Banti Disease

BANTI DISEASE (Banti), described in 1894 by the Florentine pathologist Guido Banti, is a symptom complex that is essentially a hepato-splenic disease, distinguished by certain features that allow it to be regarded as a special pathological entity: 1) the disease begins with pathological changes in the spleen; the liver becomes involved later; 2) in B. d., characteristic morphological changes occur in the spleen that are not observed in other splenomegalies. The etiology of B. d. is unknown. Pathological-anatomical changes in B. d. occur mainly in the spleen, liver, and the veins of the portal system. In the first stage of the disease, the spleen is greatly enlarged (2-8 kg), its capsule is thickened in places; on cross-section, the spleen is dark red in color. The trabeculae and Malpighian follicles are clearly distinguishable. Microscopically, in the follicles, around the central artery, one can see a ring-like proliferation of connective tissue, in places undergoing hyalinization. This process, called Banti fibroadenia, is the most characteristic. In the pulp, there is diffuse hyperplasia of its cellular elements, and in a later period, complete sclerosis of the pulp, often with deposition of iron salts and formation of so-called sclero-pigment nodules (Gandy). Very often, in the splenic vein, an endophlebitic process (in the form of proliferation of the inner coat) is found, extending to the portal vein. Even at this stage, the liver is somewhat enlarged, but its surface and edge remain completely smooth, and its density and color are normal. The bone marrow presents a picture of hypoplastic condition. The second stage of Banti disease is characterized by the onset of cirrhotic changes in the liver, and the third by the accumulation of serous transudate in the abdominal cavity. The liver is now significantly reduced in size, its surface is rough, and its edge is uneven; on cross-section, it is granular and presents histologically typical changes for annular cirrhosis. Endophlebitic phenomena are widespread throughout the veins of the portal system. The bone marrow is active, red. In accordance with the anatomical changes is the entire course of B. d., in which three stages are distinguished. The first, stage anemic, according to Banti, is characterized by slow and prolonged course (from 3 to 8 years), and occasionally may last for several months. Patients experience general malaise, fatigue, and weakness; nosebleeds, palpitations, shortness of breath, and a feeling of heaviness in the left side appear. Objective examination reveals pallor of the skin and mucous membranes, emaciation, significant enlargement of the spleen, which appears completely smooth, dense, and painless. The liver may also be changed, but its enlargement (compared to the spleen) is insignificant. In other organs, nothing pathological is usually found. Blood examination reveals moderate hypochromic anemia, slight anisocytosis and poikilocytosis. The number of leukocytes is reduced due to neutrophils, often relative lymphocytosis, relative and absolute mononucleosis. There are no signs of enhanced blood regeneration. The second stage, stage intermedio, is caused by the beginning of cirrhotic changes in the liver: the first sign is decreased diuresis; the urine becomes more concentrated, urobilin appears in it, and then bilirubin. The retention of pigments and toxic products leaves a special imprint on the patient's skin: from pale it becomes dirty-brown. The liver is distinctly palpable, dense, rough; later, as it shrinks, it decreases. Irregularities in the intestine, bleeding along the digestive tract, are manifestations of the beginning congestion in the portal system. The second stage of B. d. usually lasts several months (12-18) and gradually passes into the third stage ascitic, which corresponds to fully expressed cirrhotic changes in the liver. In this stage, ascites predominates in the picture of the entire disease. With sharp general emaciation and pallor of the patient, a significant increase in the abdomen is noted; later, edema in the lower extremities is added. In accordance with the accumulation of fluid, there is an even greater decrease in diuresis. Urine is excreted in small amounts, the concentration of pigments in it is very significant; especially much urobilin with little bilirubin. Blood, in general, shows the same changes as in the first stage. The ascitic fluid has all the properties of transudate. After emptying, the accumulation of fluid occurs very quickly. The duration of the third stage of B. disease does not exceed 6-12 months. According to the latest French authors (Nanta, Pinoy, Oberling, etc.), in spleens with splenomegalias of the B. d. type (precisely in the so-called sclero-pigment nodules), aspergilli are found in almost 100%. Aspergilli were also found in the preparations of Chiari, who described original Banti preparations, the latter confirming these findings. On the other hand, cautionary voices are heard, indicating the possibility of secondary settlement of the fungus in sclero-pigment nodules, since the fungus was found in these nodules in other diseases, having nothing in common with B. d. The prognosis in B. d. depends on the stage of the disease and partly on the degree of anatomical changes in the spleen, liver, and bone marrow. In general, this disease within 8-10 years inevitably leads to death from phenomena of liver insufficiency and general exhaustion. Splenectomy performed in early stages in many cases not only prevents further development of the process but even leads to restoration of normal blood composition and reduction of the liver. The treatment of B. d. is primarily surgical: splenectomy. Less effective is roentgenotherapy of the spleen. In the presence of ascites, it is necessary to add to the roentgenotherapy fixation of the omentum to the peritoneum with the aim of creating collateral circulation (the latter, however, is achieved only extremely rarely). Conservative treatment in cases of true B. d. gives no positive results and amounts only to a series of abdominal punctures to release ascitic fluid.

L. Bukhstab, A. Oke. The surgical treatment of Banti disease is of all the methods of treatment the only one that gives success in some cases. The operation consists of splenectomy-removal of the spleen. After Rodman and Willard published 47 cases of splenectomies collected from the literature, there followed a series of reports from other authors, among whom in terms of the number of operated cases, the first place is occupied by Mayo, who published 61 cases of operations with a mortality rate of 11.5%, and Fowler - a collective statistics of 36 cases, with 36.1% mortality. The different percentage of favorable outcomes depends mainly on the stage in which the patient was operated on. The best results are obtained from operations in the first stage, when there are no large adhesions complicating the removal of the spleen, and patients are not weakened by the disease. Unfortunately, it is rare to operate at this stage, since B. d. is difficult to diagnose initially. Most often, one has to operate in the second and third stages of B. d. In the second stage, splenectomy gives good results, even remote ones. There are cases followed up for many years (up to 16 years, Fowler). Among Russian authors, successful outcomes are reported by Herzen, Popov, Okinshevich, etc. But even in the third, ascitic period of B. d., one cannot refuse splenectomies, since it, being rather dangerous (mortality rate according to Banti up to 60%), still improves the general condition of patients, eliminating individual distressing symptoms (ascites). The addition to splenectomy in the third stage of the Talma operation significantly reduced mortality. Regarding the technique of the operation, access to the spleen--see Spleen.