A. Durst’s scientific contributions

Since the publication of the protocol elaborated by International experts convened by the WHO in Cairo 1993, practical experience has been gained by groups working on Asian schistosomiasis. Based on the analysis of their work and our own experience, we propose some modifications to improve the protocol. For the standard investigations we propose: 1. to omit all measurements from standard investigations except for the portal stem. 2. ultrasound pictures should be compared to standard image patterns (IP) covering both, interseptal fibrosis (“network patterns”) and portal fibrosis. 3. combined network- and portal fibrosis patterns are proposed. 4. network patterns should be sub-devided into two classes with predominant mesh size <2.5 and >2,5 cm. 5. to obtain a more finegrained grading in “inbetween”- findings and to reduce intra- and inter-observer variance we porpose that the ultrasonographist should have a second image pattern (IP) choice. 6., risk scoring for gastrointestinal bleeding should be simplified by a score built by the IP-score and the portal vein (PV) quotient (PVQ= PV/height. 7., all reports on hepatic abnormalities due to schistosomiasis must state how many patients have been screened for hepatic co-infections such as liver flukes, HBV, HCV, HDV. Additional investigations should include: 1., height-adjusted spleen length and depth to allow the evaluation of the relation to portal hypertension and hypersplenism in non-malaria endemic areas. 2., gallbladder changes including sludge, calculi as well as the response to the ultrasonographic Murphy manoevre. With the advent of more sophisticated portable ultrasound machines including Doppler facilities as well as in hospital settings of emerging or industrialized countries comparison of ultrasound findings with other techniques including elastography of liver and spleen, contrast ultrasonography, CT and MRI the knowledge will increase with respect to the nature and dynamics of intestinal, hepatic, portal circulatory and splenic abnormalities encountered in hepatosplenic schistosomiasis.

Since the publication in 2000 of the protocol elaborated by International experts convened by the WHO, practical experience has been gained by groups working on schistosomiasis. Based on a systematic analysis of their work and our own experience, we propose some improvements of the protocol. For the standard investigations we propose: 1. to omit all measurements from standard investigations except for the portal stem. 2. to obtain a more finegrained grading also covering “in-between”-findings and to reduce intra- and interobserver variance we the ultrasonographist should have a second image pattern (IP) choice. 3. risk scoring for gastrointestinal bleeding should be simplified by a score built by the IPscore for portal fibrosis and the portal vein quotient (PVQ=PV diameter/height). 4., gallbladder changes including external echogenic wall protuberances, sludge, calculi as well as the result of a ultrasonographic Murphy manoevre should be part of the standard protocol. 5. all reports and publications on hepatic abnormalities due to schistosomiasis must state how many patients have been screened for co-infections due to HBV, HCV, or HDV. Additional investigations should include: 1., assessment of height-adjusted spleen length and depth for evaluating its relation to portal hypertension and hypersplenism in non-malaria endemic areas as well for regression of morbidity after therapy. 2., with the advent of more sophisticated portable ultrasound machines including Doppler facilities portal flow and portosystemic collaterals may be assessed more accurately. 3., intestinal lesions might be assessed more accurately with high frequency transducers, hydrosonography. 4., gallbladder contractility after a fatty meal may be assessed. In hospital settings of emerging or industrialized countries comparison of ultrasound findings with other techniques including elastography of liver and spleen, contrast ultrasonography, CT and MRI increase the knowledge on the nature and dynamics of liver, portal circulation and spleen abnormalities encountered in hepatosplenic schistosomiasis.

Since the publication of the protocol elaborated by International experts convened by the WHO in 2000, practical experience has been gained by research groups working on schistosomiasis. Based on a systematic analysis of their work and our own experience, we propose some modifications for improving the protocol. For the standard investigations we propose: 1., to provide height adjusted minimal urinary bladder fillings allowing a proper examination, in order to rule out erroneously assumed pathology. 2., to state whether or not the bladder contains blood clots, sediment, sludge or calculi. 3., to simplify and improve the urinary bladder findings scoring as follows: grade 0: no abnormality of the urinary bladderwall which is less then to 5 mm thick; grade 1: any area of bladder wall with minor thickening of the bladder wall 5-7mm; grade 2: maximum bladder-wall thickening of 8–9 mm; grade 3: maximum bladder-wall thickening of 10 mm or more, thus including any polyp, mass or tumor 4., to provide a more finegrained urinary tract obstruction (UTO) scoring including the information if there a fissure of the renal pelvis between 2 and 5 mm, 6 and 10 mm, or 11 mm and more is present Optional investigations: “fibrosis of the renal pelvis” should be omitted since this has never been observed. Presence of ureteric lesions, of calcifications, of prostatic echogenic lesions, of hydrocele or any other possible sign of genital involvement should be added. In pregnant women fetal growth parameters should be specificly compared with gestation time and placenta should be scanned for any lesion.