Gallbladder and biliary tract disease in AIDS

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Acute Acalculous Cholecystitis-Associated Bacteremia Has Worse Outcome

Background: Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder without gallstones in the setting of critical illness. It represents 2%-15% of acute cholecystitis (AC) cases. Bacteremia is associated with increased morbidity and mortality rates in patients in the intensive care unit (ICU). The incidence of bacteremia in acute calculous cholecystitis (ACC) has been described; however, the incidence of bacteremia in AAC has not been reported. We hypothesized that patients with AAC have higher bacteremia rates, leading to worse outcomes than in those with ACC. Methods: A prospectively collected acute care surgery (ACS) institutional database of patients treated from 2008 through 2018 was queried for patients having ACC using International Classification of Diseases (ICD) 9 and 10 codes. Demographics, microbiology findings, and outcomes were extracted. Only patients with positive blood cultures were included in the study. We defined two cohorts: AAC with bacteremia and ACC with bacteremia. The Student t-test was used for continuous variables and the χ² and Fisher exact tests for categorical variables. Multivariable regression was applied, and statistical significance was set at p < 0.05. Results: Of 323 patients with AC, 57 (17.6%) had AAC and 266 (82.4%) had ACC. Of the 19 patients who had a blood culture, 11 (57.8%) were positive. Patients with positive blood cultures had a mean age of 56.7 ± 15.3 years and a mean Body Mass Index (BMI) of 26.7 ± 4.9. The incidence of bacteremia was significantly higher in AAC (n = 6; 10.5% versus n = 5; 1.9 %; p = 0.005), although the time between admission and diagnosis of bacteremia was similar in the two groups (1.2 ± 1.1 versus 0.2 ± 0.5 days; p = 0.128). The patients with AAC and bacteremia were younger (53.8 ± 19.2 versus 60.2 ± 8 years; p = 0.021) and had a longer ICU length of stay (LOS) (12.6 ± 7.2 versus 1.3 ± 2.1 days; p = 0.030). However, there was no difference in the mortality rate in the groups (n = 2; 33.3% versus 1; 20.0%; p = 1.000). After adjusting for age, gender, BMI, and Charlson Comorbidity Index, bacteremia in AAC patients was found to be an independent variable for longer ICU LOS (odds ratio 8.8; 95% confidence interval 1.7-15.9; p = 0.024). Conclusions: The incidence of bacteremia in patients with AAC is five-fold higher and the ICU stay eight days longer than in patients with ACC.

Acute cholecystitis secondary to dog bite

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This is the second known case of Cholecystitis due to Capnocytophaga canimorsus.

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Accurate diagnosis of this condition requires thorough history and examination.

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Prolonged targeted antibiotic therapy may be required for symptom resolution.

Introduction

The gram-negative bacteria known as Capnocytophaga canimorsus (C. canimorsus) is found in dog saliva and rarely can cause severe infection in humans following a bite or scratch. There has previously been just a single case described in the literature of Acute Acalculous Cholecystitis (AAC) secondary to C. canimorsus.

Presentation of case

Here we describe the second ever published case of C. canimorsus bacteremia presenting with acute cholecystitis. The patient presented with epigastric pain and sepsis three weeks post domestic dog bite. On further examination, he was Murphy’s sign positive. Investigations included blood cultures, Ultrasound Scan and Computed Tomography of the Abdomen. He was treated with intravenous fluid resuscitation, and intravenous ceftriaxone and metronidazole. He required an extended course of antibiotics for complete symptom resolution. His blood cultures were positive for C. Canimorsus.

Discussion

This case highlights the ever-present need for thorough history and examination, and consideration of prolonged antibiotics for cases of cholecystitis that could be secondary to C. canimorsus bacteremia.

Conclusion

We strongly advocate blood cultures in patients who present with abdominal pain and sepsis, particularly when they have a recent history of animal bite. In cases of cholecystitis secondary to C. canimorsus it may be necessary to monitor the patient’s progress more closely and treat with prolonged targeted antibiotic therapy.

Critical Care Aspects of Gallstone Disease

Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals. This review deals with the important critical care aspects associated with a gallstone-related disease.

