1. PANCREATIC & BILIARY DISORDERS IN HIV
Dr.BujjiBabu ,M.D
Consultant HIV Physician
Dr.Bujjibabu HIV Clinic

2. Pancreatic Disorders Acute Pancreatitis
Chronic Pancreatitis(On Autopsy usually)
Pancreatic Neoplasm – Lymphoma Kaposi’s Sarcoma

3. Acute Pancreatitis Hyperamylasemia in ~40% of all AIDS
Clinical pancreatitis < 10% of all
Even lesser in those not on drugs
Usually mild unless due to drug
Drugs account for 40-50% cases
Hyperamylesemia(<3ULN) can occur without pancreatitis

4. Mechanism HIV itself Opportunistic Infections
CMV,HSV,MAC,Crypaococcus, Toxoplasma,
Myco.tuberculosis, Candida
Usually involves other organs also
Pancreatic neoplasms:Lymphoma, Kaposi Sarcoma
5% of AIDS; Pancreatitis rare
Usually in setting of wide spread disease
DRUGS

5. Drugs causing Acute Pancreatitis in HIV
Co-trimaxozole
Pentamidine (I.V. or Inhalational)
Dideoxylnosine (ddl)
Clinical course mild,severe or fatal
ddl : >40% develop asymptomatic hyperamylasemia
> 20% Clinical Pancreatitis (Usually after several months Advanced AIDS & Previous H/o Pancreatitis – high risk
Dose reduction decreases the risk
Careful monitoring of glucose

6. CECT : Acute pancreatitis in HIV

7. Diagnosis Clinical features Elevated amylase & lipase
Imaging (USG & or CT)
Occasionally FNAC for etiology

8. Acute pancreatitis in HIV
Cappell et al Gut,1995
Ac.Panc+HIV(44)
Ac. Pancreatitis(44)
Clinical Features
Similar
Anemia
More
Less
hypoalbuminemia
Leucopenia
Fever,Diarrhoea, hepatomegaly
More incidence
Drug Induced 18 2
Gall stone 22
Severe course (Prolong stay & death) 12
Ranson & Glasgow
Poor
Good
APACHE II

9. Acute Pancreatitis in 939 HIV cases
Conclusion
Incidence 4.7% in HIV +ve patients
Clinical features similar in 2 groups
High frequency of drug induced and low frequency of gall stones
High frequency of HIV related etiology
AIDS and Leukopenia – Severe hospital course
APACHE II –Good for predicting severity, prognosis & death
Cappell et al GUT; 1995

10. Acute pancreatitis in HIV:
Total No: 73
Drug Induce – 46%
Idiopathic 26%
25% had severe pancreatitis by Atlanta
15% Severe hospital course & death
APACHE –II – Best (Accuracy 75%)
Glasgow & Ranson – Poor
Conclusion:
AP in HIV Pts. had similar outcome as general population & APACHE-II is useful and applicable in this group Gan et al Am J Gastro 2003

11. Biliary Disorders in HIV Patients
Non HIV associated :
Stones, benign strictures, ascariasis ,neoplasms etc
Acalculus cholecystitis
AIDS cholangiopathy

12. CBD Stone in an AIDS Patient

13. Periampullary Ca

14. Acalculus cholecystitis in AIDS
Uncommon – Few case reports only
CMV & cryptosporidum usually
Young & ambulatory patients with RUQ pain and abnormal LFT
USG or scintigraphy for diagnosis
Cholecystectomy is therapeutic

15. AIDS Cholangiopathy Classification (Cello JP et al 1987)
Papillary stenosis
Sclerosing cholangitis
Pap. stenosis with extra and Intrahepatic sclerosing cholangitis:most common
Long extrahepatic bile duct stricture (>1-2cms)

16. AIDS Cholangiopathy : Clinical Features
Mean age years
AIDS usually labeled 1-2 years before
RUQ & /or epigastric pain : 64-88%
Fever : 20-65%
Cholestasis : 75 – 80%
ALP(>2ULN) : Almost all
S.bilirubin usually normal or mild increase
USG/CT – Dilated ducts(Intra &/or extra hepatic)
ERCP : Gold standard

