Gastrointestinal disorders eng_d2-4

www.aidsknowledgehub.orgRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia

Advanced ART Training for Adults and Adolescents – Ukraine, 2004

Gastrointestinal disorders

Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org

• The purpose of the session: to discuss clinical features of the common gastrointestinal disorders in patients with HIV/AIDS and to learn the current recommendations for their diagnosis and treatment

• Objectives: after completing this session, the participants will be able to:– Identify the common gastrointestinal disorders in patients

with HIV/AIDS and the common causes of diarrhea in patients with HIV/AIDS

– Provide a differential diagnosis for the common gastrointestinal disorders in patients with HIV/AIDS

– Describe laboratory evaluation of the common gastrointestinal disorders in patients with HIV/AIDS

– Provide treatment for gastrointestinal disorders in patients with HIV/AIDS

The purpose of the session

The Common Gastrointestinal Disorders in Patients with HIV

• Anorexia, Nausea, Vomiting

• Acute Diarrhea - MEDICATION-RELATED ACUTE DIARRHEA- CAMPYLOBACTER JEJUNI- CLOSTRIDIUM DIFFICILE- ENTERIC VIRUSES- SALMONELLA- SHIGELLA- ESCHERICHIA COLI- IDIOPATHIC (PATHOGEN-NEGATIVE)

• Chronic Diarrhea - CYTOMEGALOVIRUS- ENTAMOEBA HISTOLYTICA- GIARDIA LAMBLIA- CRYPTOSPORIDIA - MICROSPORIDIA- MYCOBACTERIUM AVIUM COMPLEX (MAC)- IDIOPATHIC (PATHOGEN-NEGATIVE)

• Cholangiopathy• Pancreatitis

WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States, March 2004

Anorexia, Nausea, Vomiting

• MAJOR CAUSES: - Medications (especially antiretrovirals, antibiotics, opiates, and NSAIDs)- Depression - Intracranial pathology - GI disease- Hypogonadism - Pregnancy- Lactic acidosis- Acute gastroenteritis(John G. Bartlett, Medical Management of HIV Infection, 2003)

Anorexia, Nausea, Vomiting (continued)

• EVALUATION: - Drug holiday - Lactic acid level - Fasting testosterone level- GI evaluation (endoscopy, CT scan)- Intracranial evaluation (head CT scan or MRI)

• TREATMENT: Treat underlying condition.

(John G. Bartlett, Medical Management of HIV Infection, 2003)

Diarrhea

• Acute- as ≥3 loose or watery stools for 3 to 10 days

• Chronic - as >2 loose or watery stools/day for ≥30 days in advanced HIV infection

(WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of Independent States, March 2004; John G. Bartlett, Medical Management of HIV Infection, 2003)

Medication-related Acute Diarrhea

• Main antiretroviral agents:– Nelfinavir – Lopinavir/ritonavir– Saquinavir

• Management:– Loperamide– Pancreatic enzymes

Pathogen Detection• Blood culture: MAC, Salmonella

• Stool culture: Salmonella, Shigella, C. jejuni, Vibrio, Yersinia, E. Coli 0157

• Stool assay for C. difficile toxin A and B

• Ova & Parasite examination + AFB (Cryptosporidia, Cyclospora, Isospora), trichrome or other stain for Microsporidia and antigen detection (Giardia)

Main Pathogens of Acute Diarrhea

• BACTERIAL: Campylobacter jejuni, Clostridium difficile, Escherichia coli, Salmonella, Shigella

• ENTERIC VIRUSES: Adenovirus, Astrovirus, Picornavirus, Calicivirus

• IDIOPATHIC

Acute Diarrhea: CAMPYLOBACTER JEJUNI

• FREQUENCY: 4% to 8% of HIV infected patients with acute diarrhea

• CLINICAL FEATURES: Watery diarrhea or bloody flux, fever, fecal leukocytes variable; any CD4 count

• DIAGNOSIS: Stool culture; most laboratories cannot detect C. cinaedi, C. fennelli, etc.

Acute Diarrhea: CLOSTRIDIUM DIFFICILE• FREQUENCY: 10% to 15% of HIV infected patients with acute

diarrhea

• CLINICAL FEATURES: Watery diarrhea, fecal WBCs variable; fever and leukocytosis common; prior antibacterial agents (especially clindamycin, ampicillin, and cephalosporins); any CD4 count

• DIAGNOSIS:- Endoscopy: pseudomembranous colitis, colitis, or normal (this procedure is not usually indicated)- Stool toxin assay- CT scan: Colitis with thickened mucosa

• TREATMENT: Metronidazole, Vancomycin.

!!! Antiperistaltic agents are contraindicated.

• RESPONSE: - fever resolves within 24 h- diarrhea resolves within 5 days- 20% to 25% have relapses at 3 to 14 days after treatment stopped.

