Surgical management of portal hypertension.

Portal hypertension is frequently complicated by upper gastrointestinal tract bleeding and ascites. Hemorrhage from esophageal varices is the most common cause of death from portal hypertension. Medical treatment, including resuscitation, vasoactive drugs, and endoscopic sclerosis, is the preferred initial therapy. Patients with refractory hemorrhage frequently are referred for immediate surgical intervention (usually emergency portacaval shunt). An additional cohort of patients with a history of at least 1 episode of variceal hemorrhage is likely to benefit from elective shunt operations. Shunt operations are classified as total, partial, or selective shunts based on their hemodynamic characteristics. Angiographically created shunts have been introduced recently as an alternative to operative shunts in certain circumstances. Devascularization of the esophagus or splenectomy is done for specific indications. Medically intractable ascites is a separate indication for surgical intervention. Liver transplantation has been advocated for patients whose portal hypertension is a consequence of end-stage liver disease. In the context of an increasingly complex set of treatment options, we present an overview of surgical therapy for complications of portal hypertension.     

Pathology of Schistosomiasis mansoni in rabbits

The pathology of schistosomiasis mansoni in rabbits was studied with special consideration to worm burden and duration of infection. Heavy and prolonged infections resulted in severe changes involving the intrahepatic portal vein branches, such as: polypoid endophlebitis, granulomatous endophlebitis and, later on, vascular occlusion and recanalization, vascular ectasia, fibrosis and hyalinization of the endothelial polyps. Living and dead adult worms, rather than the mature eggs, were the main pathogenetic factors. For some time the lesions tend to be limited to the portal vein branches, not extending to the periportal tissues, but, after 8 to 10 months, variable degree of portal, septal and intra-parenchymal fibrosis can be formed. However, both vascular and fibrotic changes in the liver had a focal distribution and therefore did not appear to cause portal hypertension and had no resemblance to the human pathology seen in cases of hepatosplenic schistosomiasis. Pathology of schistosomiasis in rabbits has peculiar aspects, which are worthwhile studying, since the model can be of interest for investigations, especially concerning the immunology and immunopathology of schistosomiasis mansoni.     

Schistosomiasis mansoni in low transmission areas: abdominal ultrasound

In endemic areas with low prevalence and low intensity of infection, the diagnosis of hepatic pathology due to the Schistosoma mansoni infection is very difficult. In order to establish the hepatic morbidity, a double-blind study was achieved in Venezuelan endemic areas, with one group of patients with schistosomiasis and the other one of non-infected people, that were evaluated clinically and by abdominal ultrasound using the Cairo classification. Schistosomiasis diagnosis was established based on parasitologic and serological tests. The increase of the hepatic size at midclavicular and midsternal lines (in hepatometry) and the hard liver consistency were the clinical parameters able to differentiate infected persons from non infected ones, as well as the presence of left lobe hepatomegaly detected by abdominal ultrasound. The periportal thickening, especially the mild form, was frequent in all age groups in both infected and uninfected patients. There was not correlation between the intensity of infection and ultrasound under the current circumstances. Our data suggest that in Venezuela, a low endemic area of transmission of schistosomiasis, the hepatic morbidity is mild and uncommon. The Cairo classification seems to overestimate the prevalence of periportal pathology. The specificity of the method must be improved, especially for the recognition of precocious pathology. Other causes of hepatopathies must be investigated.     

A thirty years follow-up study on Schistosomiasis mansoni in a community of Minas Gerais, Brazil

During thirty years - 1973-2003 - a group of individuals infected by Schistosoma mansoni in Capit?o Andrade, Rio Doce Valley, Minas Gerais, Brazil, was evaluated by the same authors, being one of the longest follow-up studies on schistosomiasisis mansoni in an endemic area. The diagnosis of S. mansoni was based on parasitological stool tests. In the clinical classification, three groups were considered: type I - schistosomiasis-infection, type II - hepatointestinal form, and type III- hepatosplenic form. The prevalence of infection were 60.8% in 1973, 36.2% in 1984, 27.3% in 1994, and 19.4% in 2003, while the index of hepatosplenomegaly were respectively 5.8%, 2.8%, 2.3% and 1.3%. The maintenance of high prevalence and severity of clinical forms are probably related to reinfection.     

