Positive consequences of splenectomy for patients with schistosomiasis-induced variceal bleeding

BACKGROUND

Patients with hepatic schistosomiasis are at high risk of gastroesophageal variceal bleeding, which is highly torrential and life threatening. This study aimed to assess the effects of splenectomy on patients with schistosomiasis-induced variceal bleeding, especially those influences related to overall survival (OS) rate.

METHODS

From January 2005 to December 2018, 112 patients with schistosomiasis-induced varices were enrolled. In that period, all the patients with hepatic schistosomiasis who received endoscopic treatment for primary and secondary prophylaxis of gastroesophageal variceal bleeding were found eligible. The patients were divided into splenectomized group (n = 44, 39.3%) and control group (n = 68, 60.7%).

RESULTS

Multivariate regression analysis of OS showed that splenectomy, hepatic carcinoma, and times of endoscopic treatment were independent prognostic factors for OS. Kaplan-Meier analysis revealed that the 5-year OS rate was 82.7% in splenectomized group versus 53.2% in control group (P = 0.037). The rate of no recurrence of variceal bleeding during 5-year (56.8% vs. 47.7%, P = 0.449) indicated that there was no significant difference between the two groups. Patients who received splenectomy had increased risk of portal vein thrombosis (52.3% vs. 29.4%, P = 0.012) and decreased proportion of severe ascites (20.5% vs 50.0%, P = 0.002).

CONCLUSION

Splenectomy prior to endoscopic treatment provides a superior long-term survival for patients with schistosomiasis-induced variceal bleeding.

Toxocariasis Suspected of Having Infiltrated Directly from the Liver to the Lung through the Diaphragm

A 37-year-old woman presented to our hospital with mild abdominal pain experienced for 2 months and hepatic nodules in segments 3 and 8. Peripheral blood eosinophilia was observed, and toxocariasis was serologically diagnosed. Seventeen days after the first imaging evaluation, a new lesion was found in segment 9 of the right lung, which was contiguous through the diaphragm to the hepatic nodule in segment 8. After treatment with albendazole, the liver and lung nodules disappeared. We suspect that larvae had directly invaded the lung from the liver, through the diaphragm.

Surgical portosystemic shunts versus devascularisation procedures for prevention of variceal rebleeding in people with hepatosplenic schistosomiasis

BACKGROUND

Hepatosplenic schistosomiasis is an important cause of variceal bleeding in low-income countries. Randomised clinical trials have evaluated the outcomes of two categories of surgical interventions, shunts and devascularisation procedures, for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. The comparative overall benefits and harms of these two interventions are unclear.

OBJECTIVES

To assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, LILACS, reference lists of articles, and proceedings of relevant associations for trials that met the inclusion criteria (date of search 11 January 2018).

SELECTION CRITERIA

Randomised clinical trials comparing surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with GRADE and Trial Sequential Analysis. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We found two randomised clinical trials including 154 adult participants, aged between 18 years and 65 years, diagnosed with hepatosplenic schistosomiasis. One of the trials randomised participants to proximal splenorenal shunt versus distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy, and the other randomised participants to distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy. In both trials the diagnosis of hepatosplenic schistosomiasis was made based on clinical and biochemical assessments. The trials were conducted in Brazil and Egypt. Both trials were at high risk of bias.We are uncertain as to whether surgical portosystemic shunts improved all-cause mortality compared with oesophagogastric devascularisation with splenectomy due to imprecision in the trials (risk ratio (RR) 2.35, 95% confidence interval (CI) 0.55 to 9.92; participants = 154; studies = 2). We are uncertain whether serious adverse events differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 2.26, 95% CI 0.44 to 11.70; participants = 154; studies = 2). None of the trials reported on health-related quality of life. We are uncertain whether variceal rebleeding differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 0.39, 95% CI 0.13 to 1.23; participants = 154; studies = 2). We found evidence suggesting an increase in encephalopathy in the shunts group versus the devascularisation with splenectomy group (RR 7.51, 95% CI 1.45 to 38.89; participants = 154; studies = 2). We are uncertain whether ascites and re-interventions differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy. We computed Trial Sequential Analysis for all outcomes, but the trial sequential monitoring boundaries could not be drawn because of insufficient sample size and events. We downgraded the overall certainty of the body of evidence for all outcomes to very low due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

Given the very low certainty of the available body of evidence and the low number of clinical trials, we could not determine an overall benefit or harm of surgical portosystemic shunts compared with oesophagogastric devascularisation with splenectomy. Future randomised clinical trials should be designed with sufficient statistical power to assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisations with or without splenectomy and with or without oesophageal transection.

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.

Among the species of Schistosoma that infect humans Schistosoma mansoni is one of the most common causes of illness. In the areas where schistosomiasis mansoni is endemic, around 10% of infected individuals develop hepatosplenic schistosomiasis (HSS) with portal hypertension. Portal hypertension may promotes an imbalance in the hepatic production of vasoactive substances, which may act on the lungs promoting the formation of arteriovenous fistulas and pulmonary vascular dilation, a condition that is called a pulmonary shunt. When the pulmonary shunt is of higher grades, small thrombus or septic emboli that would normally be filtered through the pulmonary capillaries reach the left heart and the systemic circulation, which can lead to neurological complications. We found pulmonary shunts in patients with HSS and esophageal varices and we also found that patients with higher grades of pulmonary shunts presented with a significantly higher frequency of advanced periportal fibrosis and an enlarged splenic vein diameter. No neurological complications were observed. Our findings suggest that pulmonary shunts may be present in patients with HSS and esophageal varices. The abdominal ultrasound findings compatible with advanced HSS could be used as screening to investigate pulmonary shunt.

