HIV and GI TRACT 2

8/6/2019 HIV and GI TRACT 2

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HIV and GI TRACT

S.Charoensri

GIcomplaints

in HIVpatient

HIV Related

Non-HIVrelated

Adverse effectof

medications

OpportunisticInfections

HIV-relatedneoplasm

Introduction

� Incidence of GI complaints among HIV-infected

patients varies between 30% and 90%.

� Can involved all structures from the mouth to the

Oral and Esophageal Disease

Symptoms

� Oral thrush

� Odynophagia

�Dysphagia

� Angina

� Hiccups

(From esophageal spasm)

MOSTLY FROM OPPORTUNISTIC INFECTION

Others eg. Lymphoma, GERD, pills induced

� Incidence increased when CD4 < 200/mm3

� Candida is the most common

� Suggested ulcerative esophagitis when odynophagia

with l ess dysphagia and without oral thrush

Odynophagia and Dysphagia

Ulcerative Esophagitis

� 40-50% of cases

� Odynophagia at substernal area

� Oral thrush (white mucosal plaque-like)

± Positive predictive value 90%

� Initial empiric treatment : Oral azole antifungal

(fluconazole loading dose of 200 mg, followed by

100 to 200 mg/day)� If no improvement in 7 to 10 days, diagnostic

endoscopy should be performed.

Candida Esophagitis

� Esophagitis despite receiving antifungal therapy ???

± Defect in drug absorption

± Drug resistance

± Fungal superinfection with a resistant strain

± Non-fungal etiology

� The clinician may prescribe increased doses of

fluconazole (up to 800 mg/day)

� Further investigation should be considered

± Barium swallowing

± Endoscope

Candida Esophagitis

Candida HSV CMV HIV

Candida

CMV+HSV

� Oral valganciclovir

� Intravenous ganciclovir

� Foscarnet

� An ophthalmologic examination to assess the

presence of concurrent CMV retinal disease.

� Relapse is common

CMV Esophagitis

For 3 to 6 weeks.

� Acyclovir, valacyclovir or famciclovir for 2 weeks in

mild or moderate case

� Intravenous acyclovir for 2 weeks in severe case

� Foscarnet should be used when acyclovir-resistant

HSV is suspected.

� Recurrent HSV esophagitis may be suppressed with

maintenance dosing of oral acyclovir, valacyclovir, orfamciclovir.

HSV Esophagitis

Gastroesophageal reflux disease

� Proton pump inhibitors (omeprazole, lansoprazole),

possibly in combination with pro-motility agents

(metoclopramide).

A phthous ulcers

� Topical corticosteroids to manage aphthous ulcers;

however, caution should be taken because steroiduse may result in candidal overgrowth.

Others

� Acyclovir, valacyclovir or famciclovir for 2 weeks in

mild or moderate case

� Intravenous acyclovir for 2 weeks in severe case

� Foscarnet should be used when acyclovir-resistant

HSV is suspected.

� Recurrent HSV esophagitis may be suppressed with

maintenance dosing of oral acyclovir, valacyclovir, orfamciclovir.

HSV Esophagitis

Diarrhea

� Before HAART, 90% of patients.

� In the era of HAART, less frequent complaint.

�Etiologically is most often drug-induced(antiretroviral therapy) or is caused by

disorders unrelated to HIV.

Protozoa

� Cryptosporidium : Most frequent

� Sel f-l imited in healthy hosts

�Small bowel

� Diarrhea is typically severe, with stool

volumes of several liters per day

Borborygmi, nausea, and weight loss

Protozoa

� Cryptosporidium

� Diagnosis

Acid-fast stain of the stool ± Stool antigen and PCR

± Small bowel or rectal biopsies

Cryptosporidium

Protozoa

� Isospora

� Isospora bell i, like Cryptosporidium, is a cause

of chronic diarrhea in untreated patients withHIV infection.

� More frequent and endemic in developing

countries.

� Identified by acid-fast stain of the stool or

duodenal secretions or on mucosal biopsy.

Protozoa

� Microsporidium

� Enterocytozoon bieneusi and Encephal itozoon

intestinal is.

� Watery, nonbloody diarrhea of mild to

moderate severity usually without associated

crampy abdominal pain.

� Weight loss is common, although not to the

degree observed with Cryptosporidium.

Protozoa

� Giardia l ambl ia

� Entamoeba histol ytica

�Bl astocystis hominis, Entamoeba col i arenonpathogenic protozoa that are seen more

commonly in homosexual and are often found

in association with other protozoal parasites.

Helminths

� Strongy l oides stercoral is

� Ascaris l umbricoides

�The clinical syndrome and recurrence rateassociated with these parasites do not appear

to be altered in the setting of HIV infection

� Most l y l arge bowel , rarel y small bowel

� CMV is the most common viral cause and the

most frequent cause of chronic diarrhea inpatients with AIDS.

� Abdominal pain, peritonitis, watery, nonbloody

diarrhea or hematochezia.

� Endoscopic : subepithelial hemorrhage and

mucosal ulceration

� Diagnosis

± Histopathologic from tissue specimens

± immunostaining and/or in situ hybridization

± Cultures identification

� All patients should have an ophthalmologic

examination to exclude CMV retinitis

H&E stained section showing

typical owl-eye inclusions

� Other viruses (Norwalk, adenovirus)

� Enteric viruses (astrovirus, picobirnavirus)

less frequent

� HIV can be identified within gut tissue in some

patients with AIDS, the virus has been

confined to lamina propria macrophages and

enterochromaffin cells, and not epithelial cells.

