Splenic palpation for the evaluation of morbidity due to schistosomiasis mansoni

This study was undertaken to determine the accuracy of splenic palpation for the diagnosis of splenomegaly, and to determine whether the frequency of individuals with a palpable spleen in an endemic area can be considered as an index of morbidity of schistosomiasis. For the clinical diagnosis of splenomegaly, two criteria have been tested: (A) presence of a palpable spleen and (B) presence of a palpable spleen whose border could be felt more than 4 cm below the costal margin. In an area of high prevalence of the disease (66.3%) 285 individuals aged 18 years or more have been submitted to abdominal ultrasonography and physical examination. Splenomegaly was defined as a splenic length greater than 120 mm by ultrasound and the sensitivity, specificity, positive and negative predictive values of criterion A were 72.2%, 90.5%, 35.1% and 97.8%. The values for criterion B were 27.8%, 98%, 50% and 95%, respectively. In an non endemic area, 517 individuals were submitted to the same protocol and 22 individuals had a palpable spleen, but no patient fulfilled criterion B for splenomegaly, and only one met the ultrasonographic criterion for splenomegaly. The authors concluded that abdominal palpation is a poor method for the diagnosis of splenomegaly.

Comparison between clinical and ultrasonographic findings in cases of periportal fibrosis in an endemic area for schistosomiasis mansoni in Brazil

INTRODUCTION: Abdominal palpation and ultrasound findings among patients from an endemic area for schistosomiasis in Brazil who had been followed up for 27 years were compared. METHODS: In 2004, 411 patients from Brejo do Espírito Santo, in the State of Bahia, were selected for the present investigation after giving their written informed consent. Based on clinical data, they were divided into three groups: 41 patients with evidence of liver fibrosis in 2004 (Group 1); 102 patients with evidence of liver fibrosis in the past (1976-1989) but not in 2004 (Group 2); and 268 patients without evidence of liver fibrosis at any time during the 27-year follow-up (Group 3). All of the patients underwent abdominal ultrasound in which the examiner did not know the result from the clinical examination. The data were stored in a database. RESULTS: The prevalence of periportal fibrosis on ultrasound was 82.9%, 56.9% and 13.4% in Groups 1, 2 and 3, respectively. In the presence of hard, nodular liver or prominent left lobe and a hard palpable spleen, ultrasound revealed periportal fibrosis in 70.9%. However, periportal fibrosis was diagnosed using ultrasound in 25.4% of the patients in the absence of clinical evidence of liver involvement. Thus, ultrasound diagnosed periportal fibrosis 3.1 times more frequently than clinical examination did. CONCLUSIONS: Although clinical examination is important in evaluating morbidity due to Manson's schistosomiasis in endemic areas, ultrasound is more accurate in diagnosing liver involvement and periportal fibrosis.

Revisiting the concept of hepatosplenic schistosomiasis and its challenges using traditional and new tools

Different aspects of hepatosplenic schistosomiasis are revisited here. Manson's schistosomiasis causes periportal fibrosis and portal hypertension in approximately 6% of infected subjects, usually with preservation of their hepatic function. The assessment of liver involvement is of major importance in determining the prognosis and risk of complications from schistosomiasis, such as upper digestive bleeding secondary to variceal rupture. For many years, the diagnosis of hepatosplenic schistosomiasis and liver fibrosis was made by abdominal palpation and the finding of liver and/or spleen enlargement. However, there is no consensus regarding the clinical parameters of the liver and spleen to be considered in this physical evaluation. For the last three decades, abdominal ultrasound (US) has become the best imaging technique to evaluate liver fibrosis caused by schistosomiasis mansoni. However, US is a subjective procedure and is therefore examiner-dependent. Magnetic resonance imaging (MRI) findings have provided valuable information in addition to ultrasound and clinical examination. The combination of a comprehensive history and physical examination, basic laboratory tests (a stool examination for Schistosoma mansoni eggs and a blood cell count), biomarkers for liver fibrosis/portal hypertension and imaging methods seem to offer the best approach for evaluating patients with this disease. In situations where research is involved or in patients with severe disease, MRI may be considered.

