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PANCREATIC & BILIARY DISORDERS IN HIV
Dr.BujjiBabu ,M.D
Consultant HIV PhysicianDr.Bujjibabu HIV Clinic
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Pancreatic Disorders
Acute Pancreatitis
Chronic Pancreatitis(On Autopsy usually)
Pancreatic Neoplasm – Lymphoma Kaposi’s Sarcoma
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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
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Mechanism
HIV itselfOpportunistic Infections
CMV,HSV,MAC,Crypaococcus, Toxoplasma, Myco.tuberculosis, Candida
Usually involves other organs alsoPancreatic neoplasms:Lymphoma, Kaposi Sarcoma 5% of AIDS; Pancreatitis rareUsually in setting of wide spread diseaseDRUGS
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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
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CECT : Acute pancreatitis in HIV
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Diagnosis
Clinical features
Elevated amylase & lipase
Imaging (USG & or CT)
Occasionally FNAC for etiology
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Acute pancreatitis in HIV
Ac.Panc+HIV(44) Ac. Pancreatitis(44)
Clinical Features Similar SimilarAnemia More Lesshypoalbuminemia More LessLeucopenia More LessFever,Diarrhoea, hepatomegaly
More incidence Less
Drug Induced 18 2Gall stone 2 22Severe course (Prolong stay & death)
22 12
Ranson & Glasgow Poor GoodAPACHE II Good Good
Cappell et al Gut,1995
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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
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Total No: 73Drug Induce – 46%Idiopathic 26%25% had severe pancreatitis by Atlanta15% Severe hospital course & deathAPACHE –II – Best (Accuracy 75%)Glasgow & Ranson – PoorConclusion: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
Acute pancreatitis in HIV:
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Biliary Disorders in HIV Patients
Non HIV associated :
Stones, benign strictures, ascariasis ,neoplasms etc
Acalculus cholecystitis
AIDS cholangiopathy
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CBD Stone in an AIDS Patient
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Periampullary Ca
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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
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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)
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AIDS Cholangiopathy : Clinical Features
Mean age 36-37 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
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ERCP confirmed cholangiopathy
USG Normal in 10/38 CT Normal in 5/17
ERCP NormalUSG Abnormal - 1/10
CT Abnormal - 0/9
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CECT : AIDS Cholangiopathy
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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
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CMV & AIDS
> 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
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Cryptosporidium & AIDS Cholangiopathy
82 HIV patients acquired cryptosporidiosis in an outbreak in Milwaukee ’93
29% developed biliary symptoms10 had ERCP – All had AIDS
cholangiopathySuggest biliary cryptosporidiosis CD4 < 50 high risk and all died within 1
year Vakil et al;NEJM:1996
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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
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ERCP : Papillary stenosis in HIV
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AIDS Cholangiopathy
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TREATMENT
Papillary Stenosis Endoscopic sphincterotomy
Balloon sphincteroplasty
CBD stenting Lymphoma or Kaposi Sarcoma -Chemotherapy
Acalculus cholecystitis - Cholecystectomy
Antiviral drugs if CMV or HSV
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AIDS cholangiopathy : Natural history
ERCP proven AIDS cholangiopathy : 20 cases
Median age 33.5 yrs (range 27-50 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
Forbes et al Gut 1993
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Data on HIV patients n=227 HIV related symptoms : 75%GIT symptoms : 56%Abdominal pain : 08%Jaundice/Icterus : 2.2% Hepatomegaly : 9.2%Spleenomegaly : 1.3%Hepatospleenomegaly : 6.2%Abnormal LFT : 6.2%Acute pancreatitis : 2 casesHIV cholangiopathy : 2 casesPancreatic pseudocyst : 1 case
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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
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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
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