1 بسم الله الرحمن الرحيم GASTROINTESTINAL MANIFESTATIONS OF AIDS MANIFESTATIONS OF AIDS In : Medical, health and social aspects of HIV/AIDS Medical, health and social aspects of HIV/AIDS Salimi. G. M.D 2003

2 Gastrointestinal Complications of AIDS Diarrhea Acute diarrhea with primary HIV-1 SYNDROM Chronic diarrhea with other stages of infection Abdominal pain CMV disease, Lymphoma, Pancreatitis, typhlitis Hepatobiliary Dis. Acalculus cholecystitis,papillary stenosis, sclerosing cholangitis Pancretitis Drugs(Pentamidine, dideoxyinosine); infection neoplasm( lymphoma, kaposi sarcoma) GI Bleeding upper GI: HSV, esophagitis, GI Lymphoma,MAC Lower GI:CMV, Lymphoma Opprtunistic infections esophagus, stomach, intestine,

3 The commonest symptoms Chronic diarrhea Odynophagea Dysphagea Abdominal pain Jaundice Anorectal disease

4 Primary GI evidence of AIDS Esophageal Candida Cryptosporiodosis>1 month Cytomegalovirus>1 month Herpes ulcer / Esophagitis>1 month Kaposi,s sarcoma in patient<60 Y.Old Mycobacterium avium or kansasii, disseminated

5 CMV-Assoclated organ Disease in the Gastrolntestinal Tract in HIV-1-infected Persons Esophagus Stomach Small intestine Biliary tract Gallbladder Pancreas Appendix Colon Rectum Esophagitis, ulcers Gastritis,ulcers Enteritis, Ulcers, perforation (terminal ileum) Sclerosing cholangitis, papillary stenosis, (?) cholangitis Acalculous cholecystitis Pancreatitis Appendicitis Colitis, ulcers, perforation Proctitis, ulcers

6 Oral complications of AIDS Oral candidiasis Oral Hairy Leukoplakia HSV Infection Aphthous like Ulcers Kaposi sarcoma

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8 Esophageal Complications of AIDS Frequency(%) CD4 count Candida <200 CMV <50 HSV 2-5 <200 Idiopathic <300

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15 Gastric Complications of AIDS Gastritis Peptic ulcer <5% CMV infection (erosive gastritis) Kaposi, sarcoma Lymphoma Drug-Induced gastritis

16 DIARRHEA The commonest symptom (50-90%) The most frostrating and morbid GI. Manifestation Change in normal mucosal immunity: -Untreatable infection (cryptosporidia) -More virulent clinical course (salmonella,shigella…)

17 Agents of Acute and Chronic Diarrhea in AIDS Agent Freq.% CD4 /mm3 Acute Diarrhea --Salmonella 5-15 Any Clostridium Any difficile -- Enteric Viruses Any -- Idiopathic Any

18 Cont…Agens of Chronic Diarrhea Agent Freq.% CD4 /mm3 Cryptosporidium <100 Microsporidia <100 Isospora 1-3 <100 MAC <50 CMV <50 Idiopathic Any

19 Prevalence of Pathogenes in Diarrhea Pathogene % - Cryptosporidia Microsporidia CMV MAC 9.3 Giardia Lamblia 4.9 -Entamoeba Histolitica 2.6 -Campilobacter 3.3 -Salmonella 2.1 -Shigella 1.9 -Closteridium Difficile 1.8 -Isospora belli 1.5 -Enteric viruses 3.8 -Any pathogen isolated 67

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24 Evaluation of Diarrhea in AIDS Drug History CD4 count Differentiate Acute Vs. Chronic Differentiate Colitis Vs. Enteritis

25 Evaluation Of Diarrhea In AIDS I-In all patients, stool specimen for: 1-Bacterial Culture -Salmonella -Shigella -Campylobacter 2-Stool Smear for -Fecal leukocyte -Ova and Parasite -Acid-Fast bacterial stain -Fat stain

26 Continue of evaluation of diarrhea II- In patients with Rectal Bleeding, Tenesmus, Fecal Leukocyte -FLEXIBLE SIGMOIDOSCOPY with BIOPSY of mucosa for: -Pathology( Viruse, protozoa) -Culture of rectal tissue for bacteria( especially campylo- bacter)

27 Cont….. III-If Diarrhea Persist UPPER GI ENDOSCOPY WITH Aspiration of secretion for ova and parasite bacterial culture - Small bowel mucosal biopsy; electron microscopy if avaleable

28 Causes of Abdominal Pain CMV Infection and Arteritis CMV Colitis Sclerosing Cholangitis AIDS Cholangiopathy Acute Surgical Abdomen

29 Abdominal “Pain syndrom” in AIDS Dull pain, Diarrhea Naseua, Vomiting Acute severe pain Tenderness RUQ Pain + Abn.LFT Subacute Pain, Severe Naseua/Vomiting =Infectious Enteritis =Perforation/Peritonitis =Cholecystitis ;Hepatitis Cholestasis =Obstruction

30 Differential Diagnosis of Jaundice / Hepatomegaly in AIDS Hepatic Parenchymal Disease MAC Drug-Induced( Zidovudine) CMV H.C.V, H.B.V, H.D.V Bacillary Peliosis Hepatis Lymphoma Mycobacterium T.B Cryptococcus Kaposi, sarcoma Microsporidium Biliary Disease Cholangitis caused by CMV Cryptosporidium Microsporidium Lymphoma Kaposi, sarcoma

31 ADVOISE

32 Clinical Guidelines Clinical signs and symptoms alone rarely suggest diagnosis Likely diagnoses may be predicted on the basis of immunocompromise. In late-stage HIV infection GI pathogen are usually part of a systemic infection (e.g., CMV, MAC )

33 Clinical Guidelines Evaluation should proceed from less invasive to more invasive procedures Multiple infection is common The clinician,s main goal is to identify treatable disorders Failure to establish a specific cause is not unusual Recurrence of opportunistic infection is almost invariable

34 Type of Clinical Presentation And Degree of Immunodefficiency Help to Differential diagnosis

35 DIFFICULTIES

36 Difficulty in decision Considering the vast number of infection and tumoral or nonspecific concequences of aids at once. How extensively should investigate GI. Symptoms.

37 Consider: Patient Discomfort Invasiveness Cost of Procedure Benefit of Procedure Severity of patient Complaint

38 PREVENTION

39 Approach to Prevention I-Biological Approach II-Education Approach III-Behavorial Approach

40 I-Biological Approach -Vaccination -Blood product & Biological Product Screening -Antiretroviral Treatment -Prevention of Vertical Transmissin -STD & HIV Prevention

41 II-Education Approach -Intervention vs. Education vs. Counceling -Media-Based Efforts

42 III-Behavorial Approach Behavorial Epidemiology “baseline state” -High Risk Sexual Behavior: -Multi Sexual Partner( Men & Women) >3-6 million adult with 5 partner/year -Low average age( 15.6 year) -Low Condom Use( 12%) -STD -Health-Risk Behaviors: -Smoking, Drug abuse, Alcohol

43 Behavorial Intervention: Objectives Increasing Knowledge Base Self Esteem Communication Skills Technical Efficacy Social Norms

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