� An idiopathic AIDS enteropathy has been

proposed in AIDS patients who lack an

identifiable pathogen.

Bacteria

� Enteric bacteria are more frequent and more

virulent in HIV-infected individuals compared

with healthy hosts.

� Sal monell a, Shigell a, and Campy l obacter have

higher rates of bacteremia and antibiotic

resistance.

� C l ostridium diffici l e

Mycobacteria

� Mycobacterium tubercul osis or MAC

� Although M. tubercul osis infection appears to

be symptomatic in all cases, a large number of patients with MAC have an asymptomatic GI

infection.

� Duodenal involvement is most common

� Association with malabsorption, bacteremia,

and systemic infection.

Mycobacteria

� Mycobacterium tubercul osis or MAC

� Diagnosis of GI MAC infection is best made by

endoscopic biopsy with acid-fast staining.� Unlike typical MAC infection, in AIDS there is a

poorly formed inflammatory response and

granulomas are rarely present.

High-power view with

acid-fast staining shows

numerous macrophages

filled with mycobacteria

Mycobacteria

� Luminal GI tract involvement usually involves

the ileocecal region or colon.

Fistula formation, intussusception, andperforation, as well as peritoneal and rectal

involvement, also have been reported.

Fungus

� GI histopl asmosis has been most commonly

described and occurs in the setting of

disseminated infection, often in association

with pulmonary and hepatic histoplasmosis.

� It may manifest as a diffuse colitis with large

ulcerations and diarrhea, as a mass, or as

serosal disease in association with peritonitis.

Fungus

� Rare cases of systemic cryptococcosis and

coccidioidomycosis with gut involvement also

have been described. A peculiar fungal

infection due to Penici ll ium marneffei has been

reported from Southeast Asia that can cause

colitis and chronic diarrhea.

Evaluation

Treatment

Abdominal Pain

Approach and

management

are the same asfor patients

without AIDS.

Anorectal Disease

� The frequency among homosexual AIDS

patients is higher than in other AIDS patients.

± Perirectal abscesses

± Anal fistulas

± Perianal HSV

± Idiopathic ulcerations

± Infectious proctitis

± Lymphoma, ulcerations due to CMV, TB and

histoplasmosis may also be seen

Anorectal Disease

� Anorectal squamous cell carcinomas

± homosexual men

Result from human papillomavirus (HPV)particularly types 16 and 18

� Condyloma acuminatum >> marked anal

dysplasia or squamous cell carcinoma.

� Cytologic specimens of the anal canal, similar

to Papanicolaou smears, are increasingly used

for screening.

� Hepatomegal y usually associated with one or

more liver chemistry test abnormalities.

� Currently, parenchymal abnormalities are

most often related to viral hepatitis and drug-

induced disease.

� In the era of HAART, liver disease has much

greater importance as a cause of morbidity

and mortality and now one of the most

frequent nonHIV-related causes of death

Acute Pancreatitis

� Although abdominal discomfort may be vague

or mild during early pancreatitis, the

characteristic steady, boring epigastric pain of

acute pancreatitis with its radiation to the

back and the associated signs and symptoms

of nausea, vomiting, and abdominal

distension should be expected as frequently inthe HIV-infected population as in the non-HIV-

infected population.

Acute Pancreatitis

� Alcohol

� Pancreatotoxic medications

Pentamidine ± Trimethoprim-sulfamethoxazole

± Didanosine

± Stavudine,

� Hypertriglyceridemia, either as a result of HIV

infection or as a common consequence of PI

therapy

Acute Pancreatitis

� Opportunistic pathogens

± CMV

± Mycobacteria

± Cryptococcus

± Toxoplasmosis

Biliary System

� Biliary tract involvement in AIDS may result in

marked liver test abnormalities and right

upper quadrant symptoms

� Jaundice is unusual.

AIDS Cholangiopathy

� A syndrome resembling sclerosing cholangitis

with papillary stenosis

� Significant upper abdominal pain

� Marked elevation of serum alkaline

phosphatase

� Minimal elevations of bilirubin, AST, and ALT.

ERCP in a patient

with AIDS cholangiopathy.

Papillary stenosis

is present ( arrow).

AIDS Cholangiopathy

� Papillary stenosis with intrahepatic disease as

the most common findings

� Ultrasonography or CT detects ductular

abnormalities, usually dilatation.

� Negative imaging study does not definitively

exclude the diagnosis.

� The etiology in most cases is due to infection

of the duodenal and biliary epithelium with

Cryptosporidium, CMV, or Microsporidium.

AIDS Cholangiopathy

� Sphincterotomy

� Eradication of the infecting pathogen

Survival in AIDS cholangiopathy is linked toseverity of immunodeficiency.

Biliary System

� Acalculous cholecystitis has also been

described in AIDS patients, presenting as

severe abdominal pain and, occasionally,

peritonitis.

� This syndrome is usually caused by a specific

infection, most frequently CMV, but also from

microsporidia, cryptosporidia, and Isosporabelli.

Biliary System

� Other less common

± Primary bile duct lymphoma

± Epithelial angiomatosis

± Lymphomatous nodal obstruction of the biliary

± Kaposis sarcoma

± Biloma ± Chronic pancreatitis

± Choledocholithiasis

HIV and GI TRACT 2

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