Tropical Doctor, October 1992 Further study could help identify the most useful and cheapest way of using the limited resources there are available. REFERENCES
1 Hersch C. Acute glomerulonephritis due to skin disease with special reference to scabies. S Afr Med J 1967; 1: 29-34 2 Acheampong JW, Whittle HC, Obasi EO, et al. Scabies and streptococcal skin infection in Ghana. Trop Doct 1988; 118: 151-2 3 Epidemic scabies and associated acute glomerulonephritis in Trinidad. Bull Pan Am Health Organ 1988; 22: 103-7 4 Takiguchi Y, Kusama K, Nagao S, Iijima S. A case of scabies complicated by acute glomerulonephritis. J Dermato/1987; 114: 163-6 5 Reid HF, Birju B, Holder Y, Hospedales J, Poon King T. Epidemic scabies in four Caribbean islands - 1981-8. Trans R Soc Trop Med Hyg 1990; 84: 298-300 6 Stanton B, Khanam S, Nazrul H, Nuranis, Khair T. Scabies in urban Bangladesh. J Trop Med Hyg 1987; 90: 219-26 7 Taplin 0, et al. Community control of scabies. Lancet 1991; 337: 1016-18
Sonographic changes following splenectomy for portal hypertension in Schistosoma mansoni Qurashi M Ali MD PhD' Osman A Hammour MD FRCS 2 Ibrahim M Abdel Rahim MD MRCP 3 Departments of 'Radiology, 2Surgery and "Intemal Medicine, College of Medicine, University of Gezira, Wad Medani, Sudan TROPICAL DOCTOR,
1992,22, 167-169
167 8 Blumenthal OS, Taplin 0, Schultz MG. A community outbreak of scabies. Am J Epidemiol 1976; 104: 667-72 9 Gulati PV, Braganza C, Singh KP, Borker V. Scabies in a semi-rural area of India: an epidemiologic study. lnt J Dermatol 1977; 16: 594 10 Taplin 0, Arrue C, Graham Walker J, Roth WI, Rivera A. Eradication of scabies. J Am Acad Dermatol 1983; 9: 546-50 11 Haustein EF, Hlawa B. The treatment of scabies with permethrin in comparison with lindane and benzyl benzoate. Dermatol Monatsschr 1989; 175: 296-301 12 Taplin 0, Rivera A, Graham Walker J, Roth WI, Rend 0, Meinking T. A comparative trial of three treatment schedules for the eradication of scabies. J Am Acad Dermatol 1983; 9: 550-4 13 Taplin 0, Meinking TL, Chen JA, Sanchez R. Comparison of crotamiton 10% cream and permethrin 5010 cream for the treatment of scabies in children. Pediatr Dermato/l990; 7: 67-73 14 Schultz MW, Gomez M, Hansen RC, et al. Comparative study of 5% permethrin cream and Ill70 lindane lotion for the treatment of scabies. Arch Dermatol 1990; 126: 167-70
index of liver size did not change significantly. No changes in the degree of periportal fibrosis could be detected. INTRODUCTION
Splenectomy and devascularization is the operation of choice practised in the Central Region of the Sudan, one of the endemic areas for Schistosomas mansoni. The clinical outcome of this operation is excellent. Although numerous studies have reported on the sonographic diagnosis of the disease>", the effect of the operation on the abdominal viscera and vessels involved has not been described. This study reports on the changes encountered following the operation. PATIENTS AND METHODS
SUMMARY
Eleven patients with portal hypertension due to infection with Schistosoma mansoni underwent splenectomy and devascularization operations. The patients were examined with ultrasound once preoperatively and twice postoperatively over a period of about 6 months. Following surgery there was significant and sequential reduction in the diameter of the portal vein at the hilum and the splenic vein at the pancreas. The liver lengths and Correspondence to: Qurashi M Ali, College of Medicine, Sultan Qaboos University, PO Box 32485 Al-Khod, Muscat, Sultanate of Oman
Eleven patients with known diagnosis presented to Wad Medani Teaching Hospital with haematemesis. They had a history of at least one episode of bleeding. After the initial management the patients were examined by ultrasound. They underwent operation and then were re-examined by ultrasound after 2-3 weeks, and again after 5-6 months.
