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Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
Gastrointestinal disorders eng_d2-4
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Gastrointestinal disorders eng_d2-4

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  1. Gastrointestinal disorders www.aidsknowledgehub.org Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia Advanced ART Training for Adults and Adolescents – Ukraine, 2004
  2. The purpose of the session • The purpose of the session: to discuss clinical features of the common gastrointestinal disorders in patients with HIV/AIDS and to learn the current recommendations for their diagnosis and treatment • Objectives: after completing this session, the participants will be able to: – Identify the common gastrointestinal disorders in patients with HIV/AIDS and the common causes of diarrhea in patients with HIV/AIDS – Provide a differential diagnosis for the common gastrointestinal disorders in patients with HIV/AIDS – Describe laboratory evaluation of the common gastrointestinal disorders in patients with HIV/AIDS – Provide treatment for gastrointestinal disorders in patients with HIV/AIDSRegional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  3. The Common Gastrointestinal Disorders in Patients with HIV• Anorexia, Nausea, Vomiting • Chronic Diarrhea• Acute Diarrhea - CYTOMEGALOVIRUS - MEDICATION-RELATED - ENTAMOEBA HISTOLYTICA ACUTE DIARRHEA - GIARDIA LAMBLIA - CAMPYLOBACTER JEJUNI - CRYPTOSPORIDIA - CLOSTRIDIUM DIFFICILE - MICROSPORIDIA - ENTERIC VIRUSES - MYCOBACTERIUM AVIUM - SALMONELLA COMPLEX (MAC) - SHIGELLA - IDIOPATHIC (PATHOGEN- - ESCHERICHIA COLI NEGATIVE) - IDIOPATHIC (PATHOGEN- • Cholangiopathy NEGATIVE) • Pancreatitis WHO HIV/AIDS Treatment and Care Protocols for countries of the Commonwealth of Independent States, March 2004Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  4. Anorexia, Nausea, Vomiting • MAJOR CAUSES: - Medications (especially antiretrovirals, antibiotics, opiates, and NSAIDs) - Depression - Intracranial pathology - GI disease - Hypogonadism - Pregnancy - Lactic acidosis - Acute gastroenteritis (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  5. Anorexia, Nausea, Vomiting (continued)• EVALUATION: - Drug holiday - Lactic acid level - Fasting testosterone level - GI evaluation (endoscopy, CT scan) - Intracranial evaluation (head CT scan or MRI)• TREATMENT: Treat underlying condition. (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  6. Diarrhea • Acute - as ≥3 loose or watery stools for 3 to 10 days • Chronic - as >2 loose or watery stools/day for ≥30 days in advanced HIV infection(WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth ofIndependent States, March 2004; John G. Bartlett, Medical Management of HIV Infection,2003) Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  7. Medication-related Acute Diarrhea• Main antiretroviral agents: – Nelfinavir – Lopinavir/ritonavir – Saquinavir• Management: – Loperamide – Pancreatic enzymes (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  8. Pathogen Detection • Blood culture: MAC, Salmonella • Stool culture: Salmonella, Shigella, C. jejuni, Vibrio, Yersinia, E. Coli 0157 • Stool assay for C. difficile toxin A and B • Ova & Parasite examination + AFB (Cryptosporidia, Cyclospora, Isospora), trichrome or other stain for Microsporidia and antigen detection (Giardia) (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  9. Main Pathogens of Acute Diarrhea • BACTERIAL: Campylobacter jejuni, Clostridium difficile, Escherichia coli, Salmonella, Shigella • ENTERIC VIRUSES: Adenovirus, Astrovirus, Picornavirus, Calicivirus • IDIOPATHIC(WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth ofIndependent States, March 2004; John G. Bartlett, Medical Management of HIV Infection, 2003) Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  10. Acute Diarrhea: CAMPYLOBACTER JEJUNI • FREQUENCY: 4% to 8% of HIV infected patients with acute diarrhea • CLINICAL FEATURES: Watery diarrhea or bloody flux, fever, fecal leukocytes variable; any CD4 count • DIAGNOSIS: Stool culture; most laboratories cannot detect C. cinaedi, C. fennelli, etc. (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  11. Acute Diarrhea: CLOSTRIDIUM DIFFICILE• FREQUENCY: 10% to 15% of HIV infected patients with acute diarrhea• CLINICAL FEATURES: Watery diarrhea, fecal WBCs variable; fever and leukocytosis common; prior antibacterial agents (especially clindamycin, ampicillin, and cephalosporins); any CD4 count• DIAGNOSIS: - Endoscopy: pseudomembranous colitis, colitis, or normal (this procedure is not usually indicated) - Stool toxin assay - CT scan: Colitis with thickened mucosa• TREATMENT: Metronidazole, Vancomycin. !!! Antiperistaltic agents are contraindicated.