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Leite LAC, Domingues ALC, Lopes EP, Ferreira RDCDS, Pimenta ADA, da Fonseca CSM, Dos Santos BS, Lima VLDM. Relationship between splenomegaly and hematologic findings in patients with hepatosplenic schistosomiasis. Rev Bras Hematol Hemoter 2015; 35:332-6. [PMID: 24255616 PMCID: PMC3832313 DOI: 10.5581/1516-8484.20130098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 03/14/2013] [Indexed: 01/08/2023] Open
Abstract
Background Schistosomiasis is a tropical disease. Patients who develop hepatosplenic
schistosomiasis have clinical findings including periportal fibrosis, portal
hypertension, cytopenia, splenomegaly and gastrointestinal hemorrhage. Objective The aim of this study was to analyze the hemostatic and hematologic findings of
patients with schistosomiasis and correlate these to the size of the spleen. Methods Fifty-five adults with hepatosplenic schistosomiasis and 30 healthy subjects were
selected through a history of contact with contaminated water, physical
examination and ultrasound characteristics such as periportal fibrosis and
splenomegaly in the Gastroenterology Service of the Universidade Federal de
Pernambuco. Blood samples were collected to determine liver function, blood
counts, prothrombin (international normalized ratio), partial thromboplastin time
and fibrinogen and D-Dimer levels using the Pentra 120 hematological analyzer
(HORIBA/ABX), Density Plus (test photo-optical Trinity Biotech, Ireland) and COBAS
analyzer 6000 (Roche). Furthermore, the longitudinal size of the spleen was
measured by ultrasound (Acuson X analyzer 150, Siemens). The Student t-test, the
Fisher test and Pearson's correlation were used to analyze the results with
statistical significance being set for a p-value < 0.05. Results The mean age was higher for the Study Group than for the Control Group (54 ± 13.9
vs. 38 ± 12.7 years). The average longitudinal diameter of the spleen was 16.9 cm
(Range: 12.3-26.3 cm). Anemia is a common finding in patients with schistosomiasis
(36.3%). The mean platelet and leukocyte counts of patients were lower than for
the Control Group (p-value < 0.001). Moreover, the international normalized
ratio (1.42 vs. 1.04), partial thromboplastin time (37.9 vs. 30.5 seconds) and
D-Dimer concentration (393 vs. 86.5 ng/mL) were higher for the Study Group
compared to the Control Group. Conclusion This study suggests that hematological and hemostatic abnormalities are associated
with splenomegaly, hypersplenism and portal hypertension.
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Leite LA, Ferreira Rde C, Hatzlhofer BL, Correia MC, Bandeira ÂP, Owen JS, Lima VL, Domingues AL, Lopes EP. Portal vein thrombosis associated with protein C deficiency and elevated Factor VIII in hepatosplenic schistosomiasis. Blood Coagul Fibrinolysis 2016; 27:210-2. [PMID: 26397884 DOI: 10.1097/MBC.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Portal vein thrombosis is considered a vaso-occlusive process that can appear during the course of hepatosplenic Schistosoma mansoni, but may result from impaired portal blood flow or be associated with acquired or inherited thrombophilic factors. Here, we report the case of a 67-year-old woman who developed thrombocytopenia as a result of hypersplenism. Following the diagnosis of hepatosplenic schistosomiasis, portal vein thrombosis was detected by ultrasound examination, while haematological tests revealed low levels of protein C (43.3%) and high levels of factor VIII (183.1%). The pathogenesis of portal vein thrombosis remains unclear in some patients with S. mansoni. We recommend, therefore, that early clinical and haemostatic investigations are done to evaluate risk of portal vein thrombosis and hence avoid further complications.
