Can Schistosomiasis Cause Cirrhosis?
Schistosomiasis does NOT typically cause true cirrhosis, but rather causes periportal fibrosis ("pipestem fibrosis") that leads to portal hypertension without the hepatocellular dysfunction characteristic of cirrhosis. This is a critical distinction that affects prognosis and management.
Key Pathophysiologic Distinction
Schistosomiasis causes presinusoidal portal fibrosis from egg deposition in small portal venules, particularly with S. mansoni, S. japonicum, and S. mekongi infections, resulting in the characteristic "pipestem" fibrosis pattern 1
This periportal fibrosis creates portal hypertension through presinusoidal obstruction, involving both mechanical blockage from fibrosis and local vascular inflammation from schistosome eggs 1
Unlike alcoholic or viral cirrhosis, hepatocellular function is typically preserved in schistosomiasis, as the fibrosis is confined to portal tracts rather than causing diffuse hepatocyte destruction and regenerative nodules 2
The size and shape of the liver remain relatively preserved in schistosomal disease, contrasting with the nodular, shrunken liver of true cirrhosis 3
Clinical Manifestations of Hepatosplenic Schistosomiasis
Hepatosplenic schistosomiasis manifests as hepatosplenomegaly, portal hypertension with esophageal varices, and progressive hepatic fibrosis 1
Approximately 90% of infected individuals develop only small focal areas of periportal fibrosis with scattered periovular granulomas, while a minority develop extensive disease with numerous granulomas throughout the portal system 2
Portal hypertension complications include variceal bleeding, which can precipitate acute hepatic decompensation and jaundice in advanced cases 1
When True Cirrhosis May Develop
Coinfection with hepatitis B virus significantly increases the risk of progression from schistosomal fibrosis to true cirrhosis and hepatocellular carcinoma 4
Schistosomiasis should be assessed in persons from endemic areas (S. mansoni or S. japonicum) who have chronic HBV infection, as schistosomiasis might increase progression to cirrhosis or HCC in the presence of HBV infection 4
Heavy chronic infections with extensive portal fibrosis may eventually lead to hepatocellular dysfunction resembling cirrhosis, though this represents a severe form of chronic hepatopathy rather than classic cirrhosis 2
Diagnostic Imaging Patterns
Sonography in S. mansoni infection shows echogenic thickening or fibrotic bands along portal veins, with CT demonstrating low-attenuation bands around large portal vein branches with marked enhancement 3
Sonography in S. japonicum infection shows echogenic septae outlining polygonal liver lobules in a "fish-scale" network appearance, with CT showing periportal septae producing a "turtle-back" appearance from calcified eggs 3
Abdominal ultrasound demonstrating hepatic "pipestem" fibrosis and portal hypertension supports the diagnosis of hepatosplenic schistosomiasis 5
Critical Clinical Pitfalls
Do not confuse periportal fibrosis with cirrhosis when counseling patients—the prognosis and hepatocellular reserve are fundamentally different 2
Conventional liver function tests provide little information about the dynamics of schistosomal fibrosis, as hepatocellular function remains largely intact until very advanced disease 6
Jaundice in schistosomiasis typically occurs only in chronic, heavy infections with established hepatosplenic disease and portal hypertension, not in early or light infections 1
Always screen for viral hepatitis coinfection (HBV, HCV) in patients with schistosomiasis, as this combination dramatically increases cirrhosis and HCC risk 4