Anti-idiotypic T lymphocyte responsiveness in murine Schistosomiasis mansoni

Pooled sera from CBA/J mice infected for greater than or equal to 16 weeks with the blood fluke Schistosoma mansoni were immunoaffinity purified using soluble schistosome egg antigens (SEA) coupled to Sepharose 4B. The bound and then eluted fraction was shown to contain only immunoglobulins and to have anti-SEA activity. These anti-SEA antibodies stimulated proliferation of lymph node cells from mice infected with S. mansoni for 8, 12, or greater than or equal to 16 weeks but not from uninfected mice. The cells stimulated by anti-SEA antibodies were nylon wool adherent, Thy-1.2+, L3T4+, Lyt-2-lymphocytes. Immunoglobulins without anti-SEA activity isolated from the sera of syngeneic uninfected mice were not stimulatory for cells from normal or infected animals. Thus the responding T cells appear to be stimulated by the idiotypes expressed on the syngenic anti-SEA antibodies. These data present evidence for anti-idiotypic cellular reactions in murine schistosomiasis that could play important immunoregulatory roles in this disease.     

Schistosomiasis mansoni: follow-up of control program based on parasitologic and serologic methods in a Brazilian community of low endemicity

A field survey on schistosomiasis was carried out in 1998, in the municipality of Pedro de Toledo, a low endemic area in the state of S?o Paulo, Brazil. According to the parasitologic Kato-Katz method, the prevalence rate was 1.6%, with an infection intensity of 40.9 eggs per gram of stool. By the immunofluorescence test (IFT) for detection of IgG and IgM antibodies in the serum, IgG-IFT and IgM-IFT, respectively, prevalence indices of 33.2% and 33.5% were observed. To assess the impact of the schistosomiasis control program in the area, parasitologic and serologic data obtained in 1998, analyzed according to the age, sex, and residence zone, were compared to previous data obtained in a epidemiologic study carried out in 1980, when prevalence indices were of 22.8% and 55.5%, respectively by Kato-Katz and IgG-IFT. A significant fall of the prevalence was observed, indicating that the control measures were effective. Nonetheless, residual transmission was observed, demonstrating the need for a joint effort to include new approaches for better understanding the real situation and improving the control of the disease in low endemic areas.     

Schistosomiasis mansoni in areas of low transmission: epidemiological characterization of Venezuelan foci

Severe schistosomiasis is a rare event in Venezuela nowadays, after a successful national campaign by the Schistosomiasis Control Program. Unfortunately, this program has practically disappeared, and snail surveillance in field is not a priority, anymore. Thus, schistosomiasis has become a neglected disease in this country. However, surveys in different populations from the endemic area have shown particular epidemiological features described herein. In five communities we evaluated 2,175 persons and searched for the presence of Biomphalaria glabrata snails. Some markers were used for classifying schistosomiasis foci: mean age of the persons with Schistosoma mansoni eggs in the stools, serological tests, presence of B. glabrata snails, and intensity of infection. Places without B. glabrata snails and with few schistosomiasis cases were defined as "past transmission sites"; a site with abundant snails but few cases was defined as "potential risk"; "new transmission" foci were characterized by the presence of infected snails and young people passing eggs in the stools. A "re-emergent" focus has shared these last features, showing in addition a place where schistosomiasis had been reported before. Recent evidences of active transmission with the increasing dispersion of B. glabrata snails, point out the necessity for the re-establishment of the Schistosomiasis Control Program in Venezuela.     

Schistosomiasis: from risk assessment to control

In this article, an account of some of the hot areas in schistosomiasis research is given, emphasizing what has been achieved during the past several years in impact assessment and identifying the research frontiers where further action is needed.     

Schistosomiasis mekongi: from discovery to control

In the Mekong River basin, the first case of schistosomiasis was reported in 1957. In the 1960s, endemic areas of the infection, of which profiles were similar to those of schistosomiasis japonica, were discovered in Khong Island, Laos, to Kratie province, Cambodia. A new intermediate snail host; Neotricula aperta was identified and the Mekong strain of schistosome was elevated to a new species: Schistosoma mekongi in 1978. Baseline epidemiological surveillance was performed and schistosomiasis mekongi was described as a public health implication in the middle Mekong River basin. Because of political and economical confusion, endemic situation had become worse, and no control program had been implemented until mass treatment program with praziquantel on Khong Island in 1983. Since then, the prevalence of S. mekongi infection has rapidly decreased in each endemic area. Serological diagnosis has been useful to detect new but low endemic foci. Clinical manifestations of S. mekongi infection are similar to those of S. mansoni and S. japonicum infections. As the reduction of prevalence and intensity of S. mekongi infection, morbidity due to the disease has changed, and ultrasonographic examination is now useful to evaluate morbidity due to schistosomiasis mekongi. Transmission of the disease occurs in a couple of months during low water season. Control of N. aperta is difficult and long-lasting effective control measurements have, so far, not been available. In the next step for controling S. mekongi infection, mass treatment should be continued, and it is needed to combine other appropriate control activities.     