Hepatobiliary and pancreatic ascariasis

Hepatobiliary and pancreatic ascariasis (HPA) was described as a clinical entity from Kashmir, India in 1985. HPA is caused by invasion and migration of nematode, Ascaris lumbricoides, in to the biliary tract and pancreatic duct. Patients present with biliary colic, cholangitis, cholecystitis, hepatic abscesses and acute pancreatitis. Ascarides traverse the ducts repeatedly, get trapped and die, leading to formation of hepatolithiasis. HPA is ubiquitous in endemic regions and in Kashmir, one such region, HPA is the etiological factor for 36.7%, 23%, 14.5% and 12.5% of all biliary diseases, acute pancreatitis, liver abscesses and biliary lithiasis respectively. Ultrasonography is an excellent diagnostic tool in visualizing worms in gut lumen and ductal system. The rational treatment for HPA is to give appropriate treatment for clinical syndromes along with effective anthelmintic therapy. Endotherapy in HPA is indicated if patients continue to have symptoms on medical therapy or when worms do not move out of ductal lumen by 3 wk or die within the ducts. The worms can be removed from the ductal system in most of the patients and such patients get regression of symptoms of hepatobiliary and pancreatic disease.

HEPATOPROTECTIVE ROLE OF PLACENTA HYDROLISAT - LAENNEC IN THE TREATMENT OF PATIENTS WITH VIRAL AND PARASITIC LIVER DISEASES

The article presents data on non-alcoholic fatty liver disease and chronic viral hepatitis C in combination with opisthorchosis invasion. With the system approach considers the specific features of the clinical, laboratory and functional data in patients with combined pathology. Observed frequency of the pain, asthenic and allergic cholestatic syndromes, the latter as part of the triad Paltsev. The high efficiency of the placenta hydrolisat - laennec, as means of pathogenetic therapy.

Radiofrequency ablation for treatment of hypersplenism: A feasible therapeutic option

We present a case of a patient with hypersplenism secondary to portal hypertension due to hepato-splenic schistosomiasis, which was accompanied by severe and refractory thrombocytopenia. We performed spleen ablation and measured the total spleen and ablated volumes with contrast-enhanced computed tomography and volumetry. No major complications occurred, thrombocytopenia was resolved, and platelet levels remained stable, which allowed for early treatment of the patient’s underlying disease. Previous work has shown that splenic radiofrequency ablation is an attractive alternative treatment for hypersplenism induced by liver cirrhosis. We aimed to contribute to the currently sparse literature evaluating the role of radiofrequency ablation (RFA) in the management of hypersplenism. We conclude that splenic RFA appears to be a viable and promising option for the treatment of hypersplenism.

Enhanced Neutrophil Apoptosis in Neutropenic Patients with Hepatosplenic Schistosomiasis: Evidence of Serum Fas Ligand

Enhanced neutrophil apoptosis has been reported in neutropenic hepatosplenic schistosomiasis. The shortening of neutrophil survival via apoptosis may explain the neutropenia that occur in these patients. However, the regulation of neutrophil apoptosis in hepatosplenic schistosomiasis has not been clearly defined. Neutrophils harvested from neutropenic patients with hepatosplenic (HS) schistosomiasis, (n=25), non-neutropenic patients with hepatointestinal (HI) schistosomiasis (n=10), and age-/gender-matched healthy control subjects (n=10) were incubated with autologous serum. Neutrophils apoptosis was quantified by flow cytometry through determination of propidium iodide nuclear staining and confirmed by DNA gel electrophoresis at 0 (i.e. fresh neutrophils), 4 and 24 h culture. Neutrophils from healthy subjects were also incubated with either 10% heterologous normal or neutropenic serum, with and without anti-Fas ligand antibody. Fas expression was assessed in fresh neutrophils using flow cytometry. Compared with normal healthy neutrophils, and HI neutrophils, neutropenic neutrophils demonstrated greater apoptosis in the presence of autologous serum (P<0.01, 0.05, respectively). Furthermore, compared with normal neutrophils exposed to heterologous normal serum, those exposed to heterologous neutropenic serum exhibited higher apoptosis rates ( P<0.01). Moreover, anti-Fas L antibody attenuated the neutropenic serum-induced neutrophil apoptosis in normal neutrophils. Fas expression was significantly higher in the neutropenic group when compared to both HI and normal healthy controls (P<0.05). In addition, Fas expression by neutrophils was paralleled by high neutrophil apoptosis. On the other hand, neutrophil apoptosis was not correlated to the size of spleen in neutropenic group. In conclusion, the rate of neutrophil apoptosis is accelerated in patients with neutropenic hepatosplenic schistosomiasisis. These findings suggest that the enhanced neutrophil apoptosis that occurs in neutropenic HS patients is triggered by a serum factor, which is mostly a Fas ligand.

Parasitic liver disease in travelers

Liver disease is an important source of morbidity among ill returning travelers. Jaundice is one of the most common and obvious symptoms of liver disease, the differential diagnosis of which is extensive, especially in travelers. Jaundice in travelers can arise from both infectious and noninfectious causes. We herein summarize the most common parasitic etiologies that may lead to jaundice in the returned traveler, visitors of friends and relatives, or new immigrants, and describe the etiology, epidemiology, and pathogenesis of clinical features of each.

[Research progress on the relationship between three kinds of liver fluke infections and cholangiocarcinoma]

Liver fluke disease caused by Clonorchis sinensis, Opisthorchis viverrini and O. felineus is a food-borne zoonotic parasitic disease and widely prevalent in Asia. The definitive hosts including human beings get the infection by ingestion of raw or undercooked fish or shrimp infested with metacercariae. Long-term or severe infection of the flukes can lead to dysfunction of the liver, such as cholelithiasis, cholecystitis, and so on. Researches indicated that there is an etiology relation between the fluke infection and cholangiocarcinoma. This paper reviews the relationship and possible mechanisms of the liver fluke-associated cholangiocarcinoma

[Two cases of pulmonary amebiasis]

CASE 1: A 74-year-old man having a week's fever and diagnosed with a liver abscess was treated with several antibiotics and percutaneous liver drainage. His respiration gradually worsened and chest computed tomography (CT) showed right pleural effusion and a left-lung mass. Percutaneous fine needle aspiration of the pulmonary mass detected Entamoeba histolytica. CASE 2: A 44-year old, zoo office worker admitted for fever and right chest pain was found in CT to have right pleural effusion and a mass with a liver abscess necessitating abscess drainage. Injected contrast medium detected a fistula connected to the right. Following surgical drainage, E. histolytica was detected from the resected lung. Both cases responded well to metronidazole.