17. ERCP confirmed cholangiopathy
USG Normal in 10/38
CT Normal in 5/17
ERCP Normal
USG Abnormal - 1/10
CT Abnormal /9

18. CECT : AIDS Cholangiopathy

19. Pathogenesis Possibly multifactorial
Infections – CMV, cryptosporidium, microsporidium & HIV
Immunosuppression
HIV itself
Genetic predisposition
Not clear 50% have no identifiable pathogen
Neoplasms – Lymphoma & Kaposi’s sarcoma

20. CMV & AIDS >50% AIDS have CMV viremia
> 90% AIDS have e/o CMV(Autopsy)
>50% AIDS have CMV viremia
5-44% AIDS +extrahepatic CMV Also have hepatic CMV inclusions
33% of CMV Viremia have abnormal LFT
33% of abnormal LFT will have abnormal bile ducts

21. Cryptosporidium & AIDS Cholangiopathy
82 HIV patients acquired cryptosporidiosis in an outbreak in Milwaukee ’93
29% developed biliary symptoms
10 had ERCP – All had AIDS cholangiopathy
Suggest biliary cryptosporidiosis
CD4 < 50 high risk and all died within 1 year
Vakil et al;NEJM:1996

22. ERCP in AIDS cholangiopathy
Papillary stenosis & dilated CBD & IHD
Beaded appearance (Intramural/Submucosal edema or Infiltrates)
Left hepatic duct more often involved
Irregular sacculations containing debris & mucosal sloughs
Markedly irregular ducts and pruning of smaller intrahepatic ducts
CBD Irregularly strictured and rarely > 4-5 mm diameter
>50% have pap.stenosis plus sclerosing cholangitis

23. ERCP : Papillary stenosis in HIV

24. AIDS Cholangiopathy

25. TREATMENT Papillary Stenosis Endoscopic sphincterotomy
Balloon sphincteroplasty
CBD stenting
Lymphoma or Kaposi Sarcoma -Chemotherapy
Acalculus cholecystitis Cholecystectomy
Antiviral drugs if CMV or HSV

26. AIDS cholangiopathy : Natural history
Forbes et al Gut 1993
ERCP proven AIDS cholangiopathy : 20 cases
Median age 33.5 yrs (range yrs)
Abd.pain 100%,Wt. Loss 90%,Diarrhea 55%,Skin KS 20%, Hepatomegaly 25%,Abn.LFT 80%,Liver Bx. Scl. Cholangitis 50%, Abn.USG50%(CBD dilated40%,thick25%),CD4 median24/cmm
Cryptosporidium: 13(Stools12, Ampulla Bx.2,Intestinal Bx.5) CMV at some site:6(Ampulla Bx.3,Intestine Bx.5,Retina 1) Cryptosporidium + CMV : 4
ERCP : Extrahepatic 2,Intrahep 3,Wide spread 15, Cystic lesion 2 Panc duct : Marked dialation 3,Minor changes 4
17/20 Died(median 7month), 3Alive at 10,11 & 21 months Poor correlation with CD4 counts & Increased age protective

27. Data on HIV patients n=227 HIV related symptoms : 75%
GIT symptoms : %
Abdominal pain : %
Jaundice/Icterus : %
Hepatomegaly : %
Spleenomegaly : %
Hepatospleenomegaly : %
Abnormal LFT : %
Acute pancreatitis : cases
HIV cholangiopathy : cases
Pancreatic pseudocyst : 1 case

28. Diagnosis of AIDS Cholangiopathy
CLINICAL FEATURES
LFT
Normal Abnormal
Look for other causes USG &/or CT
If no other cause Dilated ducts
ERCP with histology & bile c/s
Endoscopic TT

29. Conclusions
Pancreatitis in HIV is no different than in non-HIV patients & should be treated in the same way
Careful monitoring & selection of drug reduces incidence
AIDS cholangiopathy is a grave situation with a very high mortality
Maintenance of CD4 counts with HAART therapy appears to have reduced the incidence

30. Thank You