• RESPONSE: - fever resolves within 24 h - diarrhea resolves within 5 days - 20% to 25% have relapses at 3 to 14 days after treatment stopped. (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  12. Acute Diarrhea: ENTERIC VIRUSES • FREQUENCY: 15% to 30% of HIV infected patients with acute diarrhea • CLINICAL FEATURES: Watery diarrhea, acute, but one-third become chronic; any CD4 cell count • DIAGNOSIS: clinical laboratories cannot detect most viruses • TREATMENT: Supportive treatment (Lomotil or Loperamide) + rehydration (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  13. Acute Diarrhea: SALMONELLA• FREQUENCY: 5% to 15% of HIV infected patients with acute diarrhea• CLINICAL FEATURES: Watery diarrhea, fever, fecal WBCs variable; any CD4 count• DIAGNOSIS: Stool culture, blood culture (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  14. Acute Diarrhea: SHIGELLA• FREQUENCY: 1% to 3% of HIV infected patients with acute diarrhea• CLINICAL FEATURES: Watery diarrhea or bloody flux, fever, fecal WBCs common; any CD4 count• DIAGNOSIS: Stool culture (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  15. Acute Diarrhea: ESCHERICHIA COLI Agent Clinical PresentationEnterotoxigenic (ETEC) Traveler’s diarrheEnterohemorrhagic Bloody diarrhea0157:H7 (EHEC)Enteroinvasive (EIEC) DysenteryEnteropathic (EPEC) Watery diarrhea!!! EHEC - Antibiotics contraindicated (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  16. Treatment of Acute DiarrheaNon-typhoid Ciprofloxacin 500mg PO BID for > 2 weekssalmonelloses + RehydrationShigelloses Ciprofloxacin 500mg PO BID for 5 days, OR Nalidixic acid 500mg PO QID for 5 days, OR Sulphamethoxazole/trimethoprim 800mg/160mg PO BID for 5 days + RehydrationCampylobac- Erythromycin 500 mg PO qid x 5 days; fluoroquinoloneteriosis resistance rates are >20% + RehydrationVirus diarrhea RehydrationETEC Cipro 500 mg bid x 3 days or TMP-SMX DS bid x 3 days + RehydrationEIEC Cipro 500 mg bid x 5 days or TMP-SMX DS bid x 5 days + Rehydration(WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of IndependentStates, March 2004; John G. Bartlett, Medical Management of HIV Infection, 2003) Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  17. Acute Diarrhea: IDIOPATHIC DIARRHEA • FREQUENCY: 25% to 40% of HIV infected patients with acute diarrhea • CLINICAL FEATURES: Variable noninfectious causes; rule out medications, dietary, irritable bowel syndrome; any CD4 cell count • DIAGNOSIS: Negative studies including culture, O&P examination, and C. difficile toxin assay • TREATMENT (sever acute idiopathic diarrhea): empiric antibiotic treatment (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  18. Main Pathogens of Chronic Diarrhea • CYTOMEGALOVIRUS • ENTAMOEBA HISTOLYTICA • GIARDIA LAMBLIA • CRYPTOSPORIDIA • MICROSPORIDIA • MYCOBACTERIUM AVIUM COMPLEX (MAC) • IDIOPATHIC (PATHOGEN-NEGATIVE)(WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth ofIndependent States, March 2004; John G. Bartlett, Medical Management of HIV Infection, 2003) Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  19. Chronic Diarrhea: CRYPTOSPORIDIA• FREQUENCY: 10% to 30% of chronic diarrhea in AIDS patients• CLINICAL FEATURES: Enteritis; watery diarrhea; no fecal WBCs; fever variable; malabsorption; wasting; large stool volume with abdominal pain; remitting symptoms for months; CD4 cell count <150/mm3 is associated with recurrent or chronic disease.• DIAGNOSIS: AFB smear of stool to show oocyst of 4-6 µm• TREATMENT: - Best results are with HAART - Paromomycin 1000 mg bid or 500 mg PO bid x 7 days; efficacy is marginal - Azithromycin 600 mg/day + paromomycin (above doses) x ≥4w - Nutritional support plus Lomotil• RESPONSE: The most effective treatment is immune reconstitution; even small rises in CD4 count often succeed in controlling diarrhea (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  20. Chronic Diarrhea: CYTOMEGALOVIRUS• FREQUENCY: 15% to 40% of chronic diarrhea in AIDS patients• CLINICAL FEATURES: Colitis and/or enteritis; fecal WBC and/or blood; cramps; fever; watery diarrhea ± blood; may cause perforation; hemorrhage, toxic