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Leite LA, Pimenta Filho AA, Ferreira Rde C, da Fonseca CS, dos Santos BS, Montenegro SM, Lopes EP, Domingues AL, Owen JS, Lima VL. Splenectomy Improves Hemostatic and Liver Functions in Hepatosplenic Schistosomiasis Mansoni. PLoS One 2015; 10:e0135370. [PMID: 26267788 DOI: 10.1371/journal.pone.0135370] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 07/08/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Schistosomiasis mansoni is a chronic liver disease, in which some patients (5-10%) progress to the most severe form, hepatosplenic schistosomiasis. This form is associated with portal hypertension and splenomegaly, and often episodes of gastrointestinal bleeding, even with liver function preserved. Splenectomy is a validated procedure to reduce portal hypertension following digestive bleeding. Here, we evaluate beneficial effects of splenectomy on blood coagulation factors and liver function tests in hepatosplenic schistosomiasis mansoni compared to non-operated patients. METHODOLOGY/PRINCIPAL FINDINGS Forty-five patients who had undergone splenectomy surgery were assessed by laboratory analyses and ultrasound examination and compared to a non-operated group (n = 55). Blood samples were obtained for liver function tests, platelet count and prothrombin time. Coagulation factors (II, VII, VIII, IX and X), protein C and antithrombin IIa, plasminogen activator inhibitor-1 were measured by routine photometric, chromogenic or enzyme-linked immunosorbent assays, while hyperfibrinolysis was defined by plasminogen activator inhibitor-1 levels. Both groups had similar age, gender and pattern of periportal fibrosis. Splenectomized patients showed significant reductions in portal vein diameter, alkaline phosphatase and bilirubin levels compared to non-operated patients, while for coagulation factors there were significant improvement in prothrombin, partial thromboplastin times and higher levels of factor VII, VIII, IX, X, protein C and plasminogen activator inhibitor-1. CONCLUSION/SIGNIFICANCE This study shows that the decrease of flow pressure in portal circulation after splenectomy restores the capacity of hepatocyte synthesis, especially on the factor VII and protein C levels, and these findings suggest that portal hypertension in patients with hepatosplenic schistosomiasis influences liver functioning and the blood coagulation status.
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Leite LAC, Pimenta Filho AA, da Fonseca CSM, dos Santos BS, Ferreira RDCDS, Montenegro SML, Lopes EP, Domingues ALC, Owen JS, Lima VLDM. Hemostatic dysfunction is increased in patients with hepatosplenic schistosomiasis mansoni and advanced periportal fibrosis. PLoS Negl Trop Dis 2013; 7:e2314. [PMID: 23875049 PMCID: PMC3715409 DOI: 10.1371/journal.pntd.0002314] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 06/03/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Schistosomiasis mansoni is an endemic parasitic disease and a public health problem in Northeast Brazil. In some patients, hepatic abnormalities lead to periportal fibrosis and result in the most severe clinical form, hepatosplenic schistosomiasis. This study aimed to evaluate whether abnormal blood coagulation and liver function tests in patients with hepatosplenic schistosomiasis (n = 55) correlate with the severity of their periportal fibrosis. METHODOLOGY/PRINCIPAL FINDINGS Blood samples were used for liver function tests, hemogram and prothrombin time (International Normalized Ratio, INR). The blood coagulation factors (II, VII, VIII, IX and X), protein C and antithrombin IIa (ATIIa), plasminogen activator inhibitor 1 (PAI-1) and D-dimer were measured by photometry or enzyme linked immunosorbent assay. Hyperfibrinolysis was defined on the basis of PAI-1 levels and a D-dimer concentration greater than a standard cut-off of 483 ng/mL. Standard liver function tests were all abnormal in the patient group compared to healthy controls (n = 29), including raised serum transaminases (p<0.001) and lower levels of albumin (p = 0.0156). Platelet counts were 50% lower in patients, while for coagulation factors there was a 40% increase in the INR (p<0.001) and reduced levels of Factor VII and protein C in patients compared to the controls (both p<0.001). Additionally, patients with more advanced fibrosis (n = 38) had lower levels of protein C compared to those with only central fibrosis (p = 0.0124). The concentration of plasma PAI-1 in patients was one-third that of the control group (p<0.001), and D-dimer levels 2.2 times higher (p<0.001) with 13 of the 55 patients having levels above the cut-off. CONCLUSION/SIGNIFICANCE This study confirms that hemostatic abnormalities are associated with reduced liver function and increased liver fibrosis. Of note was the finding that a quarter of patients with hepatosplenic schistosomiasis and advanced periportal fibrosis have hyperfibrinolysis, as judged by excessive levels of D-dimer, which may predispose them to gastrointestinal bleeding.
