HIV/AIDS: gastrointestinal and liver manifestations

Chapter 22 HIV/AIDS


GASTROINTESTINAL AND LIVER MANIFESTATIONS




KEY POINTS



• In acquired immunodeficiency syndrome (AIDS), reduction in oral intake is a critical factor in malnutrition and cachexia. Nutritional supplementation is important in treatment and comprises appetite stimulants, enteral alimentation and total parenteral alimentation.

• The CD4 lymphocyte count facilitates the assessment of chronic diarrhoea. If the CD4 lymphocyte count is <200/mm3 (μ/L), check for Cryptosporidium, Microsporidium and Clostridium difficile. If <100/mm3, check for cytomegalovirus infection and Mycobacterium avium infection. Panendoscopy will increase the diagnostic yield if stool tests are negative.

• The spectrum of hepatobiliary disease includes viral hepatitis and opportunistic infections.

• In the presence of hepatobiliary disease, a CD4 count of >500/mm3 suggests a liver-specific process. If the CD4 cell count is <200/mm3 it suggests that the liver is involved as part of a systemic opportunistic infection.

• AIDS cholangiopathy presents with upper abdominal pain and diarrhoea; endoscopic retrograde cholangiopancreatography is diagnostic.


INTRODUCTION


Acquired immunodeficiency syndrome (AIDS) has become a pandemic, resulting in 25 million deaths and 40 million persons infected with the AIDS virus. The disease prevalence is particularly high in developing countries. The enormity of the problem is highlighted in the sub-Saharan African continent, which represents only 10% of the world’s population, but constitutes 77% of AIDS deaths.


Clinical advances have evolved in consonance with a greater understanding of the virologic and immunologic markers of disease stage, mechanisms of viral transmission and the problem of viral resistance to antiretroviral drugs. Gastrointestinal and hepatobiliary complications are important components of the HIV/AIDS syndrome. They are common and affect most patients with AIDS during the course of their illness.



MALNUTRITION AND CACHEXIA


Survival in AIDS patients is strongly associated with nutritional status. Weight loss is a cardinal feature of AIDS. The factors contributing to weight loss include anorexia, inadequate oral intake, intestinal malabsorption and alterations in metabolism and endocrine dysfunction.


Reduction in oral intake allied to anorexia is a critical factor in weight loss. Malnutrition also has deleterious effects on the immune system. Careful assessment of the patient and the diagnosis, with treatment of systemic illness or upper gastrointestinal disease, usually results in weight gain.


Nutritional supplementation in the form of appetite stimulants and enteral alimentation often leads to a greater feeling of well-being. Total parental nutrition may be indicated in some cases.



CHRONIC DIARRHOEA


Because of the wide spectrum of potential infections that may cause diarrhoea (Table 22.1), it is appropriate to have a systematic approach in investigating the aetiologic agent/s (Figure 22.1; Table 22.2). Weight loss and diarrhoea suggest an opportunistic infection, malabsorption or small bowel bacterial overgrowth. Severe watery diarrhoea suggests cryptosporidiosis. Diarrhoea with nausea and abdominal pain may indicate Giardia, Isospora belli or Mycobacterium avium. Rectal bleeding may indicate viral or bacterial colitis or Kaposi’s sarcoma.


TABLE 22.1 Common causes of diarrhoea in AIDS



























Protozoa Microsporidium; Cryptosporidium; Isospora belli, Giardia lamblia, Blastocystis hominis; Pneumocystis carinii; Entamoeba histolytica
Bacteria Mycobacterium tuberculosis; Mycobacterium avium complex (MAC); Clostridium difficile; Salmonella, Shigella, Campylobacter
Viruses Cytomegalovirus; herpes simplex; adenovirus; rotavirus
Fungi Candidiasis; Cryptococcus; Histoplasmosis; Coccidioidomycosis
Neoplasms Lymphoma, Kaposi’s sarcoma
Drug-induced HIV protease inhibitors
Idiopathic AIDS enteropathy
Pancreatic disease Pancreatitis; infectious pancreatitis; drug-induced pancreatitis

image

FIGURE 22.1 Assessment of diarrhoea in AIDS.


Based on Wilcox CM. AIDS and the gut. In: Weinstein WM, Hawkey CJ, Bosch J, eds. Clinical gastroenterology and hepatology. Philadelphia: Mosby; 2005:8331–6, with permission.


TABLE 22.2 Assessment of diarrhoea in AIDS






• History including detailed drug history

• Physical examination

• Stool specimen for bacterial culture: Salmonella, Shigella, Campylobacter

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Mar 29, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on HIV/AIDS: gastrointestinal and liver manifestations

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