Review article: the therapy of gastrointestinal infections associated with the acquired immunodeficiency syndrome

Gastrointestinal manifestations in patients with acquired immunodeficiency syndrome

Gastrointestinal (GI) involvement is common in patients with acquired immunodeficiency syndrome; however, opportunistic disorders are generally not seen until the CD4 count falls below 200 cells/μl. Although any part of the gastrointestinal tract can be affected, the most common parts involved are the oesophagus and colon. Common oesophageal manifestations are dysphagia and odynophagia, caused by organisms such as Candida and cytomegalovirus (CMV). Common infectious and opportunistic disorders affecting the colon are Salmonella, Shigella, Campylobacter and CMV, which can result in diarrhoea, rectal bleeding and abdominal pain. Endoscopy is the preferred invasive procedure to diagnose most GI diseases. The main advantages of endoscopy are direct visualization of the entire GI tract, the option to obtain mucosal biopsy (which is often necessary to establish a specific diagnosis), and the ability to perform endoscopic therapy (e.g. injection of bleeding vessels). Therapy is based on the individual organism demonstrated.

Human immunodeficiency virus and endoscopy: Experience of a general hospital in Singapore

INTRODUCTION

As the human immunodeficiency virus (HIV) pandemic continues, demand on the endoscopic services will also increase. The aim of the present study was to characterize the characteristics and endoscopic findings of HIV-infected Asian patients.

METHODS

Patients with HIV/AIDS who had endoscopy from January 1997 to September 2002 were identified and retrospectively reviewed.

RESULTS

There were 125 patients (male, 111; mean age: 43.2 +/- 11 years; mean CD4 count 63 +/- 85/mm(3), range, 1-342/mm(3)) who underwent 181 procedures (upper gastrointestinal endoscopy [UGIE], n = 141; lower gastrointestinal endoscopy [LGIE], n = 40). The median time from diagnosis to endoscopy was 240 days (-660 to 4680 days). For UGIE the main findings were candidiasis, 23.1%; cytomegalovirus esophagitis/ulcers, 11.2%; duodenal ulcers, 8.4%; gastric ulcers, 7.0%; portal-hypertensive-related changes, 6.3%; idiopathic esophageal ulcers, 3.5%; herpes simplex esophagitis/ulcers, 3.5%; and tuberculosis, 2.1%. The CD4 counts were significantly lower in those with opportunistic infections (P = 0.004) but there was no difference between significant and non-significant findings (P = 0.191). For LGIE 35% had endoscopic colitis, 80% of which were non-specific. Significant findings were ileal tuberculosis, n = 3; colon cancer, n = 1; and colonic fistula, n = 1. Ten patients had undergone 16 procedures (UGIE, n = 13; LGIE, n = 3) prior to the diagnosis of HIV/AIDS. They were all male Chinese patients, with positive contact with commercial sex workers (CSW) and had lymphopenia at time of endoscopy. The median time from endoscopy to diagnosis was 180 days (range, 1-660 days). There were no significant differences in age (P = 0.512) and CD4 count at diagnosis (P = 0.066) between patients who had endoscopy before and after diagnosis of HIV/AIDS. Four procedures led to the suspicion of HIV.

CONCLUSIONS

Endoscopic findings of symptomatic HIV Asian patients are comparable to those of the West. Universal precautions should always be exercised in all procedures to avoid transmission of disease.

Diagnosis and management of infectious esophagitis associated with human immunodeficiency virus infection

Esophageal disease is a common complication and cause of morbidity in patients with human immunodeficiency virus (HIV) infection. Opportunistic infections are the leading cause of esophageal complaints and may be a predictor of poor long-term prognosis, presumably as a reflection of severe underlying HIV immunodeficiency. The esophagus may be the site of the first acquired immunodeficiency syndrome (AIDS)-defining opportunistic illness in a large number of patients. Barium esophagography and upper gastrointestinal endoscopy are diagnostic modalities, commonly used to evaluate esophageal complaints in patients with AIDS. Treatment for most etiologies of esophagitis generally has a high degree of success, with a resultant improvement in quality of life. In addition to optimizing antiretroviral therapy, a thorough diagnostic assessment of every HIV-infected patient with esophageal complaints is warranted, followed by timely and appropriate treatment.

Infections gastro-intestinales chez le patient immunocompromis

Le tractus gastro-intestinal est fréquemment le siège de manifestations infectieuses chez les patients immunocompromis.

Les symptômes les plus fréquemment rencontrés sont l'odynophagie, la dysphagie et les diarrhées.

Ces affections sont plus souvent observées chez les patients HIV.

Ces affections gastro-intestinales sont de différents types: soit liées au virus HIV lui-même (entérite liée au HIV, œsophagite ulcérée idiopathique), soit liées à des germes également responsables d'infections chez les patients immunocompétents (Salmonellose, shigellose, …), soit des infections opportunistes (CMV, Mucormycose,Cryptosporidium, Mycobactéries,Isospora belli, …).

La prévalence, la pathogenèse, les manifestations cliniques, les aspects macroscopique et microscopique sont discutés pour chaque entité.

Diagnosis and treatment of esophagitis in AIDS

At least 30% of patients with AIDS experience esophageal symptoms at some point during the course of HIV infection. The aim of this review is to provide a practical approach to the evaluation and therapy of esophagitis in AIDS.

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.

Esophageal strictures complicating ulcerative esophagitis in patients with AIDS

OBJECTIVE

Esophageal strictures have been reported to complicate opportunistic esophageal infections in human immunodeficiency virus (HIV)-infected patients, although the etiology, prevalence, and incidence of strictures after these infections have not been studied.

METHODS

HIV-infected patients undergoing upper endoscopy for clinical indications over a 7.5-yr period were prospectively identified. The cause of esophageal ulceration was defined by previously proposed criteria. Endoscopic re-examination was performed in most patients after treatment, and long term clinical follow-up was obtained. An esophageal stricture was defined as circumferential luminal narrowing of > or = 30% at endoscopy and/or barium esophagography.

RESULTS

A total of 160 HIV-infected patients were identified with esophageal ulcer. Of these patients, 13 (8%; 95% CI 4-12%) developed esophageal strictures. Strictures were identified at the time of initial endoscopy in three patients (cytomegalovirus [CMV] in one patient and gastroesophageal reflux disease in two), and at the site of ulcer healing or persistence in the other patients (four, CMV; four, idiopathic; one, herpes simplex virus [HSV]; one, CMV/HSV). Long term follow-up did not identify any additional patients who developed an esophageal stricture.

CONCLUSION

Esophageal strictures infrequently complicate ulcerative esophagitis caused by opportunistic infections in HIV-infected patients.

Diagnosis and treatment of colonic disease in AIDS

The colon is a frequent site of gastrointestinal complications in patients with HIV infection, and these colonic disorders increase in frequency as immunodeficiency worsens. The most common clinical manifestations of colonic disease in AIDS are diarrhea, lower gastrointestinal bleeding, and abdominal pain. Toxic megacolon, intussuseption, typhlitis, idiopathic colonic ulcer, and pneumatosis intestinalis also have been described. In the HIV-infected patient with preserved immunity, the most common cause of colitis is bacterial, but as the degree of immunodeficiency worsens, opportunistic pathogens (CMV, protozoa, mycobacteria, fungi) and neoplasms become more frequent. The frequent use of antibiotics, chemotherapeutic agents, and frequent hospitalization increase the susceptibility to cf2Clostridium difficule cf1colitis. Endoscopy plays an integral role in the management of many colonic disorders in AIDS.