Sonographic examinations 'The initial examination of the liver consisted of measurement of the parasternal, midclavicular and anterior axillary lengths. The index of liver size (ILS) was calculated from the above parameters
Tropical Doctor, October 1992
168
Table 1. Liver, spleen and vascular measurement before and after operation (S and NS, significant and insignificant change respectively) Liver
Before operation 2-3 weeks after operation (significance) 5-6 months after operation (significance)
Vessel diameter (em)
Parasternal length (em)
Midclavieular length (em)
Index of liver size
7.1±2.4 7.4±2.3 (NS)
7.6± 1.2 7.9± 1.8 (NS)
56.9± 16.1 57.4± 13.8 (NS)
7.2 ± 2.4 (NS)
7.6±2.2 (NS)
51.5±8.7 (NS)
according to the equation used by Dittrich et al. 4. The diameters of the portal vein at the porta hepatis and the splenic vein at two sites - splenic hilum and pancreas - were measured. The length, width and thickness of the spleen were used for calculating the splenic volume from the equation for an ellipsoidv>. Following the removal of the spleen, the splenic vein could only be identified behind the body of the pancreas for postoperative measurements. The vein was easily identified and consistently measured in transverse abdominal scans at the level of the origin of the superior mesenteric artery.
Operative procedure The lesser sac was opened at the distal end of the stomach on the greater curvature side, internal to the epiploic vessels, by a 10-20 em hole made in the greater omentum. This gave good access to the splenic artery at the superior edge of the pancreas. The artery was tied in continuity using a (00) silk tie. Devascularization of the greater curvature was carried upwards to include the vasa brevia and the vessels in the gastrosplenic ligament. The spleen was delivered anteromedially and the lienorenal ligament was severed between two clamps as it usually contained two to four big veins in these patients. Any splenculi in the pedicle were removed and the splenectomy was completed after freeing adhesions with adjacent structures. The splenic bed was inspected, all bleeding points were cauterized and the cavity packed. At the distal end of the stomach, a hole was made in the lesser omentum. The left gastric (coronary) vein was ligated. Devascularization of the lesser curvature was carried out superiorly to the gastro-oesophageal junction. Both vagi were identified and preserved. A big redivac drain was left in the splenic vein before the abdomen was closed.
Splenic volume (ml) 1369.5 ± 621.4
Portal vein diameter
Splenic vein at pancreas
1.6±0.3 1.4±0.3 (NS)
1.3 ± 0.4 1.0±0.3 (S)
1.1 ±0.2 (S)
0.7±0.2 (S)
RESULTS
The preoperative sonographic assessment revealed features of advanced hepatosplenic schistosomiasis. These included hepatic periportal fibrosis, a normal or enlarged left lobe of the liver, a small right lobe of the liver, a dilated portal vein, an enlarged spleen, a congested splenic hilum with grossly dilated splenic vein and collaterals. Table 1 summarizes the visceral and vascular measurements before and after the operation. In these patients the minimum volume of the spleen was 452 cm', compared with the mean volume of 116.3 in controls studied in the same region with the same presentation and diagnosis'. The diameters of the portal vein at the porta hepatis and the splenic vein at the pancreas became smaller after the operation.
