Devascularization procedure and DSRS: a controlled randomized trial on selected haemodynamic portal flow pattern in schistosomal portal hypertension with variceal bleeding.

OBJECTIVES: The use of duplex studies for the portal tree has revolutionized the concepts of haemodynamic pathophysiology in the case of portal hypertensive bleeders. The identification of possible haemodynamic patterns in schistosomal bleeders, and the effects of devascularization procedure and distal lienorenal shunts on a selected haemodynamic pattern, are the aim of this work. PATIENTS AND METHODS: Patients (219) with schistosomal hepatic fibrosis and history of bleeding oesophageal varices were studied. The patency, diameter, velocity and flow volume/min in the portal and splenic veins were followed by coloured Duplex. Two matched groups (30 patients each) with the most commonly found haemodynamic pattern (splenic vein flow exceeding portal vein flow) were operated upon. Devascularization procedure was done for the first group (A) and distal splenorenal shunt for the second group (B). RESULTS: Coloured duplex assessment of portal circulation in schistosomal patients identified four haemodynamic patterns. Pattern I (approximately 59%); splenic vein flow exceeds the portal vein flow. Pattern II (approximately 28%); portal vein flow exceeds splenic vein flow. In both patterns, the portal flow was hepatopedal. Patterns III and IV (8% and 5%, respectively) were associated with hepatofugal flow. Splenic vein flow exceeds portal vein flow in pattern III and the reverse in pattern IV. Distal lienorenal shunts done for patients with haemodynamic pattern I was followed by a rebleeding rate of 3.3% while devascularization done for patients with the same pattern was followed by a rebleeding rate of 26.6%. Mild encephalopathy was detected in 10% of patients with distal lienorenal shunts and responded to dietary regulations. CONCLUSIONS: DSRS proved to be ideal for schistosomal patients with hepatopedal flow and splenic vein flow exceeding portal vein flow; since in addition to eliminating the high splenic flow out of portal circulation, it decreased the pressure in the gastroesophageal region. Other patterns with their frequencies and the suggested surgical procedures were also presented.

Risk factors in surgery of gastroduodenal ulcer disease in patients with schistosomal portal hypertension.

The present study was conducted to determine the risk factors associated with surgical treatment of peptic ulcer disease (PUD) in patients with schistosomal hepatic fibrosis (SHF). The medical records of 32 patients treated at the Department of Surgery, Alexandria Faculty of Medicine between 1984 and 1994 were reviewed and data were analyzed. Twenty-five patients were male and seven were female, with a mean age of 43.3 +/- 24. Fifteen patients belonged to Child A and 13 to Child B. Twenty-one patients were variceal non-bleeders and 11 were bleeders. The ulcer was pyloric or duodenal in 30 patients and gastric in only two. Twenty-four patients were operated upon electively mostly for pyloric obstruction (n = 15) and eight patients emergently; five for perforation and three for bleeding. Hepatic insufficiency, renal function impairment and gastrointestinal bleeding were the most detrimental postoperative complications that occurred, either alone or in combination, in 13 patients (40.6%). Eight patients died (25%) of liver failure (n = 5), gastrointestinal bleeding (n = 2) and multiple systems organ failure (n = 1). Urgency of the operation and Child B were of significance for predicting mortality in contrast to age, sex, liver size, bleeding varices and ulcer location. Based on these data, it may be concluded that 1) operations for PUD in patients with schistosomal portal hypertension are expected to have high postoperative morbidity and mortality; 2) mortality rate significantly increases by emergency operations, presence of postoperative complications and in modified Child B patients; 3) Liver function must be optimized preoperatively; and 4) the most simple and expeditious procedure must be performed to minimize postoperative complications and hepatic decompensation.

beta-Glucuronidase in schistosomal intestinal polypi of the colon.

The results of a clinical, histopathological and biochemical study on twenty patients with schistosomal polyposis of the large bowel and ten patients with normal colon as a control are reported. The biopsy showed clearly the absence of any malignant or premalignant changes in all the twenty bilharzial patients. Results of the biochemical study showed that there is a statistically significant increase in beta-glucuronidase activity in schistosomal polypi compared to normal mucosa. This enzymatic activity is absent in schistosoma ova. The causes of the increase in the enzyme activity have been attributed to leucocytic infiltration present in schistosomal granulomata and possible to some degree of liver disfunction. The protein content of the excess mucus present in the colon could also activate the enzyme. Our results also show that the increased enzyme activity does not necessarily have carcinogenic properties. We did not come across a single case of malignancy even in a patient with very high level of enzyme activity (11615 units) or in those patients with a prolonged history of the disease.