Schistosomiasis mansoni, haematobia, and japonica in hamsters: liver granuloma measurements

Differences in the granulomatous response of hamsters infected with Schistosoma mansoni, Schistosoma haematobium, or Schistosoma japonicum were studied by measuring granulomas formed around eggs in the livers at 1, 3, 5, 11, and 19 week intervals after patency of the infections. For each species, the mean diameters of both granulomas containing only 1 egg and granulomas selected at random were determined. The mean volume of single egg granulomas in S. mansoni-infected hamsters was greater than in those with other species at all time intervals studied. The decrease in single egg granuloma size with time occurred more gradually in S. mansoni infections. The mean volume of granulomas measured at random was greatest in S. japoracum-infected animals at 1, 3, and 11 weeks after patency; was greatest in S. haematobium-iufected. hamsters at 5 and 19 weeks; and was least in S. mansoni-infected hamsters at all time periods. During the 19 week period following patency, the mean volume of randomly measured granulomas increased with time in S. haematobium infections, decreased gradually in S. mansoni infections, and decreased markedly in S. japonicum infections. Multi-egg granulomas represented 2–6% of all granulomas measured in S. mansoni infections, 38–68% in S. haematobium infections, and 20–53% in S. japonicum infections. An estimated proportion of the liver occupied by granulomas, i.e., a lesion-to-tissue ratio, was computed. There was no consistent difference in this ratio among the 3 species when the data were grouped in comparable intervals of mean number of eggs per g of liver. The lesion-to-tissue ratio increased with increasing numbers of eggs per g of liver. The host response of hamsters to these 3 species of schistosomes differed markedly even at comparable levels of eggs per g of liver. This study provides further evidence of an intrinsic qualitative difference in the eggs of the 3 species. The species of eggs present in tissues apparently has greater influence on the host response than does the quantity of eggs present.     

Differential immunoregulation of granulomatous inflammation, portal hypertension, and hepatic fibrosis in murine schistosomiasis mansoni

The present study investigates the immunoregulation of hepatic fibrosis in experimental murine schistosomiasis. Disease parameters measured were portal pressure, hepatic granuloma area, hepatic interstitial collagen, and glycosaminoglycans. C57BL/6 mice were infected with 25 Schistosoma mansoni cercariae and administered splenocytes or serum derived from uninfected mice or chronically infect syngeneic mice at 6 and 7 wk of infection. Immunologically mediated modulation was noted in animals receiving splenocytes derived from chronically infected mice. Both a reduction in portal pressure and hepatic granuloma areas were noted. Hepatic collagen content but not glycosaminoglycan content was reduced by the administration of either lymphoid cells or serum from chronically infected mice. The isotypic profile of hepatic interstitial collagens was modulated by both the administration of serum or lymphoid cells. Augmented levels of type III collagen was noted on administration of serum derived from chronically infected mice, whereas type I collagen levels were relatively elevated on administration of splenocytes. The data indicate that immunomodulation of inflammation and hepatic fibrosis can occur in murine schistosomiasis but that fibrotic events and inflammatory processes are independently modulated.     

Oxamniquine, praziquantel and lovastatin association in the experimental Schistosomiasis mansoni

The activity of lovastatin associated with oxamniquine or praziquantel against schistosomiasis mansoni was evaluated in mice infected with Schistosoma mansoni. Forty days after infection, mice were treated with lovastatin, 400 mg/kg for five consecutive days by oral route, and on the last day of this sequence with 50 mg/kg oxamniquine or with 200 mg/kg praziquantel, both by oral route, single dose. Fifteen days later, the animals were perfused in parallel with an untreated control group. Studies were carried out in vitro, using lovastatin in culture medium containing S. mansoni worms proceeding from experimentally infected mice. In the in vivo trials, the association of lovastatin with oxamniquine or praziquantel did not show any additive action, but there were oogram changes when lovastatin was associated with oxamniquine. In vitro lovastatin was able to interrupt the maturation of S. mansoni eggs, which remained at the 1st or 2nd stages, depending on the dose used. The total number of morphologically dead eggs found in culture of worms exposed to 2 microg/ml or 4 microg/ml concentrations of lovastatin was significantly higher than the number of viable eggs. Using the probe Hoescht 33258 it was observed that 70% of the eggs considered morphologically viable in the treated groups (against 16% in the control group) were labeled, indicating that the majority of the viable eggs had membrane permeability increased due to lovastatin action.     

Antibody isotype responses to egg antigens in human chronic Schistosomiasis mansoni before and after treatment

In the present communication we analyzed the levels of IgG1, IgG2, IgG3, IgG4 and IgE isotypes to soluble egg antigen of Schistosoma mansoni by ELISA in individuals from an endemic area for schistosomiasis in Northeast Brazil. The analysis was performed before and after treatment to evaluate the age-dependent pattern, and to identify differences in the reactivities to antigens. Our results suggest that schistosomiasis treatment would not interfere with this sort of immune response.