Reprints available directly from the publisher Photocopying permitted by license only 0 1992 Gordon and Breach Science Publishers S.A. Printed in the United States of America MONTE CARLO

A 30 years old man presented with symptoms of Bilharziasis. Ultrasound showed gallstones in the gallbladder which was removed laproscopically, heavy bilharzial infection was detected in the gallbladder tissue. The first case in Saudi Arabia is reported. A Review of the world literatures since 1966 about the subject is presented and different aspects of the gallbladder schistosomiasis are discussed.


INTRODUCTION CASE REPORT
Schistosomiasis (Bilharziasis) cause a major health problem in many parts of the developing world.The most likely-but not definite-site for adult worm de- pends on the species; (S. haematobium in vesical veins, S. Mansoni in superior mesenteric veins.S. Japonicum & S. Mekongi in the inferior mesenteric vein) but worms can live in any of the location and mixed infection are also common.Eggs are deposited in the venules of the corresponding location of the adult worm and find their way to urine or faecies to be excreted, however certain eggs are either trapped on the way or even lose their way and settle in ectopic locations; one of the extremely rare location is the gall- bladder, we report a case of schistosomal (bilharzial) cholecystitis.Using a "Medline" search between 1966 and December 1994, there were no reported case or study concerning gallbladder bilharziasis; this is the first case of gallbladder bilharziasis with gallstones causing chronic cholecystitis to be reported from

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A 30 year old man presented to the general clinic with haematuria and right upper quadrant pain, Urine analysis showed heavy infection with S. hae- matobium and ultrasonography showed a solitery gallbladder stone.Other investigations were normal.
Although the right upper quadrant pain was not typi- cal of biliary pain there was no renal stone to explain it; Laproscopic cholecystectomy was performed after treating his schistosomiasis by Braziguantil.The Postoperative period was uneventful.Histology of the gallbladder showed chronic cholecystitis and schistosomal ova were seen in the wall of the gallbladder.

PATHOLOGY
Grossly, the gallbladder contains one small stone and the wall was thickened.Microscopically (Fig. l) the mucosa is lined by columnar epithelium and shows lymphocytic infiltrate of the lamina propria with occa- sional eosinophils.The muscle coat is hypertrophied, fibrosed and infiltrated by lymphocytic cells.Numerous ova of schistosoma haematobium with terminal spine (inset 1) and mansonai with lateral spine (inset 2) are present in the gallbladder wall.There was focal granulomatous reaction found elsewhere.The M.A. BAKHOTMAH appearances are that of chronic cholecystitis with schistosomal infection.

DISCUSSION
Schistosomal eggs which pass to the lumen of the gut or urinary bladder evoke no host reaction, those eggs which do not move fast or move in the wrong direction (as those found in the liver) are soon surrounded by inflammatory cells and granulomatous and fibrotic reactions ensure.The pathogenesis of chronic schis- tosomiasis is almost exclusively explained by this granulomatous reaction.Although liver is one of the most commonly affected organs -leading to liverfibro- may be found in perigenital tissue, spermatic cord, epididymis, testes, uterine cervix, ovary, meninges, spinal cord, brain tissue, stomach, oesophagus and pancreas1-3.As ascariasis and cryptosporidiosis6; schistosomal ova were found in mucosa, submucosa, fibrovascular coat or even free in the gallbladder contentT; but still, schistosomal granulomas of the gall- bladder causing cholecystitis is very rare4.In an important study of the distribution of the schistosomal lesions in various organs among 1220 autopsies 2.5% of cases was affected by gallbladder bilharziasis compared to 35% and 5% of the liver and pancreas respectively8.The explanation of this variation in inci- dence among organs is probably due to variation of the richness of venous drainage, the more veins avail- sis and portal hypertension the biliary system is sel- dom affected by complications of schistosomiasis.No tissue or organ is immune from wide dissemination of schistosomal eggs.-Ectopicgranulomatous lesions able in the part the more will be the chance for the female worms to get in and lay ova8; mixed infection of the gallbladder has never been addressed before but in our case a mixed infection was documented.The thickened wall and the impaired gallbladder contrac- tion after the fatty meals in patient with bilharzial hepatosplenomegaly lead to the suspicion that they may be more prone to develop gallstones, however this is not proved yet.
Schistosomal ova can form a nidus for the development of renal stones4.Neither we nor others were able to detect any schistosomal ovum in the gallstones retrieved from patients.Liver biopsy was not done because it was not necessary as liver function tests and laproscopic appearance of the liver was normal.