Hepatosplenic schistosomiasis in field-based studies: a combined clinical and sonographic definition

A combined clinical and sonographic classification of hepatosplenic schistosomiasis mansoni to be used in field-based studies is proposed herein. Seven hundred forty one individuals out of 892 (83%), living in an area endemic for schistosomiasis in Brazil, have been ubmitted to clinical and ultrasound examinations. Based on two stool examinations the overall prevalence for schistosomiasis in this area was 73%. Abdominal palpation was performed with patients in dorsal decubit, during deep breath, by two experienced physicians and a portable ultrasound was used for the evaluation of liver fibrosis, portal collaterals and spleen size. Four groups of individuals were identified using data obtained by abdominal palpation and ultrasound examination: (1) palpable spleen and intense periportal thickening in 9 individuals (1.2%); (2) spleen not palpable and intense periportal thickening in 15 (2%); (3) palpable spleen with light to moderate periportal thickening in 32 (4.3%), and (4) palpable spleen with a normal liver on ultrasound in 30 (4%). The definition of hepatosplenic schistosomiasis in field-based studies as the finding of Schistosoma mansoni eggs in the stools in an individual with splenomegaly is not acceptable anymore. Abdominal ultrasound should be combined with clinical examination to accurately identify hepatosplenics in endemic areas for schistosomiasis.

Tricobezoares no estômago, duodeno e íleo

A 21-year-old girl presents with a 15-day history of epigastric pain and vomiting. Ten days later, constipation and abdominal distension followed. The patient reported similar epigastric pain and vomiting for 6 days last year. A painless epigastric 12-by-8-centimeter tumor was observed on abdominal palpation, and rectal examination revealed an extrinsic tumor compressing anterior rectal wall. Upper digestive endoscopy showed a trichobezoar. Upon laparotomy, one gastric and one duodenal trichobezoar were removed through an anterior gastrotomy. Another one was found 40 centimeters proximal to the ileo-cecal valve and removed through a proximal ileotomy. Trichobezoar is an unspecific disease, which diagnosis is made upon suspicion. Early recognition of bezoars is important because morbidity and mortality rise considerably once complications occur. We illustrate this case to emphasize the need for early recognition and surgical management in order to reduce morbimortality.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Fatores associados à obesidade abdominal em mulheres em idade reprodutiva

OBJETIVO: Investigar variáveis potencialmente associadas à obesidade abdominal em mulheres em idade reprodutiva. MÉTODOS: Foram investigadas 781 mulheres a partir de informações coletadas pela Pesquisa Nutrição e Saúde realizada em 1996 no Município do Rio de Janeiro. A obesidade abdominal foi definida como circunferência da cintura (CC) > 80 cm ou como Razão Cintura Quadril (RCQ) > 0,85. A análise estatística envolveu o cálculo de medidas de tendência central. A associação entre obesidade abdominal e Índice de Massa Corporal, idade, paridade e uso de tabaco foi testada por meio do cálculo do "Odds Ratio" (OR), usando a técnica de regressão logística multivariada. RESULTADOS: As maiores freqüências de obesidade abdominal foram observadas em mulheres acima de 35 anos e com dois ou mais filhos (50,7%). Os valores de OR demonstram o efeito da interação entre paridade e idade para CC>80 cm quando controlado apenas o efeito dessas duas variáveis. A partir dos modelos de regressão logística, verificou-se que quando a população foi estratificada em mulheres com e sem sobrepeso, apenas a escolaridade esteve associada à RCQ, enquanto a associação com idade e paridade desapareceu para a CC>80 cm. CONCLUSÕES: A obesidade abdominal nesse grupo populacional independe da idade e da paridade quando ajustado pelo peso relativo, sendo suas maiores determinantes a adiposidade geral e a escolaridade. Ter maior escolaridade significou possuir uma RCQ menor. É fundamental implementar estratégias de prevenção para o desenvolvimento da obesidade, cujo enfoque sejam mulheres em idade reprodutiva.

Excesso de peso e gordura abdominal para a síndrome metabólica em nipo-brasileiros

OBJETIVO: A obesidade, especialmente de distribuição abdominal, associa-se a fatores de risco cardiovasculares como a dislipidemia, a hipertensão arterial (HA) e o diabetes mellitus (DM). A importância desses fatores em nipo-brasileiros foi previamente demonstrada, apesar de a obesidade não ser característica marcante dos migrantes japoneses. Realizou-se estudo com o objetivo de avaliar a prevalência de excesso de peso e a adiposidade central (AC) em nipo-brasileiros e suas relações com distúrbios metabólicos. MÉTODOS: A amostra incluiu 530 nipo-brasileiros (40-79 anos) de primeira e segunda gerações, submetidos a medidas antropométricas de pressão arterial, perfil lipídico e teste oral de tolerância à glicose. A prevalência (por ponto e intervalo de confiança) de excesso de peso foi calculada pelo valor de corte >26,4 kg/m². O diagnóstico de AC foi baseado na razão entre as circunferências da cintura e do quadril (RCQ), sendo que valores > ou = 0,85 e > ou = 0,95, para mulheres e homens, respectivamente, firmavam esse diagnóstico. RESULTADOS: A prevalência de excesso de peso foi de 22,4% (IC95%-- 20,6-28,1), e a de AC, de 67,0% (IC95% -- 63,1-70,9). Além de maiores prevalências de DM, HA e dislipidemia, estratificando-se pelo índice de massa corporal (IMC) e RCQ, indivíduos com excesso de peso e adiposidade central apresentaram pior perfil metabólico: a pressão arterial foi significantemente maior naqueles com excesso de peso, sem e com AC; indivíduos com AC apresentaram maiores índices de glicemia, triglicerídeos, colesterol total e LDL e menor HDL quando comparados aos sem excesso de peso e sem AC; a insulinemia de jejum foi significantemente maior em indivíduos com excesso de peso (sem e com AC) do que naqueles sem excesso de peso e sem AC. CONCLUSÃO: A comparação de subgrupos com e sem adiposidade central foi compatível com a hipótese de que a deposição abdominal de gordura representa fator de risco para doenças interligadas pela resistência à insulina, inclusive em população de origem oriental. A alta prevalência de síndrome metabólica nos migrantes japoneses pode ser decorrente da deposição visceral de gordura, implicada na gênese da resistência à insulina.

