Radiography

Radiography, with or without angiography, is less important whenever ultrasound is available. But it may be useful in some circumstances.

In advanced S. mansoni infections. plain radiographs of the abdomen may show moderate to marked splenomegaly without splenic calcification. The stomach may be displaced medially and the splenic flexure of the colon downward by the enlarged spleen, which at times extends below the iliac crest. There may be ascites. The liver enlarges as the infection progresses, but then shrinks as generalized hepatic fibrosis occurs. (This is more marked in S. japonicum infections). Esophageal and gastric varices (Figs. 2.54, 2.55) may be identified with a barium upper gastrointestinal series. In some patients, mediastinal varices are so large that they cause displacement of the mediastinal stripe and widening of the mediastinum (best seen on the right side) on a chest radiograph. If the gastric varices are large enough, they cause undulating pressure on the gastric fundus and the upper third of the body of the stomach. The mucosa may appear serpiginous or there may even be a mass effect on the gastric fundus. In the majority of patients the diagnosis of schistosomiasis will have been made clinically and even confirmed by laboratory tests.

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Fig. 2.54 A-F. Esophageal and gastric varices. The normal smooth outline of the esophagus indented with multiple nodular filling defects, which in the early stages may be more easily recognized with the patient horizontal. As the obstruction develops, the varices become extensive and are easily seen with the patient erect. A An African from the Sudan (same patient as in Fig. 2.36B) with esophageal varices outlined with barium. B A patient from Puerto Rico with advanced schistosomiasis mansoni, causing splenomegaly and portal hypertension. C Varices in the esophagus and fundus of the stomach. D Splenoportography with the patient prone outlines the massive gastric, esophageal, and mediastinal varices. The mesenteric and lumbar veins are also dilated. There is poor filling of the portal circulation because of the elevated portal pressure. E Large gastric varices, with pressure on the lateral wall of the stomach by the enlarged spleen. F Splenoportography shows the extensive collateral circulation through the coronary and short gastric veins, leading up to the esophageal plexus. To outline the full extent of the collateral circulation it may be necessary to do contrast studies in both the supine and prone positions. (B courtesy of Dr. H. Pagan-Saez, San Juan; C, D courtesy of Dr. H. Moskowitz, West Hartford, Connecticut).

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Fig. 2.55 A-F. Ultrasonography is an excellent way to demonstrate the varices which result from portal hypertension and an extensive collateral circulation in schistosomiasis. A Varices (arrows) in the gastric fundus (F). B Varices (arrows) in the porta hepatis. C A dilated patent umbilical vein (uv). D Splenomegaly with dilated splenic veins and collateral vessels. SP spleen; SPV splenic vein; CC collaterals. E Splenomegaly with multiple collateral vessels. SP spleen; F Multiple varices around the porta hepatis. All are African patients from Zimbabwe. (Courtesy of Dr. Sam Mindel).

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Fig. 2.56. The development of collateral circulation in patients with schistosomiasis mansoni. A-C Natural decompression of the portal system occurs and opens the collateral circulation through the coronary and short gastric veins which connect to the esophageal plexus. Hepatofugal collaterals are established through the umbilical, retroperitoneal, lumbar, renal, and mesenteric veins. The intrahepatic portal system resembles a tree in winter, or after pruning, because many of the peripheral branches do not fill. Because of this, there is unlikely to be a normal hepatogram. When there is portal vein obstruction (D-F) decompression may be by retrograde flow into the large dilated umbilical vein (D, E), sometimes known as the Cruveilhier-Baumgarten syndrome. In C the proximal portal vein is blocked while in D it is patent, but both patients have developed extensive collaterals as well as the flow through the umbilical vein. In F there is an extensive network of collaterals which involves the retroperitoneal as well as the gastric and esophageal veins. All of these patients come from Puerto Rico and have advanced schistosomiasis mansoni. (D, E courtesy of Dr. Harold Moskowitz, West Hartford, Connecticut).