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Approach to Common GI Syndromes:

Odynophagia, Abdominal Pain, and Diarrhea

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

List the differential diagnoses for odynophagia, abdominal pain, and diarrhea

Explain how to examine, diagnose, and treat these conditions

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Case 1: Anh (1)

Anh, a 23 year old HIV positive female, presents with severe pain on swallowing which has lasted for 2 weeks

She reports 2 kg loss of body weight and poor food intake

Pain occurs with both eating and drinking

No fever, no diarrhea

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Case 1: Anh (2)

Past medical history HIV positive for 3 years Briefly took stavudine (d4T) and

didanosine (ddI) but could only afford 6 months of therapy

Pulmonary TB, treated with 3 drugs for 8 months 3 years earlier

She takes no medications now

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Case 1: Anh (3)

Social History She lives in Hanoi Her husband passed away from TB 2

years ago She has 2 children who are both HIV

negative She does not smoke or drink She denies IDU

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Case 1: Anh (4)

General: mildly ill, in obvious pain

Vital signs: • temperature 38.6° C• heart rate 90 bpm• BP 134/80

Head/neck: • moderate oral thrush• (+) cervical

adenopathy 1-2 cm

Thyroid is normal Severe pain and

difficulty when swallowing

Lungs: clear Heart: regular

rhythm Abdomen: soft,

thin, non-tender Skin: normal

Physical Exam

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What is the Differential Diagnosis?

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Odynophagia (Pain with Swallowing)

Causes: Candida most frequent pathogen: 50 – 70% of cases

Virus: 30% of cases• Herpes simplex virus

(HSV) esophagitis• Cytomegalovirus

(CMV) esophagitis

Other causes:Mycobacterium avium complex esophagitisUlcers (aphthous, acid)Kaposi’s sarcomaHistoplasmosis

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What Other Information Do You Want to Know About this Patient?

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Laboratories

Complete blood count: • WBC 4,200 (N 78%, L 18%) • Hematocrit 34%• Platelets 346,000

Total lymphocyte count: 756 Glucose 5.1 mmol/L (92 mg/dL) BUN 2.1 mmol/L (5.6 mg/dL) CD4: 128

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What Should be Done Next?

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Approach to Odynophagia

Treat presumptively for esophageal

candidiasisFluconazole

200-300 mg / day

Improved within 7 days of

treatment

• Continue the treatment for 14 days• Prophylaxis with CTX• Start ARV treatment

Consider presumptive treatment for

herpes simplex

Esophagoscopy

Odynophagia

Improved after 7 days of

treatment

Yes

No

Common Causes: Candida, HSV, CMV, HIVHistory: Pain or difficulty with swallowing, decreased oral intake. History: Note any new medications, any signs of AIDSClinical exam: Note any oral thrush or ulcers, dehydration, nutritional status.

No

Yes

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Case 1: Anh (5)

Treatment Anh is started on fluconazole 200

mg/day When she returns in 7 days, the oral

thrush has resolved However, she still has severe pain with

swallowing and is unable to eat

What should be done next?

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Case 1: Anh (6)

Further Work up Consider treatment for HSV with

acyclovir (if odynophagia is not improved after 7 days on fluconazole)

Acyclovir dose:• 400 mg x 3/day x 7 days • 200 mg x 5/day x 7 days

If endoscopy available, patient can be referred for this along with biopsy of any lesions

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Case 1: Anh (7)

Follow-up Anh was given acyclovir 200 mg 5x/day She returned 7 days later and her

swallowing had improved She was eating better and gained 1.5

kg in the last week She is continued on acyclovir for 1 more

week and referred for ARV counseling

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Odynophagia: Summary

Odynophagia and dysphagia are extremely common• Most common causes are esophageal

candidiasis, HSV and CMV Most patients with esophageal

candidiasis will also have oral thrush• However, esophageal candidiasis can be

present even without visible oral thrush Esophageal candidiasis and HSV are

usually seen when CD4 count is < 200

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Case 2: Thai (1)

Thai, a 42 year old man, presents with:• 3 weeks of fever• 8 kg weight loss• progressive abdominal pain • mild nausea, but no diarrhea or vomiting

Review of systems: • Mild cough without dyspnea• No headaches, visual problems, sore throat,

chest pain, dysuria, hematuria, joint pains or neurologic symptoms

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Case 2: Thai (2)

Past medical and social history Diagnosed with HIV 2 months ago He denies:

• any previous illness and has continued to work as a motorcycle repairman until 3 weeks ago

• ever using IV drugs• any alcohol or cigarette use

States that he has visited commercial sex workers

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Case 2: Thai (3)

Medications He bought 2 ARVs in a pharmacy and

has been taking them daily

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Case 2: Thai (4)

Physical examThin man in obvious pain; lies on bed curled in a ballHeart rate: 110bpm, BP: 122/84, T: 37.6C, RR: 16Oropharynx is clear, no scleral icterus, no lymphadenopathy. Lungs are clearHeart is tachycardic, but without murmurs or gallopsAbdominal exam is notable for diffuse mild tenderness without peritoneal signs

• No masses, no hepatosplenomegaly.Genital exam, extremities, skin are normal

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What Other Information do you Want to Know About this Patient?