DISCUSSION
Ultrasonography has limited the indications for radio-isotopic splenoportography and angiography". It has replaced previous invasive procedures like trans-splenic portal manometry, radiographic splenoportography and retrograde hepatic vein catheterization". In the measurement of the splenic vein ultrasound and splenoportography were found to be equally sensitive". Measurement of the liver parasternal and midclavicular lengths, the length of the spleen and the diameters of the portal and splenic veins have been recommended recently by a WHO working group? in order to standardize parameters for quantitative assessment of Schistosoma mansoni. To have a better idea on the size of the spleen removed, our study has also included the splenic volume. The need for a postoperative site for splenic vein measurement necessitated defining the splenic vein in the pancreatic area. The study suggests, for that
Tropical Doctor, October 1992 purpose, the level of the superior mesenteric artery in transverse abdominal scans. The maximum portal vein diameter in normal subjects is 1.3 em!". A previous report by our group' has defined a portal vein diameter in controls as I ± 0.4 em. In the present study we found that the vein decreased to normal values following splenectomy. The vein size is considered to be an indicator of portal blood flow and a good reflection of the degree of hypertension and susceptibility to bleeding''-!', The splenic vein at the level of the pancreas may be another indicator. There was a rapid and significant reduction in its diameter by more than a quarter in each of the two postoperative measurements. Other investigators of portal hypertension 11 have shown the diameter of the left gastric vein to be closely related to the size of oesophageal varices. The mere visualization of the vein has been considered as evidence of portal hypertension", This vessel has not been included in this study because of the difficulty of defining an accurate landmark for repeated measurements of its diameter. Technically, it is not easy to identify a normal or a slightly enlarged left gastric vein. Current attempts of Doppler studies in schistosomiasis may arrive at a suitable technique for monitoring this vessel or its accompanying artery. Hepatomegaly is a consistent finding in early schistosomiasis--'. With the gradual advance of the disease, the left lobe remains enlarged whereas the right lobe decreases in size", We have therefore measured both the parasternal and midclavicular lengths in evaluating liver size. No effect on these diameters or in the index of liver size has followed splenectomy in the specified period of follow-up. Perhaps a longer postoperative period in a larger number of patients may reveal some changes. It is concluded that splenectomy and devascularization are followed within a short period by rapid reduction in the diameters of both the portal and splenic veins with no effect on the size
169
of the left or right lobe of the liver or its total size index. The results suggest that splenectomy and devascularization reduce blood flow in the portal system, a reduction which may in turn lessen the risk of further gastrointestinal haemorrhage. REFERENCES
1 Homeida MA, Ahmed S, Dafalla AA, Suleiman S, Elton I, Nash TH, Bennett JL. Morbidity associated with Schistosoma mansoni as determined by ultrasound: a study in Gezira, Sudan. Am J Trop Med Hyg 1988; 39: 196-201 2 Doehring-Schwertzfeger E, Ali GM, Abdel Rahim 1M, et al. Sonomorphological abnormalities in Sudanese children with Schistosoma mansoni infection; a proposed staging system for field diagnosis of periportal fibrosis. Am J Trap Med Hyg 1989; 41: 63-9 3 Homeida MA, Abdel-Gadir AF, Cheever AW, et al. Diagnosis of pathologically confirmed Symmers' fibrosis by ultrasonography: a prospective blinded study. Am J Trop Med Hyg 1988; 38: 86-91 4 Dittrich M, Milde S, Dinkel F, Baumann W, Wietzel D. Sonographic biometry of liver and spleen size in childhood. Pediatr Radiol 1983; 13: 206-11 5 Ali QM, Abdel Rahim 1M, Doehring-Schwertzfeger E, et al. Ultrasonographic evaluation of gallbladder function in patients with Schistosoma mansoni infection. Trop Doct 1990; 20: 113-15 6 Frider B, Marin AM, Goldberg A, Ultrasonographic diagnosis of portal vein cavernous transformation in children. J Ultrasound Med 1989; 8: 445-9 7 Abdel Latif Z, Abdel-Wahab MF, EI Kady NM. Evaluation of portal hypertension in cases of hepatosplenic