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ULTRASOUND
AbdomenDemonstration data

Abdominal Ultrasound: Schistosomiasis

Ultrasound is the principal imaging tool for chronic schistosomiasis, grading hepatic periportal fibrosis in S. mansoni/japonicum infection and detecting urinary-tract disease in S. haematobium. Standardised assessment follows the WHO Niamey protocol, which allows reproducible grading and community-level monitoring in endemic regions. It is safe, portable and repeatable, guiding praziquantel treatment and surveillance of portal-hypertensive and urological complications.

Indications

  • Screening in endemic communities and known or treated schistosomiasis
  • Hepatosplenomegaly or signs of portal hypertension (variceal bleeding, ascites)
  • Terminal haematuria, dysuria or suspected urinary S. haematobium disease
  • Evaluation of hydronephrosis and bladder pathology in urinary schistosomiasis
  • Assessment before and after praziquantel therapy to monitor regression or progression
  • Investigation of unexplained portal hypertension in a patient from an endemic area

Contraindications & Cautions

  • No contraindications; ultrasound is safe, non-ionising and repeatable
  • Safe in pregnancy and children
  • Bowel gas, obesity and operator dependence may limit periportal and retroperitoneal assessment
  • Grading requires standardised technique and trained operators for reproducibility

Patient Preparation

  • Fasting 4-6 hours reduces bowel gas and improves liver and portal visualisation
  • A moderately full bladder is needed to assess bladder wall thickness and masses for urinary disease
  • Supine and decubitus positioning; deep inspiration to display the liver and spleen
  • Explain the examination and obtain verbal consent
  • Record geographic exposure, species where known, and prior treatment history

Technique & Parameters

  • Curvilinear transducer 3-5 MHz; use the WHO Niamey protocol for standardised liver assessment
  • Grade periportal fibrosis by peripheral portal branch wall thickness/echogenic cuffing (image patterns A-F, network/pipe-stem)
  • Measure liver (including left lobe/caudate) and spleen dimensions and describe surface and parenchyma
  • Portal vein diameter and Doppler flow direction/velocity; assess for collaterals and ascites in portal hypertension
  • For urinary disease: measure bladder wall thickness (abnormal >5 mm at adequate filling), look for masses, calcification and pseudopolyps
  • Assess both kidneys and ureters for hydronephrosis and hydroureter

Systematic Review

  • Liver: size, echogenicity, periportal cuffing pattern and Niamey grade
  • Portal system: portal vein diameter, flow direction, collaterals and thrombosis
  • Spleen: size and any secondary changes of portal hypertension
  • Peritoneum: free fluid/ascites and gallbladder wall changes
  • Bladder: wall thickness, calcification, masses, pseudopolyps and residual volume
  • Upper tracts: hydronephrosis, hydroureter, ureteric wall thickening and calcification
  • Overall correlation of hepatic and urinary findings with species and exposure

Key Findings & Significance

  • Periportal (pipe-stem) fibrosis: echogenic bands/cuffs along portal tracts, graded 0-3 (WHO Niamey) - hallmark of hepatic S. mansoni
  • Portal hypertension: portal vein dilatation, splenomegaly, collaterals and ascites with a normal-sized or shrunken right lobe and left-lobe/caudate hypertrophy
  • Splenomegaly out of proportion to hepatocellular dysfunction (presinusoidal hypertension)
  • Bladder wall thickening >5 mm, focal masses, pseudopolyps and mural calcification in S. haematobium
  • Hydronephrosis and hydroureter from ureteric involvement and obstruction
  • Regression of early fibrosis and bladder changes after praziquantel; established fibrosis may persist

Differential Considerations

  • Periportal echogenicity: schistosomal fibrosis versus congenital hepatic fibrosis, cholangitis, portal tract oedema
  • Presinusoidal portal hypertension: schistosomiasis versus portal vein thrombosis, congenital hepatic fibrosis, non-cirrhotic portal fibrosis
  • Massive splenomegaly: schistosomiasis, chronic malaria, visceral leishmaniasis, haematological disease
  • Thick-walled bladder: schistosomiasis, chronic cystitis, neurogenic bladder, outlet obstruction, tumour
  • Bladder calcification: S. haematobium versus tuberculosis or prior therapy
  • Hydronephrosis: schistosomal ureteric disease, calculus, tuberculosis, malignancy

Pearls & Pitfalls

  • Preserved hepatocellular function with marked portal hypertension is characteristic - it is presinusoidal, not cirrhotic
  • Use the WHO Niamey image patterns for reproducible grading and follow-up
  • S. haematobium bladder disease is a recognised risk factor for squamous cell carcinoma - flag suspicious focal masses
  • Assess the bladder only when adequately filled; an empty bladder overestimates wall thickness
  • Coexisting infections (malaria, viral hepatitis, HIV, TB) can confound the hepatic and splenic picture
  • Established pipe-stem fibrosis may not regress after treatment, whereas early disease and bladder lesions often do

Structured Report

  • State species/exposure context and whether the WHO Niamey protocol was applied
  • Report liver size, periportal fibrosis pattern and grade
  • Describe portal vein calibre, flow, collaterals, spleen size and ascites
  • For urinary disease, report bladder wall thickness, calcification, masses and upper-tract dilatation
  • Flag any suspicious bladder mass warranting cystoscopy/biopsy
  • Impression: summarise disease grade and complications, correlate with clinical and lab data, and recommend praziquantel and follow-up ultrasound

References

  • WHO/TDR Niamey-Belgium Protocol: Ultrasound in Schistosomiasis (Richter J et al.)
  • WHO Guideline on control and elimination of human schistosomiasis
  • WHO Manual of Diagnostic Ultrasound
  • RadioGraphics: Imaging of Schistosomiasis

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.