hiv and gi tract 2
TRANSCRIPT
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HIV and GI TRACT
S.Charoensri
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GIcomplaints
in HIVpatient
HIV Related
Non-HIVrelated
Adverse effectof
medications
OpportunisticInfections
HIV-relatedneoplasm
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Introduction
� Incidence of GI complaints among HIV-infected
patients varies between 30% and 90%.
� Can involved all structures from the mouth to the
anus.
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Oral and Esophageal Disease
Symptoms
� Oral thrush
� Odynophagia
�Dysphagia
� Angina
� Hiccups
(From esophageal spasm)
MOSTLY FROM OPPORTUNISTIC INFECTION
Others eg. Lymphoma, GERD, pills induced
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� 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
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Ulcerative Esophagitis
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� 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
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� 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
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Candida HSV CMV HIV
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Candida
CMV+HSV
HSV
HIV
HSV
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� 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.
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� 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
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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
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� 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
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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.
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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
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Protozoa
� Cryptosporidium
� Diagnosis
±
Acid-fast stain of the stool ± Stool antigen and PCR
± Small bowel or rectal biopsies
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Cryptosporidium
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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.
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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.
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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.
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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
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Virus
� 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
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CMV
� Diagnosis
± Histopathologic from tissue specimens
± immunostaining and/or in situ hybridization
± Cultures identification
� All patients should have an ophthalmologic
examination to exclude CMV retinitis
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H&E stained section showing
typical owl-eye inclusions
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Virus
� Other viruses (Norwalk, adenovirus)
� Enteric viruses (astrovirus, picobirnavirus)
less frequent
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HIV
� 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.
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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
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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.
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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.
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High-power view with
acid-fast staining shows
numerous macrophages
filled with mycobacteria
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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.
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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.
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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.
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Evaluation
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Treatment
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Treatment
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Abdominal Pain
Approach and
management
are the same asfor patients
without AIDS.
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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
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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.
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Liver
� 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
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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.
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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
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Acute Pancreatitis
� Opportunistic pathogens
± CMV
± Mycobacteria
± Cryptococcus
± Toxoplasmosis
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Biliary System
� Biliary tract involvement in AIDS may result in
marked liver test abnormalities and right
upper quadrant symptoms
� Jaundice is unusual.
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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.
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ERCP in a patient
with AIDS cholangiopathy.
Papillary stenosis
is present ( arrow).
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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.
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AIDS Cholangiopathy
� Sphincterotomy
� Eradication of the infecting pathogen
�
Survival in AIDS cholangiopathy is linked toseverity of immunodeficiency.
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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.
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Biliary System
� Other less common
± Primary bile duct lymphoma
± Epithelial angiomatosis
± Lymphomatous nodal obstruction of the biliary
tree
± Kaposis sarcoma
± Biloma ± Chronic pancreatitis
± Choledocholithiasis
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