schistosomiasis using ultrasound. J C/in Ultrasound 1981; 9: 409-12 8 EI Ghazali y, Salam A, Barakat E, Rifaat H. Diameter of the portal vein (measured by both ultrasonography and splenic portography) in cases of portal hypertension. Abstract #0161. J Ultrasound Med 1988; 7: S46 9 Abdel-Wahab MF, Ali QM, Bergquist NR, et al. The use of diagnostic ultrasound in schistosomiasis: standardization of methodology. Acta Trop 1992; 51: (in press) 10 Cerri GG, Alves VAF, Margalhaes A. Hepatosplenic schistosomiasis mansoni: ultrasound manifestations. Radiology 1984; 153: 777-80 11 Umehara M. Hemodynamic studies of portal hypertension with esophageal varices; a role of left gastric artery and vein. Nippon-Geka-Gakkai-Zasshi 1988; 89: 1869-78
1 Hersch C. Acute glomerulonephritis due to skin disease with special reference to scabies. S Afr Med J 1967; 1: 29-34 2 Acheampong JW, Whittle HC, Obasi EO, et al. Scabies and streptococcal skin infection in Ghana. Trop Doct 1988; 118: 151-2 3 Epidemic scabies and associated acute glomerulonephritis in Trinidad. Bull Pan Am Health Organ 1988; 22: 103-7 4 Takiguchi Y, Kusama K, Nagao S, Iijima S. A case of scabies complicated by acute glomerulonephritis. J Dermato/1987; 114: 163-6 5 Reid HF, Birju B, Holder Y, Hospedales J, Poon King T. Epidemic scabies in four Caribbean islands - 1981-8. Trans R Soc Trop Med Hyg 1990; 84: 298-300 6 Stanton B, Khanam S, Nazrul H, Nuranis, Khair T. Scabies in urban Bangladesh. J Trop Med Hyg 1987; 90: 219-26 7 Taplin 0, et al. Community control of scabies. Lancet 1991; 337: 1016-18
Sonographic changes following splenectomy for portal hypertension in Schistosoma mansoni Qurashi M Ali MD PhD' Osman A Hammour MD FRCS 2 Ibrahim M Abdel Rahim MD MRCP 3 Departments of 'Radiology, 2Surgery and "Intemal Medicine, College of Medicine, University of Gezira, Wad Medani, Sudan TROPICAL DOCTOR,
1992,22, 167-169
167 8 Blumenthal OS, Taplin 0, Schultz MG. A community outbreak of scabies. Am J Epidemiol 1976; 104: 667-72 9 Gulati PV, Braganza C, Singh KP, Borker V. Scabies in a semi-rural area of India: an epidemiologic study. lnt J Dermatol 1977; 16: 594 10 Taplin 0, Arrue C, Graham Walker J, Roth WI, Rivera A. Eradication of scabies. J Am Acad Dermatol 1983; 9: 546-50 11 Haustein EF, Hlawa B. The treatment of scabies with permethrin in comparison with lindane and benzyl benzoate. Dermatol Monatsschr 1989; 175: 296-301 12 Taplin 0, Rivera A, Graham Walker J, Roth WI, Rend 0, Meinking T. A comparative trial of three treatment schedules for the eradication of scabies. J Am Acad Dermatol 1983; 9: 550-4 13 Taplin 0, Meinking TL, Chen JA, Sanchez R. Comparison of crotamiton 10% cream and permethrin 5010 cream for the treatment of scabies in children. Pediatr Dermato/l990; 7: 67-73 14 Schultz MW, Gomez M, Hansen RC, et al. Comparative study of 5% permethrin cream and Ill70 lindane lotion for the treatment of scabies. Arch Dermatol 1990; 126: 167-70
index of liver size did not change significantly. No changes in the degree of periportal fibrosis could be detected. INTRODUCTION
Splenectomy and devascularization is the operation of choice practised in the Central Region of the Sudan, one of the endemic areas for Schistosomas mansoni. The clinical outcome of this operation is excellent. Although numerous studies have reported on the sonographic diagnosis of the disease>", the effect of the operation on the abdominal viscera and vessels involved has not been described. This study reports on the changes encountered following the operation. PATIENTS AND METHODS
SUMMARY
Eleven patients with portal hypertension due to infection with Schistosoma mansoni underwent splenectomy and devascularization operations. The patients were examined with ultrasound once preoperatively and twice postoperatively over a period of about 6 months. Following surgery there was significant and sequential reduction in the diameter of the portal vein at the hilum and the splenic vein at the pancreas. The liver lengths and Correspondence to: Qurashi M Ali, College of Medicine, Sultan Qaboos University, PO Box 32485 Al-Khod, Muscat, Sultanate of Oman
Eleven patients with known diagnosis presented to Wad Medani Teaching Hospital with haematemesis. They had a history of at least one episode of bleeding. After the initial management the patients were examined by ultrasound. They underwent operation and then were re-examined by ultrasound after 2-3 weeks, and again after 5-6 months.