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Abdominal Pain: Important Points

One important cause of abdominal pain in HIV is due to side effects from ARVs • NRTI can cause hepatitis with lactic

acidosis (especially D4T, DDI)• Pancreatitis is also a side effect seen

with the use of D4T and DDI

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Case 2: Thai (5)

Work up Complete blood count:

• WBC 3,200 (N 78%, L 18%) • Hematocrit 33• Platelets 213,000

Total lymphocyte count: 634 Amylase: normal AST/ALT and bilirubin are normal CD4 count 42 cells/mm3

What would you do next?

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Case 2: Thai (6)

Work up Continued Abdominal X-ray shows no signs of obstruction Chest X Ray negative Abdominal Ultrasound reveals multiple lymph

nodes up to 3 cm and ascites Paracentesis is done:

• WBC is 200 cells/ml, mostly lymphocytes• Protein is 6 g/dL• Fluid AFB and gram stain are negative, sent for

culture Sputum is sent for AFB Stool is sent for culture, ova and parasites

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What is the Cause of the Abdominal Lymph Nodes?

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Case 2: Thai (6)

Treatment On hospital day 2, sputum returns

positive for AFB Peritoneal fluid remained AFB negative He is started on 4 drugs for TB ARVs are discontinued and patient is

counseled that mono and dual therapy are not effective

Cotrimoxazole 960 mg/day is started

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Abdominal Pain: General Principles (1)

Clinical signs and symptoms may be misleading

In general:

CD4 Count Likely OIsCD4 > 500 • Common bacteria

• Neoplasia

CD4 100-500 • TB• Bacteria

CD4 < 100 • TB• Mycobacterium avium complex (MAC)• Fungi• Cytomegalovirus (CMV)• Unusual protozoa can occur

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Abdominal Pain: General Principles (2)

In advanced HIV, abdominal pain is usually a sign of systemic infection• E.g. TB, MAC, CMV or disseminated

fungal infection Diagnosis is often difficult even with

available resources Work up should be guided by quality

and location of symptoms • Focus on treatable causes

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Abdominal Pain: General Principles (3)

Look for TB! • CXR, sputum AFB, or aspiration of

peripheral lymph node may make diagnosis of TB and allow treatment

If patient has abdominal lymph nodes and no definite diagnosis is possible, consider empiric treatment for TB

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Infectious Causes of Abdominal Pain in Vietnam

Likely to be seen TB Fungal disease

• Penicilium marneffei

• Cryptococcus Salmonella

Unknown due to lack of diagnostics

CMV Lymphoma MAC Kaposi’s sarcoma Histoplasmosis Toxoplamosis Cryptosporidium

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Diarrhea

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Overview

One of the most common manifestations of HIV• Associated with wasting syndrome, poor

prognosis Chronic infectious diarrhea usually occurs in

advanced HIV disease (CD4 < 50-100) Diarrhea may be due to:

• Infectious or non-infectious agents • HIV itself

Therapy is mostly empiric in Vietnam

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Causes of Acute vs. Chronic Diarrhea

Acute Bacterial Food poisoning Malabsorption

• dairy products• fatty foods

Increased motility Medication side

effects (esp. PIs)

Chronic Organisms typical

of HIV infection Parasitic infections Malabsorption Mucosal immune

defects and inflammation • (HIV enteropathy)

Management of Acute Diarrhea (1)

Acute diarrhea. No dehydration or hypotension

< 3 days > 3 days

• Loperamide, Smecta• Rehydration• Nutritional counseling• Review medications• Observe

• Stool culture, O&P if possible• Azithromycin or cipro x 5 days• Loperamide, Smecta• Rehydration• Nutritional counseling• Review medications

Not improved

Metronidazole x 7 days (especially if suspect entamoeba)

Acute diarrhea with dehydration or hypotension, fevers, abdominal pain

Suspect bacterial diarrheaSuspect bacteremia

• Admit to hospital• Conduct blood culture, stool culture,

O&P, special stains if available• Rehydrate with IVF• Give Cipro or 3rd gen. cephalosporin• Give Metronidazole

Management of Acute Diarrhea (2)

Take historyDo clinical examination

Complete the treatment in 14 days

Improved?

Treatment trial with fluoroquinolone and metronidazole for 7

days

Treat for detected causes

Stool examination not available

Albendazole + CTX Treat with

loperamide

Complete the treatment for 21 days

Consider other causes, such as TB, MAC; give

appropriate treatment

Consider ARV treatment

Give CTX prophylaxis

Evaluate severity of dehydration

Give rehydrationCorrect electrolyte

disturbanceCounsel on proper

diet

Yes No

Causes not found

Yes YesNo

Improved?

MOH Flowchart for Management of Chronic Diarrhea

Stool microscopy and culture for causes,

other lab tests and

investigations

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Key Points

Candida esophagitis is the most common cause of odynophagia• Treat with fluconazole 200mg /day

In advanced HIV, abdominal pain is usually a sign of systemic infection e.g. TB, MAC, CMV or disseminated fungal infection

Diarrhea is common in PLHIV• Most acute diarrhea is self-limited; can be

treated with supportive measures• Most chronic diarrhea will resolve with ART and

recovery of the immune system

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Thank you!

Questions?