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Small-bowel obstruction due to bilharziasis

TO THE EDITOR: Small-bowel obstruction is an extremely rare complication of schistosomiasis. Herein, we report on such a case after a review of the relevant literature. A 31-year-old Egyptian man was admitted to our unit complaining of acute, agonizing, generalized abdominal pain of one day’s duration associated with vomiting. The patient had a history of schistosomiasis but with no past history of surgery. The patient was in pain during the physical examination, and had a temperature of 378C, blood pressure of 150/ 70 mmHg, and a pulse rate of 77 bpm (beats per minute). The patient’s abdomen was mildly distended with pronounced tenderness all over but was relatively soft. Bowel sounds were exaggerated. Rectal examination was normal. Serum electrolytes, liver function tests, and serum amylase were normal. Hemoglobin was 16.3 g/dl and white cell count was 21.1 10/l. Abdominal X-ray showed few multiple fluid levels. Abdominal ultrasound showed free intraperitoneal fluid and mildly dilated small-bowel loops. An abdominal CT scan revealed distended small-bowel loops which were mainly located in the pelvis, cirrhotic liver, free intraperitoneal fluid, and normal mesenteric vessels without thrombosis. Gastrographin follow-through was suggestive of partial small-bowel obstruction. The patient was initially managed conservatively with intravenous fluid and nasogastric aspiration but his condition did not improve. A peritoneal tap was performed and showed bloody fluid, so laparotomy was decided on. Laparotomy showed a closed gangrenous smallbowel loop which was mainly located in the pelvis. A fibrous band had extended between the mesentery and the urinary bladder causing strangulation of the bowel. The liver was nodular and cirrhotic, the sigmoid colon was thickened and inflamed, and the appendix was thickened and fibrous. About 1.2 m of the gangrenous small bowel was resected with endto-end anastomosis. The patient then underwent an appendectomy; the postoperative course was uneventful. Histopathology of the gangrenous small-bowel segment showed ischemic enteritis with sloughing of the lining mucosa. The lamina propria displayed marked vascular telangiectasia with mixed inflammatory cell infiltration. The muscularis propria had multiple schistosomal ova embedded between the muscle layers. The microscopic examination of the fibrous band showed occasional bilharzial ova embedded within a fibrous tissue (Figure 1). The histology of the appendix was normal. Postoperatively, the patient was treated with a single dose of anti-bilharzia drugs.