Sonographic examinations 'The initial examination of the liver consisted of measurement of the parasternal, midclavicular and anterior axillary lengths. The index of liver size (ILS) was calculated from the above parameters
Tropical Doctor, October 1992
168
Table 1. Liver, spleen and vascular measurement before and after operation (S and NS, significant and insignificant change respectively) Liver
Before operation 2-3 weeks after operation (significance) 5-6 months after operation (significance)
Vessel diameter (em)
Parasternal length (em)
Midclavieular length (em)
Index of liver size
7.1±2.4 7.4±2.3 (NS)
7.6± 1.2 7.9± 1.8 (NS)
56.9± 16.1 57.4± 13.8 (NS)
7.2 ± 2.4 (NS)
7.6±2.2 (NS)
51.5±8.7 (NS)
according to the equation used by Dittrich et al. 4. The diameters of the portal vein at the porta hepatis and the splenic vein at two sites - splenic hilum and pancreas - were measured. The length, width and thickness of the spleen were used for calculating the splenic volume from the equation for an ellipsoidv>. Following the removal of the spleen, the splenic vein could only be identified behind the body of the pancreas for postoperative measurements. The vein was easily identified and consistently measured in transverse abdominal scans at the level of the origin of the superior mesenteric artery.
Operative procedure The lesser sac was opened at the distal end of the stomach on the greater curvature side, internal to the epiploic vessels, by a 10-20 em hole made in the greater omentum. This gave good access to the splenic artery at the superior edge of the pancreas. The artery was tied in continuity using a (00) silk tie. Devascularization of the greater curvature was carried upwards to include the vasa brevia and the vessels in the gastrosplenic ligament. The spleen was delivered anteromedially and the lienorenal ligament was severed between two clamps as it usually contained two to four big veins in these patients. Any splenculi in the pedicle were removed and the splenectomy was completed after freeing adhesions with adjacent structures. The splenic bed was inspected, all bleeding points were cauterized and the cavity packed. At the distal end of the stomach, a hole was made in the lesser omentum. The left gastric (coronary) vein was ligated. Devascularization of the lesser curvature was carried out superiorly to the gastro-oesophageal junction. Both vagi were identified and preserved. A big redivac drain was left in the splenic vein before the abdomen was closed.
Splenic volume (ml) 1369.5 ± 621.4
Portal vein diameter
Splenic vein at pancreas
1.6±0.3 1.4±0.3 (NS)
1.3 ± 0.4 1.0±0.3 (S)
1.1 ±0.2 (S)
0.7±0.2 (S)
RESULTS
The preoperative sonographic assessment revealed features of advanced hepatosplenic schistosomiasis. These included hepatic periportal fibrosis, a normal or enlarged left lobe of the liver, a small right lobe of the liver, a dilated portal vein, an enlarged spleen, a congested splenic hilum with grossly dilated splenic vein and collaterals. Table 1 summarizes the visceral and vascular measurements before and after the operation. In these patients the minimum volume of the spleen was 452 cm', compared with the mean volume of 116.3 in controls studied in the same region with the same presentation and diagnosis'. The diameters of the portal vein at the porta hepatis and the splenic vein at the pancreas became smaller after the operation.
