrhosis. A prolonged course of albendazole was initiated. Two weeks later, the patient presented in septic shock with severe pancytopenia. The patient was initially resuscitated, but died after 10 days with no marrow recovery. Autopsy was consistent with albendazole-induced pancytopenia. This is the third human case of pancytopenia and the first death reported in relation to albendazole-induced pancytopenia. Neutropenia seems to be related more to higher dosage and longer duration of use. Albendazole sulfoxide peak dose and half life are significantly prolonged by liver disease and concomitant administration of certain drugs. The severity and duration of albendazole-induced pancytopenia in this case was likely related to the underlying liver disease. Frequent serial monitoring of blood counts and cessation of medication with any evidence of marrow toxicity in such patients is warranted.