Intrahepatic Cholangiocarcinoma with Old Infestation of Schistosoma japonicum: Report of a Case

We report a rare case of intrahepatic cholangiocarcinoma associated with old infestation of Schistosoma japonicum. The patient was a 76-year-old Japanese man who had lived his childhood in an endemic area of this parasite. He presented with jaundice and computed tomography showed a 4-cm, hypodense tumor in segment VIII of the liver. Microscopically, the resected mass was composed of well-differentiated adenocarcinoma cells. Fibrosis and inflammation were seen around the dilated peripheral portal veins embolized with dead S. japonicum eggs. Our search of the literature found only one other case of cholangiocarcinoma coincident with S. japonicum, suggesting that it is not a risk factor for cholangiocarcinoma, although the inflammation and fibrosis caused by the S. japonicum eggshells may predispose to carcinogenesis. However, there is no evidence supporting this hypothesis. More data are necessary to evaluate the differences in clinicopathological findings between cholangiocarcinoma concomitant with S. japonicum and the usual type of cholangiocarcinoma.

Prevalence and common genotypes of HCV infection in Sudanese patients with hepatosplenic schistosomiasis

A cross-sectional hospital based study was carried out at the National Center for Gastrointestinal and Liver Disease in Khartoum, Sudan to determine the prevalence, common genotypes and risk factors for hepatitis C virus infection in Sudanese patients with hepatosplenic schistosomiasis. A total of 176 patients with hepatosplenic schistosomiasis were tested for HCV antibodies and 4.5% of the samples were reactive. PCR was positive in 2.3% of cases and genotype 4 was the major genotype isolated with subtypes 4, 4e, and 4c/4d. It is concluded that HCV was of low seroprevalence in the study population and that parenteral antischistosomal therapy was not a significant risk factor in transmission of infection in the Sudan.

[Place of surgery in the prevention of recurrences of digestive haemorrhages at the patients presenting a portal hypertension due to Schistosoma mekongi]

In spite of a decrease of the prevalence of hepato-splenic schistosomiasis thanks to mass-treatment with Praziquentel from December 1994 till now (CNM - MSF - WHO - Health Provincial Director) of target-populations in Kratie Province, severe cases of portal hypertension are not exceptional (digestive bleedings, after rupture of oesophageal varices). Out of 106 cases of portal hypertension: alI patients have had clinical survey biological tests (liver function, haematology and serology). Most of them had ultrasonography (Aloka 55,500 Sound 3.5 MHz). Nearly half of the group of 153 patients has never had bleedings. More than 45 were not eligible for surgery for different reasons: severe anaemia (few possibilities for massive transfusion in Cambodia), serology (S. mekongi) + but also hepatitis B or C +, hepatic biological exams (hepatic insufficiency). So we decided for eleven of them to use a surgical decompression procedure in order to decrease portal hypertension and the porto-systemic gradient. After defining portal hypertension, specific clinical features of portal hypertension (secondary to Schistosomiasis) the authors report eleven cases who were operated on (2000-2002): 4 mesenterico-cave shunt with interposition of a graft (Drapanas' procedure), 1 operation of HASSAB (after splenectomy), 6 proximal spleno-renal diversion (after splenectomy). After studying the results of the eleven patients, discussion with other surgical procedures, particularly endoscopic procedures is developed. The follow-up of these patients during at least five years is mandatory to give guidelines for post-systemic shunts to prevent rebleeding (near other methods). Treated too late, schistosomiasis has no benefit from drugs (Praziquentel). After a mean period of forty two months, the following results are: mortality: one case (10 days after operation): hepatic insufficiency (group Child B/C). morbidity: one occlusion of the small intestine, after 4 months (debridment), operated at the Provincial hospital of Kratie (case no1). Ten patients resume work, family and social life between Kratie and Sambor in 2002. No rebleeding. No encephalopathy.

[Histology of liver lesions due to Schistosoma mekongi. About six cases with severe portal hypertension operated in Cambodia]

Schistosomiasis mekongi was shown to be endemic, along the Mekong River, in northern Cambodia, affecting many patients with portal hypertension. Surgical procedures were proposed to some patients with digestive haemorrhage history to avoid fatal recurrence. The aim of our study was to evaluate the intensity of the liver fibrosis among these patients. During surgical treatment, liver biopsies were collected, fixed in Bouin or in formalin and processed at the Institut Pasteur of Cambodia. Sections were stained by H&E, Masson's trichrome, PAS, Ziehl-Neelsen's method and Congo Red. A total of six biopsies from patients aged 16-36 were analysed. There was complete disorganization of hepatic architecture with fibrous enlargement of portal tracts and some portal-portal bridging fibrosis, but there was no cirrhosis. In portal areas, there was blood vessel congestion and thrombosis with inflammation. Bile ducts were normal. In the parenchyma, congestion of sinusoidal capillaries was combined with focal mononuclear inflammatory infiltrate. There was no steatosis, no necrosis, no cholestasis, no iron accumulation and no amyloidosis. Numerous eggs of Schistosoma mekongi were observed in five cases, mostly in fibrous areas and more rarely in the parenchyma. Eggs were round or oval, measuring 60 x 40 microns with an acid-fast thin hyaline wall. Some eggs were surrounded by epithelioid and giant cell reaction. In conclusion, our findings illustrated a surprisingly high degree of fibrosis among young adults which contrasts with other schistosomiasis.

