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PANCREATIC & BILIARY DISORDERS IN HIV

PANCREATIC & BILIARY DISORDERS IN HIV. Dr.BujjiBabu ,M.D Consultant HIV Physician Dr.Bujjibabu HIV Clinic. Pancreatic Disorders. Acute Pancreatitis Chronic Pancreatitis(On Autopsy usually) Pancreatic Neoplasm – Lymphoma Kaposi’s Sarcoma.

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PANCREATIC & BILIARY DISORDERS IN HIV

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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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