Clinical Vignette in Antiretroviral Therapy: Jaundice

HIV caregivers face many challenges following initiation of ART. The development of jaundice is uncommon but worrisome. In this case, two distinct and contrasting episodes of jaundice were observed. In the first instance, isolated elevation of the indirect bilirubin without elevation of the alkaline phosphatase was noted. The normal PT and serum aminotransferase levels indicate the absence of intrinsic liver dysfunction. Elevations in the indirect bilirubin may result from either impaired uptake/conjugation or excess production. The latter, usually from acquired hemolysis, may be a complication of an occult NHL. A work-up for this AIDS-related malignancy was not initiated since the caregivers recognized jaundice as a complication of IDV, which inhibits UDP-glucuronyl transferase and produces a Gilbert's-like syndrome. Physicians can expect to encounter this syndrome even more frequently with ATV. Experienced patients given RTV-boosted ATV have experienced elevations of unconjugated hyper-bilirubinemia in up to 45 percent of cases in clinical trials. However, such elevations do not reflect liver dysfunction and symptomatic jaundice requiring dosage reduction that occurred infrequently (7 to 8 percent of study patients). Counseling patients about this syndrome may promote adherence and prevent self-directed interruptions of ATV that compromise efficacy. The second case of jaundice provides a more formidable diagnostic challenge. The triad of LFT abnormalities (mild elevation of aminotransferases, normal PT, and marked cholestatic jaundice) implies an acute process that is mildly toxic to hepatocytes without affecting their synthetic function. The subacute nature of the patient's cholestatic jaundice suggests either intrahepatic infiltrative disease of the liver or extrahepatic obstruction of the biliary tree, most likely due to the patient's relatively modest level of pain and lack of fever. Despite LFT abnormalities occurring 17 months after a switch in his ART, cumulative drug-related toxicities must still be considered. Ritonavir can produce significant elevations in the AST/ALT, especially with pre-existing chronic liver disease as with hepatitis C virus coinfection. The NRTIs can produce hepatic steatosis, a result of mitochondrial toxicity and impaired fatty acid oxidation. However, jaundice and cholestasis are not typical of the latter syndrome. With a negative contrast CT that excludes parenchymal liver disease, investigation of the biliary tree to assess the presence of AIDS-related cholangitis was the next step. Performing a sphincterotomy or stent placement, and obtaining brushings or biopsy specimens to determine the extent of extrahepatic obstruction may help define a pathogen and be life-saving. The negative results of the ERCP justify the final diagnostic step, a liver biopsy to evaluate microscopic infiltrative disease that might not have been detected on contrast abdominal CT. Examples might include granulomatous disease (MAC), fungal etiologies (histoplasmosis), carcinomatosis (lymphoma, hepatoma, cholangiocarcinoma), and microvascular disease (bacillary angiomatosis). The failure to observe granulomatous inflammation in the liver does not exclude MAC infection, as MAC may involve other peri-aortic or mesenteric lymph nodes. This form of IRIS is unlikely given the abdominal CT findings, lack of systemic complaints, and extended persistence of liver aminotransferases. The nonspecific results of the liver biopsy are a common outcome in advanced AIDS patients with elevated alkaline phosphatase levels. Despite not having identified a pathogen, the biopsy establishes chronic liver disease and prompts re-evaluation and change of treatment to NFV. The subsequent normalization of the patient's aminotransferase levels suggests a prior adverse effect of LPV/r in the setting of unexplained, chronic liver disease. Most importantly, this case highlights the importance of HIV caregivers to review ART for safety when noting chronic liver dysfunction. Patients need to be counseled to minimize acetaminophen use, to consume alcohol in moderation, and to avoid behavior with risk for hepatitis C. Finally, all HIV patients should receive appropriate vaccination against hepatitis A and B if serology shows lack of protective immunity.

AIDS Cholangiopathy in an Asymptomatic, Previously Undiagnosed Late-Stage HIV-Positive Patient from Kenya

AIDS-associated cholangiopathy is a form of biliary tract inflammation with stricture formation seen in AIDS patients who are severely immunosuppressed. It is no longer common in countries in which HAART therapy is widely employed but is still seen in underdeveloped countries. The majority of patients are symptomatic at the time of presentation. Herein, we describe a seventy-four-year-old woman who presented with unilateral leg swelling after a prolonged airplane flight. She was otherwise entirely asymptomatic. Routine laboratory testing was notable for a hypochromic microcytic anemia, slight leukopenia, and mild hypoalbuminemia. Liver enzymes were all elevated. Deep venous thrombosis was confirmed, and a CT scan of the chest disclosed no pulmonary emboli. However, the visualized portion of the abdomen showed dilatation of the common bile and pancreatic ducts. This was confirmed on ultrasonography and MRCP, and no obstructive lesions were noted. An ERCP revealed a dilated common bile duct without filling defects or strictures. A balloon occlusion cholangiogram showed strictures and beading of the intrahepatic ducts. Shortly thereafter, serology for HIV returned positive along with a depressed CD4 cell count, and the patient was diagnosed with AIDS-associated cholangiography.