Assessment of portal hemodynamics by Doppler ultrasound and of liver morphology in the hepatosplenic and hepatointestinal forms of schistosomiasis mansoni

The aim of this study was to compare portal and splenic blood flows and the liver morphology in hepatosplenic (HS) and hepatointestinal (HI) schistosomiasis. Doppler ultrasound measurements were performed in 48 adult patients with schistosomiasis, according to the criteria of the World Health Organization, and compared with those performed in 20 healthy controls. Portal flow was significantly higher (P < 0.0001) in both HS and HI (2481 +/- 1467 and 2159 +/- 1446 ml/min, respectively) than in normal individuals (842 +/- 322 ml/min). There was no difference in splenic blood flow (822 +/- 685 and 458 +/- 292 ml/min, respectively) between HS and HI, but these values were significantly higher than those of normal controls (243 +/- 94 ml/min). Portal and splenic overflow are found in both the HS and the HI forms of schistosomiasis.

Linfomas em pacientes com a forma hepatoesplênica da esquistossomose mansônica

RACIONAL: Cada vez mais se estabelece a correlação entre agentes infecciosos e doenças linfoproliferativas, sobretudo vírus e bactérias, através da ativação de linfócitos. OBJETIVO: Descrever 6 novos casos, de uma série de 254 pacientes (2,36%) com esquistossomose mansônica na forma hepatoesplênica. CASUÍSTICA E MÉTODOS: São descritos 6 pacientes, dentre os 254 portadores de esquistossomose mansônica na forma hepatoesplênica, acompanhados nos últimos 13 anos no Serviço de Cirurgia Geral do Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE. RESULTADOS: Todos os seis casos ocorreram em mulheres. Os exames histopatológicos evidenciaram dois casos de linfomas de zona marginal esplênica, um de linfoma de grandes células com imunoblastos, um de linfoma difuso de grandes células, um de linfoma maligno de grandes células não clivadas, e um outro caso de doença de Hodgkin. Metade das seis pacientes evoluiu para o óbito entre 4 a 15 meses após o diagnóstico. As outras três persistem em acompanhamento no Serviço de Oncologia da mesma instituição. CONCLUSÃO: A incidência de linfoma nos 254 pacientes acompanhados foi de 2,36%. Pretende-se chamar a atenção para a ocorrência de linfomas nos baços de pacientes com esquistossomose mansônica, na forma hepatoesplênica.

Liver disease in Egypt: hepatitis C superseded schistosomiasis as a result of iatrogenic and biological factors

In Egypt, schistosomiasis was traditionally the most important public health problem and infection with Schistosoma mansoni the major cause of liver disease. From the 1950s until the 1980s, the Egyptian Ministry of Health (MOH) undertook large control campaigns using intravenous tartar emetic, the standard treatment for schistosomiasis, as community-wide therapy. This commendable effort to control a major health problem unfortunately established a very large reservoir of hepatitis C virus (HCV) in the country. By the mid-1980s, the effective oral drug, praziquantel, replaced tartar emetic a s treatment f o r schistosomiasis in the entire country. This both reduced schistosomal transmission and disease and interrupted the "occult" HCV epidemic. It was evident when diagnostic serology became available in the 1990s that HCV had replaced schistosomiasis as the predominant cause of chronic liver disease. Epidemiological studies reported a high prevalence and incidence of HCV, particutarly within families in rural areas endemic for schistosomiasis. Clinical studies showed 70% to 90% of patients with chronic hepatitis, cirrhosis, or hepatocellular carcinoma had HCV infections. Co-infections with schistosomiasis caused more severe liver disease than infection with HCV alone. Schistosomiasis was reported to cause an imbalance in HCV-specific T-cell responses leading to increased viral load, a higher probability of HCV chronicity, and more rapid progression of complications in co-infected persons. As complications of HCV usually occur after 20 years of infection, the peak impact of the Egyptian outbreak has not yet occurred. Efforts have been initiated by the Egyptian MOH to prevent new infections and complications of HCV in the estimated 6 million infected persons.

Hyperéosinophilie parasitaire

Blood hypereosinophilia (eosinophilia count of more than 500 per microliter, i.e., 0.5.10(9)/L) is a laboratory finding that requires a careful workup. Review of the patient's medical history and clinical examination can usually rule out non-parasitic causes. Parasitic infections must be sought by examination of stool, urine, and blood examinations and by serological tests. These examinations, with special techniques for cosmopolitan and tropical parasites and for digestive or tissular parasites, must be repeated. Improvement of blood eosinophilia and of the serum antibody titers is one criterion of treatment effectiveness.

Postoperative portal vein thrombosis in patients with hepatosplenic mansonic schistosomiasis: relationship with intraoperative portal pressure and flow. A prospective study

BACKGROUND/AIMS

Portal vein thrombosis is a frequent postoperative complication after esophagogastric devascularization with splenectomy. The aim of this study was to analyze biochemical, hematological, coagulation blood tests and intraoperative portal vein hemodynamics after surgical treatment of hepatosplenic Mansonic schistosomal portal hypertension.

METHODOLOGY

Forty patients with hepatosplenic schistosomiasis with indication for surgical treatment were prospectively studied. All patients underwent routine pre- and postoperative biochemical, hematologic, coagulation blood tests and intraoperative portal hemodynamic evaluation (portal pressure and portal flow) before and after esophagogastric devascularization and splenectomy using a 4-F thermodilution catheter introduced inside the portal vein.

RESULTS

Portal vein thrombosis, diagnosed by routine postoperative Doppler ultrasonography was found in 22 patients (55%). It was partial in nineteen and total in three. In patients with postoperative portal thrombosis, we observed a reduction in portal flow of 971 +/- 592 mL/min (42 +/- 16%) at the end of the surgery, while this reduction was of 720 +/- 644mL/ min (33 +/- 30%) in those with postoperative pervious portal vein (p = 0.245). The decrease in portal pressure was the same in both groups: 7.2 +/- 3.0 mmHg (23 +/- 10%) and 7.6 +/- 3.8 mmHg (27 +/- 14%) with and without thrombosis respectively (p=0.759). There was also no significant difference between patients with and without portal vein thrombosis regarding pre- and postoperative hemoglobin level or platelet levels, coagulation tests, portal vein diameter and spleen's weight.

CONCLUSIONS

Portal vein thrombosis was observed in 55% of the patients but this complication did not show any correlation with the decrease in portal flow or pressure or with biochemical, hematologic, coagulation blood tests, portal vein diameter or spleen's weight.

