Gastrointestinal manifestations

The AIDS patient with abdominal pain: a new challenge for the emergency physician

As the prevalence of HIV infection continues to increase, EPs will be called upon to evaluate increasing numbers of AIDS patients who have abdominal pain, some of whom will require emergent surgical intervention. In addition to the myriad causes of abdominal pain in the nonimmunocompromised patient, the differential diagnosis in the AIDS patient includes a wide variety of opportunistic infections and neoplasms (Table 5). Evaluation frequently requires extensive laboratory studies and cultures and advanced imaging (CT, ultrasound, and so forth). A low threshold for surgical and other subspecialty consultation should be in place because of the often subtle presentation of surgical emergencies in AIDS patients.

Infectious diarrhea in human immunodeficiency virus

Chronic HIV-associated diarrhea is currently a field in flux. Improved noninvasive diagnostic tests, improved pathogen-specific regimens, and better empiric therapies may change some of the assumptions used to select algorithms for diagnostic evaluation and management. Any shift in the cause of diarrhea from pathogen-associated to idiopathic or a reduction in the overall incidence of diarrhea would have considerable impact. It is unclear how significant the problem of pathogen relapse in previous responders will become. Existing studies reviewed in this article show that the high diagnostic yield of endoscopy when stool tests are negative, coupled with significantly better outcomes when pathogens are identified, support the current practice of routine endoscopic evaluation. There currently are scant data on the economic impact of HIV-associated diarrhea as it relates to pathogen-specific and empiric therapy in the era of protease inhibitors. Such data would be integral to future evaluation of the impact of diagnostic and therapeutic strategies.

Evaluation of upper gastrointestinal tract symptoms in patients infected with HIV

OBJECTIVE

Upper gastrointestinal tract (UGI) symptoms are frequent in patients infected with the human immunodeficiency virus (HIV), but little published information exists about their characteristics or methods of evaluation. We evaluated the prevalence of nonesophageal UGI symptoms in a referral population, the utility of esophagogastroduodenoscopy (EGD) for diagnosis, and clinical predictors of abnormal endoscopic findings in patients infected with HIV.

METHODS

All HIV-infected patients referred to.the outpatient gastroenterology clinics were prospectively evaluated using recognized symptom questionnaires. EGD indications, results, and the patients' self-reported symptom scores were compared. HIV-infected patients undergoing EGD were compared with HIV-infected patients not receiving an EGD and with symptomatic non-HIV-infected patients undergoing EGD.

RESULTS

A total of 201 patients completed 280 questionnaires. Among 93 patients who underwent endoscopy, severe symptoms occurring at least several times per week included: anorexia (70%), upper abdominal pain (34%), vomiting (32%), or a recent weight loss of approximately 15 lb (31%). Patients undergoing EGD had more frequent/severe symptoms, but did not have differences in overall well-being or mean GI symptom score. The frequency of substantial and treatable endoscopic findings among patients infected with HIV was comparable to that found in the non-HIV-infected control group. There were no independent symptoms predicting substantial or treatable disease on EGD.

CONCLUSIONS

We conclude that: 1) upper gastrointestinal symptoms are common in HIV-infected patients referred for GI consultation; 2) symptomatic HIV patients have a high prevalence of both treatable and untreatable upper GI pathologies; 3) and physicians use symptom frequency and severity to select patients for EGD, but these factors correlate poorly with abnormalities on EGD. Given this discrepancy, longitudinal study is needed to determine whether treating endoscopic abnormalities improves UGI symptoms.

Simultaneous intestinal leishmaniasis and mycobacterial involvement in a patient with acquired immune deficiency syndrome

Gastrointestinal involvement is reported in approximately 50% to 93% of patients with human immunodeficiency virus. It is frequently the result of coinfection with several microorganisms. Selective Leishmania intestinal involvement presents with atypical symptoms for visceral leishmaniasis, and may appear as a relapse or as the first manifestation of the disease. The authors present a patient with acquired immune deficiency syndrome who has a history of treated leishmaniasis and gastrointestinal infection by showed Mycobacterium avium intracellulare (MAI). After the new onset of abdominal pain, an intestinal biopsy showed the presence of both MAI and Leishmania in duodenum. Intestinal infection by Leishmania must be included in the differential diagnosis in patients with a previous history of leishmaniasis or travel to an endemic area.