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Affiliation(s)
- Luiz Arthur Calheiros Leite
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | - Adenor Almeida Pimenta Filho
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | | | - Bianka Santana dos Santos
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | | | | | - Edmundo Pessoa Lopes
- Departamento de Medicina Clínica, Centro de Ciências da Saúde, Hospital das Clinicas, UFPE, Recife, Brazil
| | | | - James Stuart Owen
- Division of Medicine, University College London Medical School, Royal Free Campus, London, United Kingdom
| | - Vera Lúcia de Menezes Lima
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
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Dias HS, Domingues ALC, Cordeiro FTM, Jucá N, Lopes EP. Associating portal congestive gastropathy and hepatic fibrosis in hepatosplenic mansoni schistosomiasis. Acta Trop 2013; 126:240-3. [PMID: 23435257 DOI: 10.1016/j.actatropica.2013.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 02/08/2013] [Accepted: 02/12/2013] [Indexed: 02/05/2023]
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.
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MIRANDA MAC, FERRAZ ÁAB, DOMINGUES ALC, CHAVES RCM, JUCÁ N, MOTA DLD. IMPROVEMENT OF SCHISTOSOMAL PORTAL HYPERTENSIVE COLOPATHY AFTER SURGICAL TREATMENT. Arq Gastroenterol 2013; 50:153-6. [DOI: 10.1590/s0004-28032013000200026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 03/28/2013] [Indexed: 11/22/2022]
Abstract
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.
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Silva CC, Domingues AL, Lopes EP, Morais CN, Santos RB, Luna CF, Nader HB, Martins JR. Schistosomiasis mansoni: ultrasound-evaluated hepatic fibrosis and serum concentrations of hyaluronic acid. Ann Trop Med Parasitol 2011; 105:233-9. [PMID: 21801502 DOI: 10.1179/136485911x12987676649629] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Schistosomiasis mansoni is a fibrogenic liver disease that constitutes a major health problem in north-eastern Brazil. Although one common manifestation of the disease, periportal fibrosis (PPF), can be assessed by ultrasonography by well-trained physicians, the necessary equipment and personnel are not always readily available. Serum markers, including hyaluronic acid (HA), have been used as alternative means of measuring fibrosis. Recently serum concentrations of HA have been evaluated in 77 Brazilians (61 cases of schistosomiasis mansoni and 16 healthy controls) and compared against the ultrasound-evaluated PPF in the same subjects. The HA was measured using a non-competitive fluorescence-based assay, while the PPF was explored using a portable ultrasound scanner (SSD-500; Aloka, Tokyo) and graded, as patterns A-F, according to the World Health Organization's 'Niamey protocol'. In general, the serum concentrations of HA were found to be positively correlated with the severity of the PPF. The mean concentration of HA in the sera of the 16 controls was significantly lower than that recorded in the schistosomiasis cases who showed PPF of patterns D or E (P<0·001 for each). The cases who showed pattern-C PPF also had significantly less HA in their sera than the cases with PPF of patterns D or E (P<0·001 for each), and the cases with pattern-D fibrosis had significantly lower HA concentrations in their sera than the cases with PPF of pattern E (P<0·001). In an analysis based on a receiver-operating-characteristic (ROC) curve, an HA concentration of 20·2 μg/litre of serum was identified as a threshold that could be used to distinguish moderate cases of PPF (i.e. patterns C or D) from the more advanced cases (i.e. patterns E or F), with a sensitivity of 60% and specificity of 65%. In conclusion, it appears that serum concentrations of hyaluronic acid could be used as markers for periportal fibrosis in patients with schistosomiasis mansoni.