Schistosomal hepatic fibrosis and the interferon gamma receptor: a linkage analysis using single-nucleotide polymorphic markers

A minority of individuals infected with the parasite Schistosoma mansoni develops hepatic fibrosis. HLA studies in Egypt and a candidate gene search in a Sudanese population indicate that the host's genetics contribute to disease susceptibility. In an Egyptian community, 32.7% of individuals 11 years and older had significant fibrosis by WHO ultrasound criteria. Linkage to 10 candidate genes was tested using 89 affected sibling pairs from 40 pedigrees in this community. The candidates included genes that initiate fibrosis, participate in collagen synthesis, or control collagen degradation. Two to four single-nucleotide polymorphisms (SNPs) were genotyped per locus, and 188 individuals were genotyped at 48 markers. Model-free modified Haseman-Elston analysis identified linkage to a SNP in the interferon gamma receptor locus (P=0.000001). There was also weak evidence for linkage to the interleukin 13-4 region and tissue growth factor beta 1.

An unusual cause of recurrent biliary colics

Hepato-biliary ascariasis is a rare condition in non-endemic areas; however, it should always be taken into account in patients with recurrent biliary colics and/or cholangitis, since these are among the most frequent modes of clinical presentation. We report a case of a young woman suffering from recurrent biliary colics in whom a diagnosis of biliary ascariasis was made. Endoscopic retrograde cholangiopancreatography with sphincterotomy and endoscopic extraction of the worm, using a Dormia basket, proved to be a safe and effective procedure for removing the living Ascaris from the biliary tree and relieving symptoms. In the era of worldwide travels, physicians in Western countries should be more aware of this infection especially in patients with biliary symptoms who have travelled to endemic areas or immigrant from endemic countries.

Hypertensive portal colopathy in schistosomiasis mansoni: proposal for a classification

Portal hypertension is a frequent complication of chronic liver disease, detected not only in schistosomiasis, but also in cirrhosis of any etiology. Vascular alterations in the colonic mucosa are a potential source for acute or chronic bleeding and have been observed in patients with portal hypertension. The purpose of this prospective study was to describe and propose a classification for the vascular alterations of portal hypertension in the colonic mucosa among patients with hepatosplenic schistosomiasis mansoni. One or more alterations of portal colopathy were observed in all patients and they were classified according to their intensity, obeying the classification proposed by the authors. Portal colopathy is an important finding in hepatosplenic schistosomiasis and might be the cause of lower gastrointestinal bleeding in patients with severe portal hypertension.

Portal hyperflow in patients with hepatosplenic mansonic schistosomiasis

PURPOSE

The purpose of this study was to assess portal hemodynamics in patients with portal hypertension due to hepatosplenic schistosomiasis as well as to assess the contribution of splanchnic hyperflow to the pathophysiology of the portal hypertension.

METHODS

Sixteen patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophageal varices rupture underwent elective esophagogastric devascularization and splenectomy and were prospectively studied. All patients underwent intraoperative invasive hemodynamic portal monitoring with a 4F-thermodilution catheter. The intraoperative portal hemodynamic assessment was conducted after laparotomy (initial) and after esophagogastric devascularization (final).

RESULTS

The initial portal pressure was elevated (mean 28.5 +/- 4.5 mm Hg), and a significant drop of 25% was observed at the end of the surgery (21.9 +/- 4.9 mm Hg). The initial portal flow was elevated (mean 1766.9 +/- 686.6 mL/min). A significant fall (42%) occurred at the end of the surgical procedure (1025.62 +/- 338.7 mL/min). Fourteen patients (87.5%) presented a portal flow of more than 1200 mL/min, and in 5 cases, values greater than 2000 mL/min were observed.

CONCLUSIONS

Esophagogastric devascularization and splenectomy promote a significant reduction of the elevated portal pressure and flow in schistosomal portal hypertension. These data favor the hypothesis of portal hyperflow in the physiopathology of portal hypertension of schistosomiasis.

Mechanism of impairment of cytochrome P450-dependent metabolism in hamster liver during leishmaniasis

The mechanism of impairment of cytochrome P450 (P450)-dependent metabolism in hamster liver during leishmaniasis is reported. A significant decrease in the level of P450 was observed on the 20th day of infection when the parasite load in the liver was maximum. The decrease in P450 level was accompanied by a significant increase in the level of marker enzymes of liver and degeneration of liver tissue. The impairment was isozyme-specific and concomitant with the induction of nitric oxide synthase. The results of in vitro experiments with generated nitric oxide and with scavengers demonstrated that the impairment is mediated by NO. Treatment of the infected animals with a combination therapy showed reduction in parasite load, reversal of P450 impairment, and recovery of liver enzymes and tissue close to normal.

Hepatocyte dysfunction and hepatic encephalopathy in Plasmodium falciparum malaria

BACKGROUND

According to the WHO, signs of hepatic dysfunction are unusual, and hepatic encephalopathy is never seen in malaria. However, in recent years, isolated cases have been reported from different parts of world.

AIM

To identify the evidence for hepatocyte dysfunction and/or encephalopathy in jaundiced patients with falciparum malaria.

DESIGN

Prospective observational study.

METHODS

We studied 86 adult patients of both sexes who had malaria with jaundice (serum bilirubin > 3 mg%). The main outcome measures were: flapping tremor, deranged psychometric test, level of consciousness, serum bilirubin level, serum aspartate transaminase (AST) and alanine transaminase (ALT) levels, blood ammonia level, viral markers for hepatitis, ultrasonography of liver and gall bladder and electroencephalography (EEG).

RESULTS

The range of serum bilirubin was 3-48.2 mg% (mean +/- SD 10.44 +/- 8.71 mg%). The ranges of AST and ALT levels were 40-1120 IU/l (294.47 +/- 250.67 IU/l) and 40-1245 IU/l (371.12 +/- 296.76 IU/l), respectively. Evidence of hepatic encephalopathy was seen in 15 patients. Asterexis was observed in 9 patients, impaired psychometric tests in 12 and altered mental state in 13. Arterial blood ammonia level was 120-427 meq/l (310 +/- 98.39 meq/l). EEG findings included presence of large bilateral synchronous slow waves, pseudo burst suppression and triphasic waves. Four patients died due to multiple organ dysfunction; the others made rapid recoveries.

