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Gastrointestinalmanifestations of AIDS
Janez Tomažič
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GIT manifestations
Gastrointestinal and hepatobiliary disorders are amongthe most frequent complaints in patients with HIVdisease
Effective ART and chemoprophylaxis (PCP, MAC, andCMV) has significantly reduced the occurrence ofGIT opportunistic infections
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Decreased incidence of opportunistic infections afterintroduction of HAART. Emerg Infect Dis 2004;10:1713-20.
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GIT and AIDS defining diseasesClinical Category C
Candidiasis: esophagealCryptosporidiosis: chronic intestinal (>1 month)CMV: other than liver, spleen, nodesHistoplasmosis: disseminated, extrapulmonaryIsosporiasis: chronic (>1 month)Kaposi sarcomaLymphoma: Burkitt, immunoblasticM. avium or M. kansasii : extrapulmonaryM. tuberculosisSalmonella: bacteremia, reccurentWasting syndrome
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GIT & HIV - Clinical Category B
Candidiasis: oropharyngeal
Constitutional: diarrhea >1 month
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Oral manifestations
Candida:
Thrush is presented by white painless plaques on oral mucosa that can easily be scarped off
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Oral manifestations
Oral hairy leukoplakia (EBV) is a raised, white lesion of the oral mucosa, usually seen on the lateral margin of the tongue that can not be scraped off and that not respond to antifungal therapy
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Oral manifestations
The cause of aphthous ulcers is unknown In dd HSV, CMV and drug-induced ulcers should be considered
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Oral manifestations
Anaerobic bacteria cause gingivitis:from linear gingival erythema, necrotizing gingivitis, necrotizing peridontitis to necrotizing stomatitis
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Oral manifestations
Other oral lesions:Kaposi sarcoma (purple-red lesions)non-Hodgkin lymphoma (either swelling or ulcers)oral wartssalivary glands may be enlarged by infiltration with CD8+ cells
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KaposiKaposi’’s s SarcomaSarcoma in Oral in Oral CavityCavity
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Oral manifestations
Other oral lesions:Kaposi sarcoma (purple-red lesions)non-Hodgkin lymphoma (either swelling or ulcers)oral wartssalivary glands may be enlarged by infiltration with CD8+ cells
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Oral manifestations
Other oral lesions:Kaposi sarcoma (purple-red lesions)non-Hodgkin lymphoma (either swelling or ulcers)oral wartssalivary glands may be enlarged by infiltration with CD8+ cells
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Esophageal disease causing dysphagia and/or odynophagia
Candida: most common cause of esophageal symptomsinfrequently associated with feverempiric dg (trush, odynophagia, CD4 <100)
CMV:usually focal pain associated with fever
dg: biopsy of erithema, erosions or ulcers
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Esophageal disease causing dysphagia and/or odynophagia
HSV: often associated with oral manifestationsusually focal pain with inferquent feverdg: brush, biopsy or culture of erithema, erosions or ulcers
Aphtous ulcers:usually focal pain, infrequently associated with fever
dg: negativ tests for Candida, CMV, HSV and other infections
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Diarrhea
Diarrhea is the most common GIT symptom in patients with HIV,occurs in up to 80% of patients with AIDS
Bacterial, viral, protozoal and fungal organisms may cause diarrhea inpatients with AIDS
An infectious cause can be identified in 60-80% of cases
Pathogen-negative diarrhea: motility disorders, bacterialovergrowth, HIV-enteropathy
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Diarrhea
Bacterial Infections– Mycobacterium avium complex– Salmonella– Shigella– Campylobacter sp.– Clostridium difficile– Small-bowel overgrowth– Vibrio parahaemolyticus
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Diarrhea
Viral Infections– Cytomegalovirus– Herpes simplex– Adenovirus– Picornavirus– HIV
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Diarrhea
Protozoal/Helminth Infections– Cryptosporidium– Microsporidium– Isospora belli– Leishmania donovani– Giardia– Cyclospora– Entamoeba histolytica– Strongyloides stercoralis
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Diarrhea
Fungal Infections– Candida albicans– Histoplasma capsulatum
Neoplasms– Lymphoma, Kaposi's sarcoma
Idiopathic– “HIV-enteropathy"
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DiarrheaMedications: a common cause ("early" HIV disease),especially PIs. Often self-limited, lasting for2-4 weeks from initiation of medication
Small bowel overgrowth:may cause diarrheaand malabsorption of fat, vitamin B12, andcarbohydrates. The prevalence of small bowelbacterial overgrowth with HIV-associateddiarrhea is 38%
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Cholangiopathy
- relatively rare diseases, seen primarily inlate stage AIDS
- most common identified microbial cause:Crytposporidium, Microsporidia, CMV andCyclospora
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Endoscopic retrograde cholangiopancreatogram, demonstrating diffuse intrahepatic strictures of
both the intrahepatic and extrahepatic bile ducts
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Pancreatitis
- NRTIs: ddI or ddI + d4T (mitochondrial toxicity)- PIs (hypertriglyceridemia)- opportunistic infections (CMV, non-tuberculous
and tuberculous mycobacteriosis, cryptosporidiosis)- conditions that cause pancreatitis in general
population (especially alcoholism; less common gallstones and hypertriglyceridemia)
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Hepatic abnormalities
- quite common - viral hepatitis- HIV-related opportunistic infections- medication toxicity (all ART)- alcohol, nonalcoholic fatty liver disease - malignancy (Kaposi sarcoma, non-Hodgkin
lymphoma, hepatocellular carcinoma)
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HCV and HIV
- higher HCV RNA loads - more rapid progression of HCV-related liverdisease
- major cause of hospital admissions and deaths- effective HCV treatment strategies are needed- pegINFα + ribavirin: may be effective- early monitoring of HCV RNA response atweeks 4 and 12 identify persons with virologic nonresponse preventing unnecessary exposure toxicity
- liver transplantation
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HBV and HIV
- HIV infection can accelerate progression of HBV
- treatment for all HBV/HIV-coinfectedpatients is recommended
- tenofovir + emtricitabine or lamivudine- HBV vaccination
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Abdominal pain
right upper quadrant pain: thickening or dilatationof the bile duct (AIDS related sclerosing cholangitis)
epigastric pain: peptic ulcer, Kaposi sarcoma, lymphoma,CMV infection of the distal oesophagus
lower abdominal pain: sever constipation (opiate use)
difusse abdominal pain: bacterial or CMV causes ofdiarrhea
loin pain: indinavir (4% of patients taking this drug haverenal stones)
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GIT bleeding
upper GIT bleeding: more common (~50% areattributed to HIV-related conditions: esophagitis, ulcers, Kaposi sa, lymphoma)
lower GIT bleeding: less common (~70% areattributed to HIV-related conditions: CMV colitis, idiopathic colon ulcers, Kaposi sa, lymphoma, MAC)
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Bowel perforation
in AIDS patients, the most common cause of life-threating abdominal pain is peritonitis from smallbowel or colon perforation (CMV enteritis, Kaposi sa,lymphoma, MAC)
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Wasting syndrome
involuntary loss of at least 10% of originalbody weight accompanied by:
- persistent diarrhea (at least to bowelmovements daily for more than 30 days)or
- extreme fatigue and/or fever withoutapparent infectious etiology
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“May HIV flow from our blood intohistory books ?”
~ Bill Clinton, 2005 ~
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