Small Bowel

S. mansoni does not commonly cause radiological changes in the small bowel although ova may be recovered from the duodenum, jejunum, and upper ileum (Figs. 2.36, 2.38). When the infection is severe, the radiological changes resemble other parasitic infections or regional enteritis, and it may be difficult to distinguish the etiology even on histological examination.

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Fig. 2.36 A-D. All varieties of schistosomiasis can affect the duodenum; patients present clinically with vague symptoms suggesting peptic ulceration. A Marked deformity and narrowing of the pylorus and duodenum in a 22-year-old Puerto Rican male with a 4-year history of pain and vomiting, with weight loss in the past few months. The stomach is dilated. At surgery the pylorus was involved in a 5x5 cm mass, adherent posterioly to the pancreas, gallbladder, and first part of the duodenum. There was local lymphadenopathy. Histology showed chronic peptic duodenal ulceration, with schistosomal granulomas in the submucosa of the first part of the duodenum, and also in the lymph nodes, where there were multiple schistosome eggs. There were similar findings in the appendix and liver AFIP 68-9019-7. B The edematous second and third parts of the duodenum of an African from the Sudan. There was decreased peristalsis. He had portal hypertension and hepatomegaly due to S. mansoni. (From P.E.S. Palmer, in: Simpkins K.C. (ed): A Textbook of Radiological Diagnosis, vol 4, 5th edn. London, H.K. Lewis, 1988, pp 678-705) C Four views of the first and second part of the duodenum of a Chinese patient with schistsomiasis japonica. (Courtesy of Prof. Xing-Rong Chen, Shanghai) D The very edematous duodenum of a patient from Iran with schistosomiasis mansoni.

Acute mesenteric ischemia has been caused by S. mansoni, but in a patient who was dehydrated and who had previous splenectomy because of splenomegaly. There were many eggs in the thrombosis.

Patients with chronic schistosomal bowel infection become anemic and they have a protein-losing enteropathy. In one series from Egypt, well over half the patients had marked clubbing of the fingers, pain, swelling and tenderness around the wrists, knees and ankle joints. Radiographically there was periosteal reaction and new bone formation, particularly around the wrists. Treatment for the schistosomal polyposis improved the patient's swelling and tenderness but the clubbing persisted and the periosteal reaction did not improve. There was some correlation between the extent of the polyposis and the finger clubbing, but those who had hepatosplenomegaly had this only to a moderate degree. It is possible that clubbing may be more frequent than is reported, because many middle aged and older patients in the tropics have chronic lung disease from other causes,and clubbing is not unexpected.