DISCUSSION

There is strong evidence of hepatocyte dysfunction and hepatic encephalopathy in some of these patients, with no obvious non-malarial explanation. Current guidelines may need to be revised.

[Leishmaniasis in a patient with liver cirrhosis]

We present a 35 years-old man with fever related leishmania infection as the first complication of a previously undiagnosed cirrhosis. Diagnosis of leishmaniasis is often complicated. Clinical and therapeutical aspects are commented.

Assessment of splenic functions in patients with hepato-splenic schistosomiasis using non-invasive techniques

This study was carried out on forty cases, classified into 3 groups; group I: 10 healthy controls subjects, group II: 20 patients with hepatosplenic schistosomiasis and group III: 10 bilharzial patients who underwent total splenectomy. All cases were subjected to clinical examination, abdominal ultrasonography, rectal snips and laboratory investigations which included: stool and urine analysis, complete blood picture, IHAT for bilharziasis, liver function tests, viral markers, estimaton of T-lymphocyte subpopulations (CD(+)3, CD(+)4, & CD(+)8) by flow Cytometry, silver stained blood films to detect argyrophilic inclusions and 99mTc sulphur colloid splenic scan which was applied to group II only. The present results revealed varying degrees of hypersplenism (anaemia, leukopenia & thrombocytopenia) in GII. Seventy percent of this group was positive for HbsAg, HCV or both in association with schistosomiasis. Abnormal red blood cells (acanthocytes, target cells, pitted cells & normoblasts) and inclusion bodies (Howell Jolly bodies, argyrophilic inclusions & pappenhiemer bodies) were detected with different values in GIII. CD(+)4 cells were moderately reduced in GII while they were markedly decreased in GIII. CD(+)8 cells were elevated in GII and returned nearly to the normal values in GIII with decrease in number of total T-lymphocytes. Most patients of GII showed marked squestration of 99mTc labelled R.B.Cs. in the spleen with reversed hepatic/splenic ratio (normally hepatic/splenic ratio is over two). IHAT showed positivity in 90% of patients in GII while it was 50% in GIII. Although total splenectomy improved the haematological pattern and the cytopenias, which are prominent features in hepatosplenic schistosomiasis, yet the immunological profile was still altered. So, it is recommended to perform segmental splenectomy with retention of a normal mass of functioning residual spleen to preserve more immunological function and to protect against life-threatening occurrence of post-splenectomy sepsis.

Cholangiocarcinoma: recent progress. Part 1: epidemiology and etiology

An attempt is made in this review to update the reader on recent developments and progress in the study of cholangiocarcinoma: a major primary carcinoma of the liver with a very poor prognosis. Knowledge of the cell biology and physiological functions of the cholangiocyte has recently so progressed that our understanding of cholangiocarcinogenetic mechanism is expected to follow. The first part of the review deals with semantic problems, temporal changes in the incidence of cholangiocarcinoma and geographic differences in epidemiology, etiologic factors (particularly opistorchiasis in Thailand and hepatolithiasis in the Far East), and discusses a recently disclosed role of hepatitis C virus infection (30% of cholangiocarcinoma patients have antibodies against hepatitis C virus in Japan).

Treatment by splenectomy of a portal vein aneurysm in hepatosplenic schistosomiasis

Portal vein aneurysm is a rare medical entity that can be caused by chronic hepatic diseases with portal hypertension. We describe a 45-year-old man with variceal bleeding from hepatosplenic schistosomiasis and an incidentally found intrahepatic aneurysm. Diagnosis was confirmed with non-invasive imaging exams, arteriography and liver biopsy. Following splenectomy, the aneurysm diameter decreased substantially.

Liver fluke-associated cholangiocarcinoma

BACKGROUND

Infection with liver flukes has been reported to be associated with bile duct malignancy.

METHODS

The review is based on a literature search (Medline) and, in some cases, direct contact with authors or principal investigators.

RESULTS

A large body of evidence indicates that Opisthorchis viverrini is a definite cause of human cholangiocarcinoma, whereas Clonorchis sinensis is a probable cause. The evidence regarding Opisthorchis felineus is insufficient to assess its role in carcinogenesis. Possible mechanisms of carcinogenesis include chronic irritation, nitric oxide formation, intrinsic nitrosation and activation of drug-metabolizing enzymes. Early detection of bile duct malignancy is difficult and not clinically available at present, although cholangiocarcinoma-associated soluble antigen has been reported in an experimental study to be a useful early marker of cancer development. Long-term survival after surgical treatment of liver fluke-associated cancer is similar to that reported in patients without liver fluke infestation.

CONCLUSION

Liver fluke-associated cholangiocarcinoma is still a health problem in developing countries. Mechanisms of carcinogenesis should be explored further in order to reduce the impact of this disease.

Right hepatic segmentectomy for the treatment of intrahepatic biliary stones due to ascaris lumbricoides: report of a case

We report herein the case of a 46-year-old woman investigated for recurrent acute cholangitis. Ultrasound, endoscopic retrograde cholangiopancreatography, and computed tomography scan revealed dilatation and multiple images suggestive of intrahepatic biliary stones in the ducts that drained segments V and VI of the liver. Endoscopic treatment was attempted unsuccessfully, and based on the severity of the last crisis of cholangitis a laparotomy was performed. A right hepatic lobectomy including segments V and VI was carried out without any complications, resulting in complete relief of symptoms. Pathological examination of the liver demonstrated the presence of worm nests in the liver parenchyma with chronic granulomatous lesions.

Comparative study of portal hypertensive gastropathy in schistosomiasis and hepatic cirrhosis

BACKGROUND AND STUDY AIMS

Portal hypertensive gastropathy (PHG) is a common finding in chronic liver disease, but it has not been evaluated in hepatosplenic schistosomiasis, a significant cause of noncirrhotic portal hypertension worldwide. Our study was aimed at comparing cirrhosis with hepatosplenic schistosomiasis with regard to the endoscopic and histological findings of PHG.

