Gastrointestinal Manifestations of HIV Disease
Gastrointestinal and hepatobiliary disorders are among the most frequent complaints in patients with HIV disease. Effective antiretroviral therapy and chemoprophylaxis (PCP, MAC, and CMV) has significantly reduced the occurrence of gastrointestinal opportunistic infections.
Diarrhea
Diarrhea is the most common GI symptom in patients with HIV, affecting 0.9 to 14% of outpatients. Protozoal, viral, and bacterial organisms may cause diarrhea in patients with AIDS. MAC and CMV infections are observed in patients with CD4 cell count <100/mm3. Pathogen-negative diarrhea is the cause of the most cases of diarrhea in this patient group.
| Causes of Diarrhea in HIV-Infected Patients and Patients with Advanced HIV Disease |
| Protozoal/Helminth Infections
Cryptosporidium Microsporidium Isospora belli Leishmania donovaniGiardia
Cyclospora
Entamoeba histolytica Strongyloides stercoralis
|
| Bacterial
Mycobacterium avium complex Salmonella Shigella Campylobacter sp.Clostridium difficile
Small-bowel overgrowth
Vibrio parahaemolyticus |
| Viral
Cytomegalovirus Herpes simplex Adenovirus Picornavirus
HIV
|
| Fungal
Candida albicans
Histoplasma capsulatum
|
| Neoplasms
Lymphoma
Kaposi’s sarcoma
|
| Idiopathic“AIDS enteropathy” |
Medications are a common cause of diarrhea in patients with “early” HIV disease, especially protease inhibitors, such as nelfinavir and saquinavir. The diarrhea is often self-limited, lasting for 2 to 4 weeks from initiation of medication.
Small Bowel Overgrowth. Small bowel bacterial overgrowth may cause diarrhea and malabsorption of fat, vitamin B12, and carbohydrates. The prevalence of small bowel bacterial overgrowth with HIV-associated diarrhea is 38%.
AIDS enteropathy. HIV itself may be an indirect diarrheal pathogen. AIDS enteropathy causes diarrhea in HIV-infected patients who lack an identifiable pathogen.
Evaluation of Diarrhea
A careful history should exclude medications, lactose or food/fatty food intolerance, inadvertent use of cathartics (eg, megadoses of vitamin C, lactose-containing medications, sorbitol-containing foods), and symptoms suggestive of a systemic infection or neoplasm. Order Brand Cialis
Cramps, bloating, and nausea suggest gastric or small-bowel involvement secondary to infection with Cryptosporidium, Microsporidium, Isospora belli, or Giardia. Hematochezia and tenesmus imply large-bowel inflammation resulting from CMV, Shigella, Campylobacter, or C. difficile infections. Tenesmus can occur as a result of herpes, Shigella, or Campylobacter infections.
Multiple sexual contacts or receptive anal intercourse increases the possibility of sexually transmitted diarrheal pathogens. Brand Levitra 20 mg
Laboratory evaluation should include stool culture for enteric bacteria, a specimen for Clostridium difficile toxin (in the setting of antibiotic use), and at least three stool specimens for ova and parasite examination (including acid-fast bacilli and trichrome stain). Three or more stool specimens should be tested. If a diagnosis is not reached following careful stool analysis, sigmoidoscopy is appropriate to identify CMV infection. Buy TADALAFIL SOFT
Management of diarrhea in HIV disease
Chronic administration of alternating antibiotics may be necessary for recurrent Salmonella, Shigella, Campylobacter, or Isospora infections. An empiric trial of oral antibiotics or antiparasite therapy for the possibility of small bowel overgrowth, undetected Campylobacter, Isospora enteritis, or undetected protozoa can be considered. Sulfonamides, ciprofloxacin, tetracyclines, or metronidazole may be effective.
| Management of Diarrhea in HIV Disease | |||
| Enteric Pathogen | Clinical Features | Diagnosis | Treatment |
| Mycobacterium avium complex | Blood culture, fever, severe anemia, night sweats, >10% weight loss, diarrhea, abdominal pain, hepatomegaly, increased alkaline phosphatase | Mycobacterial culture of blood and boneMucosal biopsy | Rifabutin if CD4 <200 Azithromycin Clarithromycin Ethambutol Clofazimine Rifabutin Rifampin Ciprofloxacin |
| Cryptosporidium parvum | Non-bloody stool, diarrhea, nausea, vomiting, abdominal cramps | O and P | Paromomycin Spiramycin Erythromycin |
| Cytomegalovirus | Submucosal hemorrhage, mucosal erosions, ulcerations, abdominal pain, diarrhea, bleeding, perforation, hematochezia | Mucosal biopsy | GanciclovirFoscarnet |
| Microsporidia | Diarrhea | Mucosal biopsy | Albendazole |
Chronic diarrhea should be treated symptomatically with Imodium, Lomotil, or tincture of opium drops. Lactose-containing foods should be avoided as a diagnostic trial. Bulk-forming agents, including effersyllium, bran and pectin, may be helpful.
Octreotide, a subcutaneous somatostatin analogue, is particularly effective in patients with diarrhea who lack a specific infection.
Dysphagia and odynophagia
Dysphagia, odynophagia, or both, due to esophagitis are very common in advanced HIV disease. The majority of patients with dysphagia or odynophagia have candidal esophagitis. Malignancies, such as KS and lymphoma, and acid-reflux esophagitis can also occur.
Candida and herpes esophagitis are predominantly identified in patients with CD4 cell counts less than 200 cells/mm3. CMV and idiopathic ulcers are noted below a CD4 cell count of 100 cells/mm3.
Evaluation of dysphagia and odynophagia. Endoscopy with biopsy is the best method of establishing a specific etiology.
Treatment of dysphagia and odynophagia
Patients with odynophagia who have oral thrush should be treated empirically with fluconazole ( Diflucan),100 to 200 mg/day or itraconazole ( Sporanox), 200 mg/day.
Refractory Candida esophagitis requires treatment with amphotericin B. Herpes esophagitis responds to acyclovir (200-mg capsules every 4 hours). Acyclovir-resistant herpes may respond to foscarnet. Infections with CMV generally respond to a 2- to 3-week course of ganciclovir.
Nonspecific ulcerations may be treated with a short course of oral corticosteroids (40 mg/day, tapered over 3 weeks) or thalidomide (200 mg/day), or with H-2 antagonists and sucralfate.