Introduction

Banti’s syndrome (BS) is arare chronic illness that mainly affects the liver and the spleen, characterised by fibrosis of the spleen, as well as liver cirrhosis. Spleen dysfunction results in low red blood cell levels and promotes its destruction.¹ The portal vein is responsible for transporting blood from the spleen and other organs to the liver, and is largely implicated in the pathophysiology of this disease.² BS patients typically present with hypertension within the portal vein, resulting in high blood pressure.. This is caused by increased resistance to blood flow, leading to blockage. As a result, splenomegaly occurs, where the spleen is enlarged and the liver is unable to function optimally as it does not receive adequate blood.³ BS also induces pancytopenia, a condition where the red and white blood cell as well as platelet count is lower than average. Therefore, it is integral to establish the risk factors of BS and how they can be mitigated through lifestyle choices. This article will delve into the link between environmental and lifestyle risk factors and how this affects the prevalence of BS. Preventative measures will also be discussed to demonstrate how these risks can be negated through knowledge and understanding of this condition.

Understanding the causes of Banti's syndrome

The causes of BS can be classified into two categories – primary and secondary. Primary causes are typically unrelated to environmental or lifestyle factors, and often arise from underlying medical or genetic conditions. In contrast, secondary causes include environmental influences and lifestyle-related factors, which may contribute to the development or progression of the condition. Liver cirrhosis occurs when liver cells and healthy tissue is destroyed and replaced by scar tissue, eventually leading to liver dysfunction and failure. While cirrhosis can result from various causes, it is often exacerbated by lifestyle choices, particularly chronic alcohol consumption. Regardless of its origin, cirrhosis is a progressive disease, and its cumulative damage can predispose individuals to BS. In fact, liver cirrhosis is commonly observed in BS patients and significantly increases the risk of its manifestation.

There is a strong association between autoimmune diseases such as haemolytic anaemia, caused by a low red blood cell count and BS presentation. Autoimmune haemolytic anaemia leads to a reduction in red blood cell count, and while not all patients with autoimmune diseases develop BS, these conditions can accelerate its progression. Additionally, autoantibodies—immune proteins that mistakenly target the body’s own tissues—are often present in BS patients, suggesting an immune-mediated component.⁶

Portal vein thrombosis (PVT) is a condition where there is a blood clot in the portal vein that also leads to hypertension in the portal vein and is strongly correlated to the occurrence of BS.⁷ Environmental and lifestyle factors which will be explored are also major contributors of BS.

Environmental risk factors

A number of environmental risk factors have also been implicated in the development of Banti’s syndrome, with infectious agents playing a particularly significant role. For example, hepatitis B, a viral infection that can cause structural and hemodynamic changes in the portal vein. These changes often lead to portal hypertension, a key factor in the development of BS. Antiviral therapies targeting hepatitis B have been successful in reducing hypertension, highlighting the importance of managing the underlying infection. Similarly, portal hypertension is known to occur in patients with hepatitis B and C which can thus lead to liver cirrhosis.⁸

Another significant infectious cause is schistosomiasis, a parasitic infection caused by trematode worms that are situated in contaminated water. This disease contributes to an increased pressure gradient within the hepatic vein which enhances portal hypertension. Other veins such as the hepatic vein are not always affected by this disease, however portal hypertension is a major concern as it leads to BS.⁹

Contaminated water can also contribute to liver damage, through non-infections ways. For example, exposure to heavy metals such as arsenic and chromium has shown to induce oxidative stress in the liver, leading to fibrosis of the hepatic vein and liver cirrhosis.¹⁰ This process heightens the likelihood of portal hypertension and associated complications. Other environmental toxins, such as industrial pollutants, pesticides, and particulate matter like carbon black (emitted from incomplete fossil fuel combustion), further compound liver stress. These agents not only contribute to oxidative liver damage, but also increase the risk of cirrhosis and liver cancer.¹¹ 

Certain occupational exposures are also strongly associated with liver damage and progressive progression of BS. Occupations that involve exposure to certain chemicals, including asbestos, pesticides, and other biological or chemical agents, particularly in agricultural and industrial sectors, may be chronically exposed to substances that trigger biochemical change and oxidative damage in the liver. For example, studies have shown that pesticide exposure in people that work in greenhouses correlates with measurable liver damage.^12,13 Occupations that involve exposure to certain chemicals that cause oxidative liver damage such as asbestos, pesticides as aforementioned and other biological agents within the industrial and agricultural sectors are strongly associated with liver damage that can eventually lead to BS.¹³

Together, these findings highlight the multifactorial environmental risks contributing to BS and emphasises the need for preventative strategies, particularly in areas with high exposure to infectious agents and water contamination.