PATIENTS AND METHODS

We included 43 patients with a history of upper digestive hemorrhage, 22 with cirrhosis and 21 with schistosomiasis, without previous surgical or endoscopic treatment. Upper digestive endoscopies with macrobiopsies of the gastric body were prospectively performed in all cases.

RESULTS

The endoscopic signs of PHG were more prevalent in cirrhosis than schistosomiasis (81.8 % vs. 33.3 %; P < 0.05), and the mosaic pattern was the main finding. Histological abnormalities were evenly distributed.

CONCLUSIONS

In agreement with other investigations, this study shows a lower prevalence of endoscopic findings of portal hypertensive gastropathy in noncirrhotic diseases. This difference cannot be explained by the underlying microscopic alterations, which were similar in both groups, suggesting that other factors must play a role in its pathogenesis.

Relationship between hepatitis C virus infection and schistosomal liver disease: not simply an additive effect

BACKGROUND

To study the association, clinical significance, and impact of hepatitis C virus (HCV) co-infection in patients with schistosomal liver disease (SLD).

METHODS

A total of 240 patients with chronic liver diseases encountered consecutively were enrolled in the study. Fifty volunteer blood donors were enrolled as controls. HCV antibody determination (enzyme-linked immunosorbent assay), qualitative and quantitative HCV RNA assay (reverse transcriptase polymerase chain reaction), and HCV genotyping (line probe assay) were performed.

RESULTS

Twenty-eight patients had SLD alone, 60 had both SLD and chronic hepatitis C (CH-C), 120 had CH-C alone, and 32 had other liver diseases. The positivity rates for HCV antibody (76% vs 20%; P < 0.001) and HCV RNA (59% vs 10%; P < 0.001) were significantly higher in the patients with SLD (n = 88) than in the volunteer blood donors (n = 50). Complications of liver cirrhosis were more common in patients with concomitant SLD and CH-C than in those with either SLD or CH-C alone. The mean levels of alanine aminotransferase (77 +/- 42 vs 93 +/- 55 IU/l; P = 0.049) and HCV RNA concentrations (3.5 +/- 1.0 vs 4.2 +/- 1.0 log copy/ml; P < 0.001) were significantly lower in patients with concomitant SLD and CH-C than in those with CH-C alone. HCV genotype 4 predominated in both these groups (93% and 98%).

CONCLUSIONS

SLD in Egypt is significantly associated with HCV infection, with the predominance of genotype 4. Concurrent HCV infection and SLD result in much more severe liver disease than that seen with either disease alone. However, the activity of HCV infection seems to be partially suppressed in patients with SLD.

Pathogenesis of hepatic septal fibrosis associated with Capillaria hepatica infection of rats

Septal fibrosis is a common form of hepatic fibrosis, but its etiology and pathogenesis are poorly understood. Rats infected with the helminth Capillaria hepatica constitute a good experimental model of such fibrosis. To investigate the pathogenetic contribution of the several parasitic factors involved, the following procedures were performed in rats: a) regarding the role of eggs, these were isolated and injected either into the peritoneal cavity or directly into the liver parenchyma; b) for worms alone, 15-day-old infection was treated with mebendazole, killing the parasites before oviposition started; c) for both eggs and worms, rats at the 30th day of infection were treated with either mebendazole or ivermectin. Eggs only originated focal fibrosis from cicatricial granulomas, but no septal fibrosis. Worms alone induced a mild degree of perifocal septal fibrosis. Systematized septal fibrosis of the liver, similar to that observed in the infected controls, occurred only in the rats treated with mebendazole or ivermectin, with dead worms and immature eggs in their livers. Thus, future search for fibrogenic factors associated with C. hepatica infection in rats should consider lesions with both eggs and worms.

[Doppler ultrasonography evaluation of paraumbilical vein and portal hypertension]

Portal hypertension is associated to the development of portosystemic collateral veins, particularly the paraumbilical vein.

PURPOSE

To evaluate the biometric and hemodynamic characteristics of the portal vessels related to the presence of a patent paraumbilical vein, in the setting of portal hypertension secondary to hepatosplenic schistosomiasis.

METHODS

75 patients with portal hypertension secondary to hepatosplenic schistosomiasis were evaluated by Doppler US. The patients were studied based on the presence (group B) or not (Group A) of a patent paraumbilical vein. The diameter and blood flow velocity of the portal vessels and of the paraumbilical vein were recorded.

RESULTS

The paraumbilical vein was detected in 17.33% of patients. The results showed an increase of the diameter of the main and left portal vessels whenever a patent paraumbilical vein was present (portal vein: A = 1.14 +/- 0.29 cm/B = 1.33 +/- 0.16 cm; left branch: A = 0.95 +/- 0.25 cm/B = 1.30 +/- 0.24 cm). The mean blood flow velocity was also increased in the portal trunk (A = 15.96 +/- 6.17 cm/sec/B = 19.82 +/- 6.26 cm/sec) and in the left portal branch (A = 14.77 +/- 4.29 cm/sec/B = 19.92 +/- 6.88 cm/sec).

CONCLUSION

The presence of a patent paraumbilical vein is related to significant biometric and hemodynamic variations in the portal venous system, in the setting of portal hypertension secondary to hepatosplenic schistosomiasis.

Hepatic Schistosomiasis japonica in a patient with gallstones and bile duct stones--a case report

Schistosomiasis, a common parasitic disease in many countries, is found as imported cases in Taiwan. Responsible for human infections are five species, one of which, Schistosoma japonicum, is currently endemic in China and South-east Asia. Chronic infection with S. japonicum may lead to the development of liver fibrosis, calcification and portal hypertension. Under investigation by sonography and computed tomography (CT) scan, a peculiar "turtle-back" appearance of liver fibrosis and calcification may be found. Herein, we report a case referred to our department due to jaundice. The sonography of liver showed typical "turtle-back" appearance. Gallstones and bile duct stones were also found in this case. Surgical interventions with percutaneous transhepatic biliary drainage (PTBD), cholecystectomy and choledocholithotomy were performed to relieve the obstructive jaundice and remove the stones. There were no parasitic eggs in the extracted stones or in drained bile juice. However, deposits of calcified S. japonicum eggs in liver parenchyma and portal tracts were identified in liver biopsy. No special treatment was given for the schistosomiasis japonica because the calcified parasitic eggs were the sequelae of past infection.