Acute Diarrhea: ENTERIC VIRUSES• FREQUENCY: 15% to 30% of HIV infected

patients with acute diarrhea

• CLINICAL FEATURES: Watery diarrhea, acute, but one-third become chronic; any CD4 cell count

• DIAGNOSIS: clinical laboratories cannot detect most viruses

• TREATMENT: Supportive treatment (Lomotil or Loperamide) + rehydration

Acute Diarrhea: SALMONELLA

• CLINICAL FEATURES: Watery diarrhea, fever, fecal WBCs variable; any CD4 count

• DIAGNOSIS: Stool culture, blood culture

Acute Diarrhea: SHIGELLA

• CLINICAL FEATURES: Watery diarrhea or bloody flux, fever, fecal WBCs common; any CD4 count

• DIAGNOSIS: Stool culture

Acute Diarrhea: ESCHERICHIA COLI

Agent Clinical Presentation

Enterotoxigenic (ETEC) Traveler’s diarrhe

Enterohemorrhagic0157:H7 (EHEC)

Bloody diarrhea

Enteroinvasive (EIEC) Dysentery

Enteropathic (EPEC) Watery diarrhea

!!! EHEC - Antibiotics contraindicated

Treatment of Acute DiarrheaNon-typhoid salmonelloses

Ciprofloxacin 500mg PO BID for > 2 weeks+ Rehydration

Shigelloses Ciprofloxacin 500mg PO BID for 5 days, ORNalidixic acid 500mg PO QID for 5 days, ORSulphamethoxazole/trimethoprim 800mg/160mg PO BID for 5 days + Rehydration

Campylobac-teriosis

Erythromycin 500 mg PO qid x 5 days; fluoroquinolone resistance rates are >20%+ Rehydration

Virus diarrhea Rehydration

ETEC Cipro 500 mg bid x 3 days or TMP-SMX DS bid x 3 days+ Rehydration

EIEC Cipro 500 mg bid x 5 days or TMP-SMX DS bid x 5 days+ Rehydration

(WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of Independent States , March 2004; John G. Bartlett, Medical Management of HIV Infection, 2003)

Acute Diarrhea: IDIOPATHIC DIARRHEA

• CLINICAL FEATURES: Variable noninfectious causes; rule out medications, dietary, irritable bowel syndrome; any CD4 cell count

• DIAGNOSIS: Negative studies including culture, O&P examination, and C. difficile toxin assay

• TREATMENT (sever acute idiopathic diarrhea): empiric antibiotic treatment

• CYTOMEGALOVIRUS• ENTAMOEBA HISTOLYTICA• GIARDIA LAMBLIA• CRYPTOSPORIDIA • MICROSPORIDIA• MYCOBACTERIUM AVIUM COMPLEX (MAC)• IDIOPATHIC (PATHOGEN-NEGATIVE)

Main Pathogens of Chronic Diarrhea

Chronic Diarrhea: CRYPTOSPORIDIA• FREQUENCY: 10% to 30% of chronic diarrhea in AIDS patients

• CLINICAL FEATURES: Enteritis; watery diarrhea; no fecal WBCs; fever variable; malabsorption; wasting; large stool volume with abdominal pain; remitting symptoms for months; CD4 cell count <150/mm3 is associated with recurrent or chronic disease.

• DIAGNOSIS: AFB smear of stool to show oocyst of 4-6 µm

• TREATMENT:- Best results are with HAART- Paromomycin 1000 mg bid or 500 mg PO bid x 7 days; efficacy is marginal- Azithromycin 600 mg/day + paromomycin (above doses) x ≥4w- Nutritional support plus Lomotil

• RESPONSE: The most effective treatment is immune reconstitution; even small rises in CD4 count often succeed in controlling diarrhea

Chronic Diarrhea: CYTOMEGALOVIRUS• FREQUENCY: 15% to 40% of chronic diarrhea in AIDS patients

• CLINICAL FEATURES: Colitis and/or enteritis; fecal WBC and/or blood; cramps; fever; watery diarrhea ± blood; may cause perforation; hemorrhage, toxic megacolon, ulceration; CD4 cell count <50/mm3

• DIAGNOSIS:- Biopsy- CT scan- Cannot establish this diagnosis with CMV markers in blood or stool; need biopsy

• TREATMENT: 1) HAART2) Valganciclovir 900 mg PO bid x 3 weeks, then 900 mg qd3) Ganciclovir 5 mg/kg IV bid x 2 weeks, then valganciclovir 900 mg/day4) Foscarnet 40-60 mg/kg IV q8h 2 x weeks, then 90 mg/kg/day

• RESPONSE: variable; foscarnet and ganciclovir are equally effective or ineffective

Chronic Diarrhea: ENTAMOEBA HISTOLYTICA

• FREQUENCY: 1% to 3% of chronic diarrhea in AIDS patients

• CLINICAL FEATURES: Colitis; bloody stools; cramps; no fecal WBCs (bloody stools); most are asymptomatic carriers; any CD4 cell count

• DIAGNOSIS: Stool O&P examination.