Importância relativa do Índice de Massa Corporal e da circunferência abdominal na predição da hipertensão arterial

OBJETIVO: Avaliar a importância relativa do Índice de Massa Corporal (IMC) e da circunferência abdominal na determinação da hipertensão arterial em adultos. MÉTODOS: Estudo transversal com amostra de funcionários (N=1.584), entre 18 e 64 anos de idade, de hospital geral privado do município de São Paulo. A coleta de dados envolveu questionário estruturado, medida da pressão arterial, peso, altura e circunferência abdominal. A hipertensão foi diagnosticada com pressão arterial > 140/90 mmHg ou uso de medicação anti-hipertensiva. A importância relativa do IMC e da circunferência abdominal foi calculada pela fração atribuível de hipertensão correspondente a cada indicador antropométrico, empregando-se níveis de cortes usuais e baseados na distribuição observada na população estudada. Adicionalmente, foi desenvolvido um indicador que combinou simultaneamente valores de IMC e circunferência abdominal. RESULTADOS: A prevalência de hipertensão foi de 18,9% (26,9% em homens e 12,5% em mulheres). Em homens, a fração de hipertensão atribuível ao IMC superou aquela atribuível à circunferência abdominal segundo níveis de corte usuais (56% x 48%, respectivamente) e quartis da distribuição observada (73% x 69%, respectivamente). Para mulheres, a fração de hipertensão atribuível à circunferência abdominal superou ligeiramente aquela atribuível ao IMC nos níveis de corte usuais (44% x 41%, respectivamente); mas se observou situação inversa empregando a classificação em quartis (41% x 57%, respectivamente). Somente em mulheres a fração de hipertensão atribuível ao indicador que combinou IMC e circunferência abdominal (64%) superou a fração atribuível a cada medida isolada. CONCLUSÕES: Tanto o IMC quanto a circunferência abdominal se associaram positiva e independentemente com a ocorrência de hipertensão arterial, sendo superior a influência exercida pelo IMC em homens.

Consumo de bebida alcoólica e adiposidade abdominal em doadores de sangue

OBJETIVO: Analisar a associação entre o consumo de bebidas alcoólicas e adiposidade abdominal. MÉTODOS: Estudo transversal com uma amostra de homens doadores de sangue (N=1.235), de 20 a 59 anos, em Cuiabá (MT), realizado de agosto/1999 a janeiro/2000. Os indicadores de adiposidade abdominal foram circunferência da cintura e relação cintura/quadril, ajustados pela adiposidade total. As medidas aferidas foram: peso, estatura, circunferências da cintura e do quadril. O consumo de álcool foi avaliado utilizando-se um questionário sobre tipo, freqüência e quantidade da bebida consumida. A associação entre o consumo de álcool e adiposidade abdominal foi analisada por regressão linear múltipla, com os modelos ajustados para idade, atividade física, tabagismo e adiposidade total. RESULTADOS: Após ajuste, a circunferência da cintura e a relação cintura quadril mantiveram-se associadas positivamente ao consumo de cerveja (p=0,02) e ao total de álcool consumido (p=0,01 e 0,03, respectivamente). O consumo de aguardente mostrou associação somente com a circunferência da cintura (p=0,04). CONCLUSÕES: O consumo de álcool, particularmente de cerveja, associou-se com a localização abdominal de gordura.