DISCUSSION
Ultrasonography has limited the indications for radio-isotopic splenoportography and angiography". It has replaced previous invasive procedures like trans-splenic portal manometry, radiographic splenoportography and retrograde hepatic vein catheterization". In the measurement of the splenic vein ultrasound and splenoportography were found to be equally sensitive". Measurement of the liver parasternal and midclavicular lengths, the length of the spleen and the diameters of the portal and splenic veins have been recommended recently by a WHO working group? in order to standardize parameters for quantitative assessment of Schistosoma mansoni. To have a better idea on the size of the spleen removed, our study has also included the splenic volume. The need for a postoperative site for splenic vein measurement necessitated defining the splenic vein in the pancreatic area. The study suggests, for that
Tropical Doctor, October 1992 purpose, the level of the superior mesenteric artery in transverse abdominal scans. The maximum portal vein diameter in normal subjects is 1.3 em!". A previous report by our group' has defined a portal vein diameter in controls as I ± 0.4 em. In the present study we found that the vein decreased to normal values following splenectomy. The vein size is considered to be an indicator of portal blood flow and a good reflection of the degree of hypertension and susceptibility to bleeding''-!', The splenic vein at the level of the pancreas may be another indicator. There was a rapid and significant reduction in its diameter by more than a quarter in each of the two postoperative measurements. Other investigators of portal hypertension 11 have shown the diameter of the left gastric vein to be closely related to the size of oesophageal varices. The mere visualization of the vein has been considered as evidence of portal hypertension", This vessel has not been included in this study because of the difficulty of defining an accurate landmark for repeated measurements of its diameter. Technically, it is not easy to identify a normal or a slightly enlarged left gastric vein. Current attempts of Doppler studies in schistosomiasis may arrive at a suitable technique for monitoring this vessel or its accompanying artery. Hepatomegaly is a consistent finding in early schistosomiasis--'. With the gradual advance of the disease, the left lobe remains enlarged whereas the right lobe decreases in size", We have therefore measured both the parasternal and midclavicular lengths in evaluating liver size. No effect on these diameters or in the index of liver size has followed splenectomy in the specified period of follow-up. Perhaps a longer postoperative period in a larger number of patients may reveal some changes. It is concluded that splenectomy and devascularization are followed within a short period by rapid reduction in the diameters of both the portal and splenic veins with no effect on the size
169
of the left or right lobe of the liver or its total size index. The results suggest that splenectomy and devascularization reduce blood flow in the portal system, a reduction which may in turn lessen the risk of further gastrointestinal haemorrhage. REFERENCES
1 Homeida MA, Ahmed S, Dafalla AA, Suleiman S, Elton I, Nash TH, Bennett JL. Morbidity associated with Schistosoma mansoni as determined by ultrasound: a study in Gezira, Sudan. Am J Trop Med Hyg 1988; 39: 196-201 2 Doehring-Schwertzfeger E, Ali GM, Abdel Rahim 1M, et al. Sonomorphological abnormalities in Sudanese children with Schistosoma mansoni infection; a proposed staging system for field diagnosis of periportal fibrosis. Am J Trap Med Hyg 1989; 41: 63-9 3 Homeida MA, Abdel-Gadir AF, Cheever AW, et al. Diagnosis of pathologically confirmed Symmers' fibrosis by ultrasonography: a prospective blinded study. Am J Trop Med Hyg 1988; 38: 86-91 4 Dittrich M, Milde S, Dinkel F, Baumann W, Wietzel D. Sonographic biometry of liver and spleen size in childhood. Pediatr Radiol 1983; 13: 206-11 5 Ali QM, Abdel Rahim 1M, Doehring-Schwertzfeger E, et al. Ultrasonographic evaluation of gallbladder function in patients with Schistosoma mansoni infection. Trop Doct 1990; 20: 113-15 6 Frider B, Marin AM, Goldberg A, Ultrasonographic diagnosis of portal vein cavernous transformation in children. J Ultrasound Med 1989; 8: 445-9 7 Abdel Latif Z, Abdel-Wahab MF, EI Kady NM. Evaluation of portal hypertension in cases of hepatosplenic schistosomiasis using ultrasound. J C/in Ultrasound 1981; 9: 409-12 8 EI Ghazali y, Salam A, Barakat E, Rifaat H. Diameter of the portal vein (measured by both ultrasonography and splenic portography) in cases of portal hypertension. Abstract #0161. J Ultrasound Med 1988; 7: S46 9 Abdel-Wahab MF, Ali QM, Bergquist NR, et al. The use of diagnostic ultrasound in schistosomiasis: standardization of methodology. Acta Trop 1992; 51: (in press) 10 Cerri GG, Alves VAF, Margalhaes A. Hepatosplenic schistosomiasis mansoni: ultrasound manifestations. Radiology 1984; 153: 777-80 11 Umehara M. Hemodynamic studies of portal hypertension with esophageal varices; a role of left gastric artery and vein. Nippon-Geka-Gakkai-Zasshi 1988; 89: 1869-78