• TREATMENT: Metronidazole 500-750 mg PO or IV tid x 5 to 10 days, then iodoquinol 650 mg PO tid x 21 days or paromomycin 500 mg PO qid x 7 days

Chronic Diarrhea: GIARDIA LAMBLIA• FREQUENCY: 1% to 3% of chronic diarrhea in

AIDS patients

• CLINICAL FEATURES: Enteritis; watery diarrhea ± malabsorption, bloating; flatulence; any CD4 cell count

• DIAGNOSIS: Antigen detection

• TREATMENT: Metronidazole 250 mg PO tid x 10 days

Chronic Diarrhea: CYCLOSPORA• FREQUENCY: <1% of chronic diarrhea in AIDS

patients

• CLINICAL FEATURES: Enteritis; watery diarrhea; CD4 cell count <100/mm3

• DIAGNOSIS: Stool AFB smear: Resembles cryptosporidia

• TREATMENT: TMP-SMX 1 DS bid x 3 days

Chronic Diarrhea: ISOPORA BELLI• FREQUENCY: 1% to 3% of chronic diarrhea in

AIDS patients

• CLINICAL FEATURES: Enteritis; watery diarrhea; no fecal WBCs; no fever; wasting; malabsorption; CD4 cell count <100/mm3

• DIAGNOSIS: AFB smear of stool; oocysts: 20 to 30 µm

• TREATMENT: TMP-SMX 3-4 DS/day; Pyrimethamine 50-75 mg/day PO x 7 to 10 days

Chronic Diarrhea: MICROSPORIDIA (ENTEROCYTOZOON BIENEUSI OR

ENTEROCYTOZOON (SEPTATA) INTESTINALIS)

• CLINICAL FEATURES: Enteritis, watery diarrhea, no fecal WBCs; fever uncommon; remitting disease over months; malabsorption; wasting; CD4 cell count <100/mm3

• DIAGNOSIS:– Special trichrome stain– Alternative: Fluorescent stains with similar sensitivity

• TREATMENT:– Albendazole 400-800 mg PO bid x ≥3 weeks; efficacy is established

only for Septata intestinalis– Fumagillin 60 mg PO qd x 14 days for E. bieneusi; monitor for

neutropenia and thrombocytopenia

Chronic Diarrhea: MYCOBACTERIUM AVIUM COMPLEX (MAC)

• CLINICAL FEATURES: Enteritis; watery diarrhea; no fecal WBCs; fever and wasting common; diffuse abdominal pain in late stage; CD4 cell count <50/mm3

• DIAGNOSIS:– Positive blood cultures for MAC– Biopsy– CT scan

• TREATMENT:– Clarithromycin 500 mg PO bid + EMB 15 mg/kg/day– Azithromycin 600 mg/day + EMB 15 mg/kg/day ± rifabutin 300 mg/day

• RESPONSE: Slow response over several weeks

Chronic Diarrhea: IDIOPATHIC (PATHOGEN-NEGATIVE)

• FREQUENCY: 20% to 30% of chronic diarrhea in AIDS patients, who undergo a full diagnostic evaluation including endoscopy

• CLINICAL FEATURES:– Usually low-volume diarrhea that resolves spontaneously or is

controlled with antimotility agents– Typically not associated with significant weight loss and often resolves

spontaneously

• DIAGNOSIS: – Biopsy– With pathogen-negative, persistent, large volume diarrhea, must rule

out KS and lymphoma

• TREATMENT: Supportive care(John G. Bartlett, Medical Management of HIV Infection, 2003)

Cholangiopathy• CAUSE:

main - Cryptosporidiosis other - Microsporidia, CMV, and Cyclosporaidiopathic – 20-40%

• Seen primarily in late stage AIDS (CD4 count <100 cells/mm3)

• PRESENTATION: Right upper quadrant pain, LFTs show cholestasis

• DIAGNOSIS: ERCP (preferred); ultrasound is 75% to 95% specific

• TREATMENT: Based on cause

Pancreatitis in Patients with HIV Infection

• MAJOR CAUSES- Drugs: ddI or ddI + d4T ± hydroxyurea- CMV- Alcoholism

• DIAGNOSIS- Amylase- Lipase (same sensitivity but more specificity)- CT Scan

• TREATMENT: Supportive(John G. Bartlett, Medical Management of HIV Infection, 2003)

Gastrointestinal disorders eng_d2-4

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