Liver disease in the HIV-infected individual

Since the advent of effective antiretroviral therapy (ART) for human immunodeficiency virus-1 (HIV), there has been a substantial decrease in deaths related to acquired immunodeficiency syndrome (AIDS). However, in the ART era, liver disease is now the most common non-AIDS-related cause of death among HIV-infected patients, accounting for 14%-18% of all deaths in this population and almost half of deaths among hospitalized HIV-infected patients. Just as the burden of non-AIDS morbidity and mortality has changed in the ART era, the types of liver disease the clinician is likely to encounter among these patients have changed as well. This review will discuss the causes of liver disease in the HIV-infected population in the ART era, including chronic hepatitis C virus, chronic hepatitis B virus, medication-related hepatotoxicity, alcohol abuse, nonalcoholic fatty liver disease, and AIDS-related liver diseases.

Acalculous cholecystitis in a patient with Plasmodium falciparum infection: a case report and literature review

Acute acalculous cholecystitis (AAC) can occur without gallstones in critically ill or injured patients and has also been associated with various infectious agents.(1-4) We report here a case of AAC in a patient with Plasmodium falciparum malaria.

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.

Staphylococcal acalculous cholecystitis in a child

Acute acalculous cholecystitis is inflammation of the gallbladder in the absence of gallstones. It usually occurs in critically ill patients and is rare in the pediatric age group. We describe a 12-year-old boy who presented with fever, jaundice, and abdominal pain and was found to have acute acalculous cholecystitis, sacroiliitis, and pelvic osteomyelitis associated with bacteremia as a result of Staphylococcus aureus. Antibiotic therapy without surgical intervention was effective. A high index of suspicion is required to make an early diagnosis and institute appropriate treatment for children with this condition. Although cholecystectomy has been considered the standard therapy, medical treatment alone can be successful.

[Alithiasic cholecystitis in the adult: etiologies, diagnosis and treatment]

Acalculous cholecystitis represents 2% to 14% of cholecystectomies performed for acute cholecystitis. Its main etiology is ischemia of the gallbladder wall, which mainly occurs in critically ill patients, particularly in case of cardiovascular previous disease or diabetes. Acalculous cholecystitis associated with VIH are rare and have a better prognosis. Other etiologies are exceptional. Diagnosis of acalculous cholecystitis is difficult, with a lack of specificity of abdominal ultrasound for the diagnosis of ischemic cholecystitis. In all cases, cholecystectomy is a definitive treatment allowing certain diagnosis. Percutaneous drainage must be reserved to patients whose general condition does not allow general anesthesia. Medical treatment alone is not indicated in acalculous cholecystitis.

Isolated intrahepatic biliary dilatation in a patient with acquired immune deficiency syndrome (AIDS): AIDS cholangiopathy versus incidental unilobar Caroli's disease

We describe a case of possible monolobar Caroli's disease in a patient with acquired immune deficiency syndrome (AIDS) who presented with features of cholangitis. Diagnostic workup, which included endoscopic retrograde cholangiography, revealed focal intrahepatic biliary dilatation confined to the right lobe. The patient subsequently underwent right hepatic lobectomy. Pathology revealed multiple cysts filled with calculi and inflammation in the cyst walls. Special stain results for fungi and acid-fast organisms were negative. The presence of advanced AIDS in this patient raised the possibility of this being a possible manifestation of AIDS cholangiopathy.

Microsporidial AIDS cholangiopathy due to Encephalitozoon intestinalis: case report and review

Microsporidia are increasingly recognized as opportunistic infections in immunodeficient patients, predominantly patients with AIDS. The two microsporidia most commonly associated with disease in AIDS patients are Enterocytozoon bieneusi and Encephalitozoon intestinalis (previously known as Septata intestinalis). The most common clinical presentation of microsporidiosis in AIDS patients is diarrhea, most commonly caused by the Enterocytozoon bieneusi species. Encephalitozoon intestinalis is a recently described species that has been reported to cause disseminated human infection including cholangitis. We report a case of AIDS cholangiopathy that presented with abdominal pain and cholestatic liver tests. Ultrasound examination and ERCP revealed a picture of sclerosing cholangitis. Bile samples obtained at ERCP were negative for microsporidia; stool studies for microsporidia and cryptosporidia were also negative. No organisms were identified on routine light microscopy of the biopsy specimens from the duodenum, ampulla, and bile duct. E. intestinalis spores were demonstrated in the bile duct biopsies, by methylene blue and azure 11 staining and confirmed by electron microscopy. Albendazole therapy was successful in eradicating E. intestinalis with clinical improvement and improvement in CD4 count. However, the cholangiographic picture did not improve and repeat cholangiography revealed progressive bile duct injury. Albendazole therapy was delayed and may have been too late to prevent bile duct damage; the drug had to be approved by the US Food and Drug Administration for compassionate use. This is an unusual case of sclerosing cholangitis caused by an unusual organism and requiring biliary sphincterotomy and stent placement for progressive stricturing despite eradication of the infection.

