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Pancreatic and Biliary Disorders in HIV Patients: Diagnosis and Treatment Options

Learn about pancreatic and biliary disorders in HIV patients, including causes, clinical features, diagnosis methods, and treatment options such as endoscopic interventions. Explore the incidence, etiology, and management of acute pancreatitis and biliary issues in individuals with HIV.

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Pancreatic and Biliary Disorders in HIV Patients: Diagnosis and Treatment Options

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  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 monthsAdvanced 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. Cappell et al Gut,1995 Acute pancreatitis in HIV

  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 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

  17. ERCP confirmed cholangiopathy • USG Normal in 10/38 • CT Normal in 5/17 ERCP Normal USG Abnormal - 1/10 CT Abnormal - 0/9

  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 • > 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 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

  27. 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 cases HIV cholangiopathy : 2 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

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