Associating portal congestive gastropathy and hepatic fibrosis in hepatosplenic mansoni schistosomiasis

doi:10.1016/j.actatropica.2013.02.011

Acta Tropica

Volume 126, Issue 3, June 2013, Pages 240-243

https://doi.org/10.1016/j.actatropica.2013.02.011 Get rights and content

Abstract

Upper digestive bleeding is one of the most serious complications of mansoni schistosomiasis, and portal congestive gastropathy (PCG) is responsible for 25–30% of the cases of bleeding instead of bleeding due to esophageal varices. This study aimed to investigate the association between PCG with parameters of portal hypertension and the intensity of periportal fibrosis assessed by ultrasonography, in patients with mansoni schistosomiasis. A prospective study was made of 71 patients whether or not they had a history of upper digestive bleeding, and who had not been previously treated for portal hypertension (splenectomy, use of beta blockers or endoscopic treatment). Patients with other liver diseases were excluded. After signing a form of consent, the patients underwent endoscopy, as well as ultrasonography of the abdomen, and hematological, biochemical and viral markers tests. Chi-square and Fischer's exact tests were used in the statistical analysis. The mean age of the 71 patients was 50 ± 14.5 years of whom 59.2% were women. 45.1% had antecedents of upper digestive bleeding. PCG was observed in 39 patients (54.9%): severe in 8.5%, and mild in 46.5%. A positive association was observed between PCG and the grade of esophageal varices (p = 0.017); and the pattern of periportal fibrosis (p = 0.041). A negative association was observed between PCG and red spots on the varices (p = 0.024). PCG in patients with mansoni schistosomiasis not submitted to treatment for portal hypertension is associated with the sonographic pattern of hepatic fibrosis, as well as with the grade of esophageal varices.

Graphical abstract

This article observed the association between portal congestive gastropathy and the periportal fibrosis patterns in patients with mansoni schistosomiasis.

Highlights

► First evaluation of portal gastropathy according to periportal fibrosis intensity. ► Portal gastropathy in schistosomiasis is associated with hepatic fibrosis pattern. ► Portal gastropathy in schistosomiasis is associated with endoscopic signs of bleeding.

Introduction

Portal hypertension is the most important repercussion of hepatosplenic mansoni schistosomiasis, inducing esophageal varices and congestive gastropathy (Coutinho, 1968, Ferraz et al., 2003, Kelner, 1992).

Moreover, upper digestive bleeding occurs in patients with portal hypertension due to lesions from portal congestive gastropathy (PCG) in 30–40% of the cirrhotic and schistosomotic patients respectively (Cordeiro et al., 1999, McCormack et al., 1985).

In a systematic review, Viggiano and Gostout (1992) did not find any association of PCG either with portal hypertension – evaluated by the grade of esophageal varices – or with the severity of hepatic disease (Child–Pugh classification) in cirrhotic patients. An aggravation of PCG after endoscopic treatment of esophageal varices, especially after sclerotherapy, has been described (Almeida et al., 1999, Viggiano and Gostout, 1992). However, an improvement after splenectomy with ligation of the left gastric vein has been described in cirrhotic or in schistosomiasis patients (Melo et al., 2007).

Abdominal ultrasound has been proved to be as sensitive as liver wedge biopsy in the diagnosis of periportal fibrosis in schistosomiasis (Abdel-Wahab and Esmat, 1992, Homeida et al., 1988). Moreover, ultrasonography is currently an excellent non-invasive technique for evaluating the pattern of periportal fibrosis in hepatosplenic schistosomiasis (Machado et al., 2002, Prata et al., 2010, Richter et al., 1992) and of portal hypertension (Abdel-Latif et al., 1981, Domingues et al., 1993, Sebastianes et al., 2010).

Associations were found between the diameters of esophageal varices by esophagogastroduodenoscopy, and the intensity of periportal fibrosis and portal hypertension obtained by ultrasonography (Abdel-Wahab and Esmat, 1992, Domingues et al., 1993, King et al., 2003, Medhat et al., 1988, Richter et al., 1992).

Furthermore, the association between PCG and parameters of portal hypertension, as well as the intensity of periportal fibrosis has not been prospectively evaluated in mansoni schistosomiasis. Thus, this study set out to evaluate the association of PCG with endoscopic parameters of portal hypertension, as well as with the intensity of periportal fibrosis evaluated by ultrasonography, in patients with hepatosplenic mansoni schistosomiasis.

Section snippets

Patients and methods

A prospective study was made of 71 patients with the hepatosplenic form of mansoni schistosomiasis, with or without antecedents of upper digestive bleeding, and without previous treatment for portal hypertension (splenectomy, use of beta blockers or endoscopic treatment). Patients with other types of liver diseases (alcoholic, virus B and C, fat liver diseases and cirrhosis), coagulation disturbances and pregnant women were excluded.

After explaining the aims of the study to all patients, they

Results

71 patients – 42 women (59.2%) and 29 men (40.8%) – whose mean age was 50 ± 14.75 years formed the group studied. 32 patients (45.1%) had a past history of upper digestive bleeding, of whom 28 (87.5%) reported concomitant episodes of hematemasis or melena. 22 of these patients (68.7%) presented only one episode of upper digestive bleeding, 8 (25%) had two, and 2 (6.5%) had three or more episodes. In this group of 32 patients, 15 (46.9%) needed hemotransfusions.

Table 1 shows the main endoscopic

Discussion

Upper digestive bleeding is the most important consequence of mansoni schistosomiasis in terms of morbidity and mortality. In this study, the 71 patients had not yet been submitted to treatment for portal hypertension, and 61% of them had advanced or very advanced periportal fibrosis. In addition, almost half of them had a past history of upper digestive bleeding which gives a clear indication of the gravity of the evolution of this disease in the Northeast of Brazil.

Moreover, PCG was found in

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Associating portal congestive gastropathy and hepatic fibrosis in hepatosplenic mansoni schistosomiasis

Abstract

Graphical abstract

Highlights

Introduction

Section snippets

Patients and methods

Results

Discussion

Acta Trop.

Am. J. Med.

Trans. R. Soc Trop. Med. Hyg.

Acta Trop.

Acta Trop.

Evaluation of portal hypertension in cases of hepatosplenic schistosomiasis using ultrasound

J. Clin. Ultrasound.

The value of ultrasonography in assessment of portal hypertension in hepatosplenic schistosomiasis

Mem. Inst. Oswaldo Cruz.

Grading of hepatic schistosomiasis by the use of ultrasonography

Am. J. Trop. Med. Hyg.

Gastropatia da hipertensão portal na esquistossomose mansônica: associação com Helicobacter pylori

An. Fac. Med. Univ. Fed. Pernambuco

Remodeling of hepatic vascular changes after specific chemotherapy of schistosomal periportal fibrosis

Mem. Inst. Oswaldo Cruz.

Regressão da hepatoesplenomegalia pelo tratmento específico da esquistossomose

Rev. Soc. Bras. Med. Trop.

Lesões gástricas na hipertensão portal: gastrite e/ou gastropatia?

GED

Ultrasound and clinical investigation of hepatosplenic schistosomiasis: evaluation of splenomegaly and liver fibrosis four years after mass chemotherapy with oxamniquine

Am. J. Trop. Med. Hyg.