Acute (ascending) cholangitis

Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Bacteria reach the biliary system either by ascent from the intestine or by the portal venous system. Once the biliary system is colonized, biliary stasis allows bacterial multiplication, and increased biliary pressures enable the bacteria to penetrate cellular barriers and enter the bloodstream. Patients with cholangitis are febrile, often have abdominal pain, and are jaundiced. A minority of patients present in shock with hypotension and altered mentation. There is usually a leukocytosis, and the alkaline phosphatase and bilirubin levels are generally elevated. Noninvasive diagnostic techniques include sonography, which is the recommended initial imaging modality. Standard CT, helical CT cholangiography, and magnetic resonance cholangiography often add important information regarding the type and level of obstruction. Endoscopic sonography is a more invasive means of obtaining high-quality imaging, and endoscopic or percutaneous cholangiography offers the opportunity to perform a therapeutic procedure at the time of diagnostic imaging. Endoscopic modalities currently are favored over percutaneous procedures because of a lower risk of complication. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.

Gastrointestinal manifestations of HIV infection

Since the beginning of the AIDS pandemic, gastrointestinal (GI) problems have been among the most common features of the disease. Despite the introduction of highly active antiretroviral therapy (HAART) in 1995 and 1996, most HIV-infected patients continue to have GI complications. The clinician must be able to diagnose and treat the opportunistic gastrointestinal infections and neoplasms that occur in the advanced AIDS patient, as well as the treatment-induced symptoms and non-HIV-related GI disorders that predominate in early HIV disease. This review addresses the GI manifestations of HIV, with particular emphasis on new developments in the era of highly effective therapy.

Biliary Problems in People with HIV Disease

Acute cholecystitis in a patient with HIV infection represents a difficult diagnostic problem. With improved antiretroviral therapy, many of the biliary problems we have seen in these patients are identical to those in nonimmunosuppressed patients (ie, they are largely caused by gallstones). The indication for cholecystectomy is usually right upper quadrant abdominal pain that has been persistent for weeks to months. Although cholecystectomy will result in pain relief in many patients, the presence of coexisting HIV cholangiopathy in about half these patients increases the likelihood of ongoing symptoms. Patients should be counseled that postoperative endoscopic retrograde cholangiopancreatography (ERCP) may be necessary and that some of the variants of HIV cholangiopathy do not respond to endoscopic therapy. The high perioperative mortality in these patients is not related to biliary tract disease but is rather a manifestation of severe underlying disease associated with advanced HIV infection. HIV cholangiopathy represents a complication of severe immunosuppression. Patients are generally in poor condition and often have coexisting infections or malignancies. The decision regarding how aggressively to approach a patient with suspected HIV cholangiopathy, a nonfatal condition, is best made with consideration of the degree of pain being reported. All patients should undergo an abdominal ultrasound, with ERCP being offered to those with severe or debilitating pain and who are found to have dilated bile ducts suggesting papillary stenosis. Should this finding be confirmed at cholangiography, sphincterotomy is effective palliation for abdominal pain in most cases. ERCP is considerably less useful in patients who have elevated liver enzyme levels without symptoms; there is only a small likelihood of identifying an infection not previously recognized or better diagnosed noninvasively. These patients do not generally benefit from sphincterotomy. The regular use of ERCP in patients with HIV for the evaluation of elevated liver enzyme levels is to be discouraged, because the very limited potential benefit of the procedure does not outweigh the risks.

Acalculous acute cholecystitis in leukemia

Acalculous acute cholecystitis (AAC) is a well-known complication in critically ill patients. However, there is no satisfactory data regarding this complication in leukemic patients. We reviewed the medical records of 426 patients with acute or chronic leukemia retrospectively to investigate the incidence, possible pathogenetic mechanisms, and clinical course of AAC in leukemia. Six cases of AAC were identified. The incidence was 1.65% (5/302) for acute leukemias. Three out of 6 patients underwent cholecystectomy, and two recovered completely. Percutaneous cholecystostomy was performed in another patient successfully. Careful histological examinations of the surgical specimens did not reveal any specific etiopathogenetic finding. However, clinical data suggested that infectious agents and visceral ischemia may contribute to the pathogenesis of AAC in leukemia.

Acquired immunodeficiency syndrome (AIDS) of the abdominal organs: imaging features

The liver, spleen, biliary tract, pancreas, and kidneys are commonly affected by opportunistic infection, malignancy, and inflammatory disorders during the course of human immunodeficiency virus (HIV) infection. Clinical manifestations of solid abdominal visceral involvement are protean and usually nonspecific, but it is important to establish a specific diagnosis promptly in these often critically ill patients. This presentation reviews the cross-sectional imaging spectrum of HIV-associated lesions of these organs.