Educational inequality in the occurrence of abdominal obesity:Pró-Saúde Study

OBJECTIVE To estimate the degree of educational inequality in the occurrence of abdominal obesity in a population of non-faculty civil servants at university campi.METHODS In this cross-sectional study, we used data from 3,117 subjects of both genders aged 24 to 65-years old, regarding the baseline ofPró-Saúde Study, 1999-2001. Abdominal obesity was defined according to abdominal circumference thresholds of 88 cm for women and 102 cm for men. A multi-dimensional, self-administered questionnaire was used to evaluate education levels and demographic variables. Slope and relative indices of inequality, and Chi-squared test for linear trend were used in the data analysis. All analyses were stratified by genders, and the indices of inequality were standardized by age.RESULTS Abdominal obesity was the most prevalent among women (43.5%; 95%CI 41.2;45.9), as compared to men (24.3%; 95%CI 22.1;26.7), in all educational strata and age ranges. The association between education levels and abdominal obesity was an inverse one among women (p < 0.001); it was not statistically significant among men (p = 0.436). The educational inequality regarding abdominal obesity in the female population, in absolute terms (slope index of inequality), was 24.0% (95%CI 15.5;32.6). In relative terms (relative index of inequality), it was 2.8 (95%CI 1.9;4.1), after the age adjustment.CONCLUSIONS Gender inequality in the prevalence of abdominal obesity increases with older age and lower education. The slope and relative indices of inequality summarize the strictly monotonous trend between education levels and abdominal obesity, and it described educational inequality regarding abdominal obesity among women. Such indices provide relevant quantitative estimates for monitoring abdominal obesity and dealing with health inequalities.

Clinical and epidemiological aspects of abdominal angiostrongyliasis in Southern Brazil

Most of the cases of abdominal angiostrongyliasis in Brazil were reported from the southern States of São Paulo, Paraná, Santa Catarina and Rio Grande do Sul (RS). A study in 27 cases from RS revealed a distinct local epidemiology. Peasants were usually affected, either adults or children, from the mountainous areas in the north of the Suite. There was a seasonal increase in the number of cases, from late spring to autumn, that does not coincide with the rainy season. Besides the most common clinical features of abdominal pain, fever and cosinophilia in the leucogram, painful relapsing episodes were detected in some patients. The abdominal pain could be either localized or diffuse during the rapid evolution to a surgical abdominal condition, with a letality of 7.4%. The use of a serological test and the greater awareness of physicians working in endemic areas is expected to improve the recognition of uncomplicated and benign courses of the disease. This study confirms the known clinical manifestations of abdominal angiostrongyliasis and demonstrates the diversity of its epidemiology.

Jejunal perforation caused by abdominal angiostrongyliasis

The authors describe a case of abdominal angiostrongyliasis in an adult patient presenting acute abdominal pain caused by jejunal perforation. The case was unusual, as this affliction habitually involves the terminal ileum, appendix, cecum or ascending colon. The disease is caused by the nematode Angiostrongylus costaricensis, whose definitive hosts are forest rodents while snails and slugs are its intermediate hosts. Infection in humans is accidental and occurs via the ingestion of snail or slug mucoid secretions found on vegetables, or by direct contact with the mucus. Abdominal angiostrongyliasis is clinically characterized by prolonged fever, anorexia, abdominal pain in the right-lower quadrant, and peripheral blood eosinophilia. Although usually of a benign nature, its course may evolve to more complicated forms such as intestinal obstruction or perforation likely to require a surgical approach. Currently, no efficient medication for the treatment of abdominal angiostrongyliasis is known to be available. In this study, the authors provide a review on the subject, considering its etiopathogeny, clinical picture, diagnosis and treatment.

Natural infection of Deroceras laeve (Mollusca: gastropoda) with metastrongylid larvae in a transmission focus of abdominal angiostrongyliasis

Angiostrongylus costaricensis is a nematode parasitic of rodents. Man may become infected by ingestion of the third stage larvae produced within the intermediate hosts, usually slugs from the family Veronicellidae. An epidemiological study carried out in a locality in southern Brazil (western Santa Catarina State) where these slugs are a crop pest and an important vector for A. costaricensis has documented for the first time the natural infection of Deroceras laeve with metastrongylid larvae. This small limacid slug is frequently found amid the folds of vegetable leaves and may be inadvertently ingested. Therefore D. laeve may have an important role in transmission of A. costaricensis to man.

Diagnosis of abdominal angiostrongyliasis by PCR from sera of patients

Abdominal angiostrongyliasis is a zoonotic infection caused by an intra-vascular nematode parasitic of wild rodents, Angiostrongylus costaricensis. No parasitological diagnosis is currently available and immunodiagnosis presents several drawbacks. Primers constructed based on a congeneric species, A. cantonensis, were able to amplify a 232 bp fragment from serum samples of 3 patients with histopathological diagnosis. Extraction was better performed with DNAzol and the specificity of the primers was confirmed by Southern blot. This disease has been diagnosed with frequency in south of Brazil, thus, this method appears like the important and unpublished alternative to improve diagnostic of disease.