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Affiliation(s)
- C C Silva
- Universidade Federal de Pernambuco, Rua Irmã Maria Davi 154, Recife, PE, Brazil
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Ferraz AAB, Campos JM, de Araújo JGC, de Carvalho MRC, Ribeiro Neto JP, Ferraz EM. Influence of the inversion of the portal/splenic vein diameter in the results of the surgical treatment of schistossomotic portal hypertension. Rev Col Bras Cir 2011; 38:35-40. [PMID: 21537741 DOI: 10.1590/s0100-69912011000100007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 02/15/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the morbidity and mortality in surgical treatment of schistosomal portal hypertension in patients with inversion of the Portal/Splenic Vein diameter ratio. METHODS We conducted a retrospective cross-sectional study of patients undergoing surgical treatment of portal hypertension in the period between September 1993 and January 2004. The study population was divided into two groups: a) Inversion--splenic vein diameter greater than or equal to portal vein's--and b) control group (portal vein diameter greater than the splenic vein's). Statistical comparisons used the Student t test for averages difference, chi-square test for proportions difference and Fisher's exact test for small samples. RESULTS 169 patients were analyzed, with follow-up averaging 23.6 months. Twenty-one patients (12.4%) had splenic vein caliber greater of equal than the portal vein's (Inversion--study group). The mean preoperative diameter of the portal and splenic veins were respectively 1.49 and 1.14 cm in the control group, and 0.98 versus 1.07 cm in the inversion group. The portal vein diameter was significantly higher in the control group when compared to the inversion group (p <0.05). Varices in the gastric fundus were found in 33.3% of the inversion group and in 38.5% of patients in the control group. Postoperative rebleeding occurred in 23.1% of patients in the inversion group and in 13.4% of the control group ones (p > 0.05). In the postoperative evaluation with Doppler ultrasonography of portal vessels, no cases of portal vein thrombosis were observed in the inversion group, whilst in the control group portal thrombosis was identified in 16.9% of the patients (p <0.05). Death occurred in one (4.8%) individual from the inversion group; mortality was 4.1% in the control group (p>0.05). The mean serum level of platelets was significantly lower (65,950/mm²) in the inversion group than in the controls (106,647/mm²) (p<0.05). CONCLUSION The results suggest that the reversal of portal/splenic vein caliber ratio does not represent a contraindication to surgical treatment of schistosomal portal hypertension.
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Affiliation(s)
- Alvaro Antônio Bandeira Ferraz
- Department of General Surgery, Hospital das Clinicas, Federal University of Pernambuco (HC-UFPE SCG), Recife, Pernambuco, Brazil.
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Leão ARDS, Sales DM, Santos JEM, Nakano E, Shigueoka DC, D'Ippolito G. Avaliação do volume de fluxo portal em pacientes esquistossomóticos: estudo comparativo entre ressonância magnética e ultrassom Doppler. Radiol Bras 2010. [DOI: 10.1590/s0100-39842010000600005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar a concordância entre o ultrassom Doppler e a ressonância magnética e a reprodutibilidade interobservador desses métodos na quantificação do volume de fluxo portal em indivíduos esquistossomóticos. MATERIAIS E MÉTODOS: Foi realizado estudo transversal, observacional e autopareado, avaliando 21 pacientes portadores de esquistossomose hepatoesplênica submetidos a mensuração do fluxo portal por meio de ressonância magnética (utilizando-se a técnica phase-contrast) e ultrassom Doppler. RESULTADOS: Observou-se baixa concordância entre os métodos (coeficiente de correlação intraclasse: 34,5% [IC 95%]). A reprodutibilidade interobservador na avaliação pela ressonância magnética (coeficiente de correlação intraclasse: 99,2% [IC 95%] / coeficiente de correlação de Pearson: 99,2% / média do fluxo portal = 0,806) e pelo ultrassom Doppler (coeficiente de correlação intraclasse: 80,6% a 93,0% [IC 95%] / coeficiente de correlação de Pearson: 81,6% a 92,7% / média do fluxo portal = 0,954, 0,758 e 0,749) foi excelente. CONCLUSÃO: Há uma baixa concordância entre o ultrassom Doppler e a ressonância magnética na mensuração do volume de fluxo na veia porta. A ressonância magnética e o ultrassom Doppler são métodos reprodutíveis na quantificação do fluxo portal em pacientes portadores de hipertensão porta de origem esquistossomótica, apresentando boa concordância interobservador
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Bezerra ASDA, D′ippolito G, Caldana RP, Leopoldino DD, Batista GR, Borges DR, de Jesus Lopes Filho G, Ahmed M. Differentiating Cirrhosis and Chronic Hepatosplenic Schistosomiasis Using MRI. AJR Am J Roentgenol 2008; 190:W201-7. [DOI: 10.2214/ajr.07.2639] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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