Lifestyle risk factors

Certain lifestyle choices can increase the risk of BS, and the most well-known liver cirrhosis causing agent is alcohol. Although the effect of alcohol on portal vein thrombosis has not been well documented, some studies suggest that alcohol consumption can increase the tendency of portal vein damage. On the other hand, non-alcoholic cirrhosis is more strongly associated with thrombosis than alcohol induced cirrhosis.¹⁴

Diet is also another risk factor as high-fat diets can lead to non-alcoholic fatty liver disease (NAFLD).¹⁵ NAFLD is marked by lipid accumulation in the liver, which in turn raises the risk of cirrhosis and portal hypertension. Additionally, a diet low in micronutrients such as certain vitamins and minerals can compromise liver function. For example, vitamin E in moderation results in optimal enzyme function in the liver and may be beneficial in treating NAFLD. Similarly, foods rich in antioxidants, including certain fruits, vegetables, and nuts, can also prevent liver damage through reducing oxidative stress. On the other hand, diets low in antioxidants lead to higher BS susceptibility.¹⁶ 

Physical inactivity also plays a role. A sedentary lifestyle can contribute to obesity, which is a major contributing factor for NAFLD, and consequently for BS.¹⁷

Tobacco use, particularly smoking, is another harmful lifestyle factor. Smoking causes inflammation in the liver and generates free radicals that increase oxidative stress, contributing to liver fibrosis. Smoking may also cause hypoxic liver damage, further increasing the risk of BS.¹⁸ 

Another lifestyle concern is drug induced liver injury (DILI), where drugs, such as aspirin, is metabolised by the liver and can cause damage to the portal tracts. This leads to hypertension in the portal vein, thereby contributing to the progression of BS.¹⁹ A wide variety of legal and illegal drugs may pose a risk for DILI, reinforcing the need for careful monitoring and responsible medication use.

Geographical and socioeconomic factors

Various geographical and socioeconomic factors can affect the likelihood of developing BS. Healthcare in developing countries such as India and Pakistan is not as accessible compared to well-developed countries. This lack of access contributes to easier transmission of infectious diseases, particularly in areas where sanitary conditions are poor, increasing the risk of infections known to trigger or exacerbate BS.⁴ 

Lower healthcare accessibility in developing countries can lead to underdiagnosis or misdiagnosis, resulting in less people being treated. For infectious individuals, this not only worsens their condition but also increases the risk of disease transmission within the community. Furthermore, available treatments may be less effective due to inadequate medical facilities, lack of specialist care, or poor medication adherence.²⁰

Being from a lower socioeconomic group further compounds the risk. There is a strong correlation between low income and poor diet, with foods rich in nutrients being readily available and affordable. Poor living conditions often correlate with limited hygiene practices, making individuals more susceptible to infections. Additionally, exposure to pollutants is more common in lower-income areas, increasing exposure to toxic agents, further contributing to liver damage.²¹

Preventive strategies

There are various ways to mitigate the risks associated with BS development. Reducing infection risk by maintaining good hygiene will decrease the likelihood of infections such as schistosomiasis.⁹ As hepatitis B and C are viral, higher sanitation will reduce the risk of these diseases that cause portal hypertension. By targeting toxin and pollutant exposure, disease risk can be curtailed by reducing exposure.¹³ Lifestyle alterations such as avoiding alcohol, smoking and maintaining a healthy diet is very effective in preventing BS. Alcohol consumption as previously mentioned increases the chance of liver failure, thus by maintaining a healthy lifestyle with diet, exercise and avoiding alcohol and drug consumption, the risk of BS can be lowered. 

Detection is also important in risk mitigation. Vaccinations against hepatitis B and C are readily available and highly effective.²² Early detection and management of liver health can allow those with a high risk to make appropriate changes to avoid BS. The portal vein can also be examined to ensure proper functioning.²³

Summary

Overall, it has been demonstrated that while primary causes such as autoimmune liver diseases contribute to BS development, a variety of environmental and lifestyle factors also play a significant role in increasing its likelihood. Factors such as infections can lead to decreased portal vein functionality and hypertension, as can be said for an unhealthy diet and lifestyle choices. Alcohol is closely linked to liver cirrhosis and BS is more likely to occur in developing countries due to lower access to healthcare and higher chance of water contamination and infection. Preventive measures such as eating nutrient-dense foods, avoiding toxins and pollutants and maintaining a healthy lifestyle as well as early detection are key ways to prevent this disease. Detection and diagnosis remains limited in developing countries which hinders timely intervention. Raising awareness, improving diagnostic capabilities, and implementing preventive health strategies are key to reducing the burden of BS. With continued focus on education, prevention, and healthcare accessibility, the prevalence of this condition can hopefully decline in the near future.