In schistosomiasis with hepatosplenomegaly and ascites, portal hypertension is most likely due to which process?

• A. Portal hypertension from periportal fibrosis
• B. Autoimmune cholangitis
• C. Alcoholic cirrhosis
• D. Acute hepatitis

Answer: (A)

Schistosomiasis causes portal hypertension primarily from a presinusoidal process: eggs become lodged in the portal venules and trigger a granulomatous inflammatory response that evolves into extensive periportal fibrosis (often called pipestem fibrosis). This fibrosis narrows the portal venous inflow before the liver sinusoids, increasing portal pressure even while hepatocytes remain relatively intact. Clinically this leads to hepatosplenomegaly and ascites due to portal hypertension without the rampant hepatocellular injury seen in other liver diseases. Thus, the dominant mechanism is portal hypertension from periportal fibrosis induced by the schistosomal infection.