Schistosomiasis (hepatic manifestations)

Last revised by Dr Yuranga Weerakkody on 02 Aug 2021

Schistosomiasis hepatic manifestations are a chronic result of the deposition of eggs into small portal venules leading to periportal fibrosis and liver cirrhosis.  

For a general view over this trematode infection, please refer to the main article on schistosomiasis.

Associated with an increased risk of hepatocellular carcinoma, particularly secondary to the S.Mansoni subtype

Usually, these patients will present with portal hypertension signs and symptoms, including splenomegaly, gastroesophageal varices, hematemesis, and ascites. Hepatic function is commonly preserved until late stages 2

Living in the bowel lumen, Schistosomes lay eggs in the mesenteric veins and, thus, these eggs can reach the portal vein. Species S. mansoni and S. japonicum are most common. Within the portal venules, an inflammatory reaction and consequent granulomatous response will lead to periportal fibrosis as a healing process 1-3. Due to the difference in the size of the eggs, S. mansoni infection has its eggs deposited along the large portal veins of the hepatic hilum, whereas the S. japonicum infection has the eggs laying within the small peripheral portal veins 2

Imaging manifestations only occur late in the course of the chronic infection and there are some specific features related to the different distribution of the eggs depending on S. mansoni or S. japonicum infection.

  • common features
  • S. japonicum
    • septa and capsular calcifications 
  • S. mansoni
    • portal veins wall thickening and increased echogenicity
      • “bull’s-eye” appearance: an anechoic portal vein surrounded by echogenic fibrous tissue
  • common features
  • S. japonicum
    • turtle back sign: calcified septa and fibrosis resembling a turtle carapace, considered pathognomonic
    • capsular calcification
    • periportal fat extending deep into the liver due to the parenchymal retraction
  • S. mansoni
    • low-attenuation surrounding the portal vein branches associated with marked contrast enhancement (periportal fibrosis) 1-2
    • eggs calcification is not seen as commonly as calcification of S.
      japonicum eggs and consequently calcification along the portal tracts is not a common feature 2

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Cases and figures

  • Case 1: presumed S. mansoni
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  • Case 2: periportal fibrosis on US
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