The role of nutritional status and insulin-like growth factor in reduced physical growth in hepatosplenic Schistosoma mansoni infection

The influence of nutritional status and hormonal growth activity on the impaired somatic development of adolescents with the hepatosplenic clinical form of Schistosoma mansoni infection (HS), the intestinal form with high (IH) or low (IL) egg output and non-infected (NI) individuals was evaluated (in Comercinho, Minas Gerais State, Brazil, in 1996-97) by measuring body mass index (BMI), insulin-like growth promoting factor (IGF-I) and its carrier protein (IGFBP-3). BMI, IGF-I and IGFBP-3 concentrations were significantly lower in the HS group compared with the IH and the NI groups, irrespective of age. BMI did not remain associated with the clinical form in the bi-variate model that included IGF-I and BMI or IGFBP-3 and BMI, suggesting that in these groups IGF-I and IGFBP-3 levels were related to the clinical form but independent of nutritional status. It is suggested that physical growth impairment in hepatosplenic S. mansoni infection results from the synergistic action of both hepatic damage and nutritional restriction.

Clinical, virological and histopathological features: long-term follow-up in patients with chronic hepatitis C co-infected with S. mansoni

BACKGROUND/AIMS

Infection with Schistosoma mansoni is endemic in Egypt leading to hepatic schistosomiasis and eventually portal hypertension. The prevalence of antibodies against hepatitis virus C among Egyptians is 14-51%. The aim of the present study was to investigate the influence of schistosomiasis on chronic hepatitis C with respect to the natural course of the disease, immunology, virology and histology.

PATIENTS AND METHODS

One hundred and twenty-six Egyptian patients classified into three groups: group A: chronic hepatitis C (n=33); group B: chronic schistosomiasis (n=30) and group C: chronic hepatitis C and chronic schistosomiasis (n=63) were enrolled and prospectively followed for 62.7 +/- 22 months. Patients infected with other hepatic viruses and/or parasites were excluded. Detailed history, clinical examination, CD4+ and CD8+ lymphocyte counts in blood, hematological and blood chemical values, abdominal ultrasonography, upper endoscopy, HCV RNA titer by RT/PCR, genotype and histological activity index in the liver biopsy were determined.

RESULTS

Thirty patients (48%) with HCV and schistosomiasis had liver cirrhosis and Child-Pugh class C vs. five (15%) in HCV patients and none in the schistosomal group. HCV RNA levels ranged between 0.07 and 13 x 10(5) copies/ml in group A, and between 1 and 25 x 10(5) copies/ml in group C. HCV genotype 4 was detected in 58 patients with co-infection (92%) and 21 patients with HCV alone (64%). Patients with coinfection showed higher grading and staging scores in their liver biopsies. Hepatocellular carcinoma was detected only in patients with coinfection. During follow-up, the mortality rate was 12%, 3% and 48% in group A, B and C, respectively.

CONCLUSIONS

Patients with concomitant HCV and schistosomiasis infection were characterized by more advanced liver disease, higher HCV RNA titers, predominance of HCV genotype 4, higher histologic activity, higher incidence of cirrhosis and hepatocellular carcinoma as well as a much higher mortality rate.

[Reinfections and the development of schistosomal periportal fibrosis in the murine model]

Experimental pipestem fibrosis of the liver developed more frequently (69.2%) in mice submitted to repeated infections with Schistosoma mansoni, than with single infection (11.1%). The counting of eggs in the liver revealed no significant differences between the two experimental groups. Although the reason why multiple infections favor the development of pipestem fibrosis has not been elucidated, the data obtained represent an experimental support to clinico-epidemiological claims that repeated infections play a role in pathogenesis of hepatosplenic schistosomiasis

Results of sclerotherapy for bleeding esophageal varices in patients with schistosomal liver disease. A retrospective study

BACKGROUND/AIMS

The aims of the study were to evaluate results of injection sclerotherapy in patients with liver schistosomiasis inducing bleeding esophageal varices and to review ultrasonographic features of the liver disease as well as endoscopic characteristics of the esophageal disease in order to assess any interrelationship between them.

METHODOLOGY

A total of 34 patients with active or recent history of hematemesis and Schistosoma mansoni infection had emergency or elective endoscopic sclerotherapy. Each underwent ultrasound examination to assess hepatosplenic involvement and staging, and were followed-up with upper digestive endoscopy every 4 months.

RESULTS

Obliteration or reduction of the varices in small columns was achieved in 82.3% of cases. During the follow-up period (mean: 10.4 +/- 2.1 months; range: 4-16 months) rebleeding was noted in 2 patients and 2 patients died due to variceal hemorrhage. The relationship between the ultrasonographic periportal fibrosis grade and the endoscopic variceal grade or varices localization was very strong (P < 0.001). A significant difference between grade 1 vs. 3 and 1 vs. 2 of periportal fibrosis and the presence of red signs was also found (P < 0.008).

CONCLUSIONS

In view of the results obtained in terms of success rate in obliterating varices, rebleeding and mortality rates, a longitudinal study could be justified to assess the usefulness of prophylactic sclerotherapy for the prevention of the first variceal hemorrhage and in the attempt to prolong survival in patients with Schistosoma-induced esophageal varices.

[Liver involvement in HIV infection and various parasitic diseases]

During the course of systemic infections, the liver is an organ which is frequently involved. The pathology of the human immunodeficiency virus with all its infections, opportunistic tumours and some parasitoses, such as amebiasis, kala-azar, hydatidosis, schistosomiasis and fascioliasis, evolve into hepatic compromise. This development is what we attempt to summarise.