megacolon, ulceration; CD4 cell count <50/mm3• DIAGNOSIS: - Biopsy - CT scan - Cannot establish this diagnosis with CMV markers in blood or stool; need biopsy• TREATMENT: 1) HAART 2) Valganciclovir 900 mg PO bid x 3 weeks, then 900 mg qd 3) Ganciclovir 5 mg/kg IV bid x 2 weeks, then valganciclovir 900 mg/day 4) Foscarnet 40-60 mg/kg IV q8h 2 x weeks, then 90 mg/kg/day• RESPONSE: variable; foscarnet and ganciclovir are equally effective or ineffective (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  21. Chronic Diarrhea: ENTAMOEBA HISTOLYTICA • FREQUENCY: 1% to 3% of chronic diarrhea in AIDS patients • CLINICAL FEATURES: Colitis; bloody stools; cramps; no fecal WBCs (bloody stools); most are asymptomatic carriers; any CD4 cell count • DIAGNOSIS: Stool O&P examination. • TREATMENT: Metronidazole 500-750 mg PO or IV tid x 5 to 10 days, then iodoquinol 650 mg PO tid x 21 days or paromomycin 500 mg PO qid x 7 days (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  22. Chronic Diarrhea: GIARDIA LAMBLIA • FREQUENCY: 1% to 3% of chronic diarrhea in AIDS patients • CLINICAL FEATURES: Enteritis; watery diarrhea ± malabsorption, bloating; flatulence; any CD4 cell count • DIAGNOSIS: Antigen detection • TREATMENT: Metronidazole 250 mg PO tid x 10 days (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  23. Chronic Diarrhea: CYCLOSPORA • FREQUENCY: <1% of chronic diarrhea in AIDS patients • CLINICAL FEATURES: Enteritis; watery diarrhea; CD4 cell count <100/mm3 • DIAGNOSIS: Stool AFB smear: Resembles cryptosporidia • TREATMENT: TMP-SMX 1 DS bid x 3 days (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  24. Chronic Diarrhea: ISOPORA BELLI • FREQUENCY: 1% to 3% of chronic diarrhea in AIDS patients • CLINICAL FEATURES: Enteritis; watery diarrhea; no fecal WBCs; no fever; wasting; malabsorption; CD4 cell count <100/mm3 • DIAGNOSIS: AFB smear of stool; oocysts: 20 to 30 µm • TREATMENT: TMP-SMX 3-4 DS/day; Pyrimethamine 50-75 mg/day PO x 7 to 10 days (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  25. Chronic Diarrhea: MICROSPORIDIA (ENTEROCYTOZOON BIENEUSI OR ENTEROCYTOZOON (SEPTATA) INTESTINALIS)• FREQUENCY: 15% to 30% of chronic diarrhea in AIDS patients• CLINICAL FEATURES: Enteritis, watery diarrhea, no fecal WBCs; fever uncommon; remitting disease over months; malabsorption; wasting; CD4 cell count <100/mm3• DIAGNOSIS: – Special trichrome stain – Alternative: Fluorescent stains with similar sensitivity• TREATMENT: – Albendazole 400-800 mg PO bid x ≥3 weeks; efficacy is established only for Septata intestinalis – Fumagillin 60 mg PO qd x 14 days for E. bieneusi; monitor for neutropenia and thrombocytopenia (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  26. Chronic Diarrhea: MYCOBACTERIUM AVIUM COMPLEX (MAC) • FREQUENCY: 10% to 20% of chronic diarrhea in AIDS patients • CLINICAL FEATURES: Enteritis; watery diarrhea; no fecal WBCs; fever and wasting common; diffuse abdominal pain in late stage; CD4 cell count <50/mm3 • DIAGNOSIS: – Positive blood cultures for MAC – Biopsy – CT scan • TREATMENT: – Clarithromycin 500 mg PO bid + EMB 15 mg/kg/day – Azithromycin 600 mg/day + EMB 15 mg/kg/day ± rifabutin 300 mg/day • RESPONSE: Slow response over several weeks (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  27. Chronic Diarrhea: IDIOPATHIC (PATHOGEN- NEGATIVE)• FREQUENCY: 20% to 30% of chronic diarrhea in AIDS patients, who undergo a full diagnostic evaluation including endoscopy• CLINICAL FEATURES: – Usually low-volume diarrhea that resolves spontaneously or is controlled with antimotility agents – Typically not associated with significant weight loss and often resolves spontaneously• DIAGNOSIS: – Biopsy – With pathogen-negative, persistent, large volume diarrhea, must rule out KS and lymphoma• TREATMENT: Supportive care (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  28. Cholangiopathy • CAUSE: main - Cryptosporidiosis other - Microsporidia, CMV, and Cyclospora idiopathic – 20-40% • Seen primarily in late stage AIDS (CD4 count <100 cells/mm3) • PRESENTATION: Right upper quadrant pain, LFTs show cholestasis • DIAGNOSIS: ERCP (preferred); ultrasound is 75% to 95% specific • TREATMENT: Based on cause (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org
  29. Pancreatitis in Patients with HIV Infection • MAJOR CAUSES - Drugs: ddI or ddI + d4T ± hydroxyurea - CMV - Alcoholism • DIAGNOSIS - Amylase - Lipase (same sensitivity but more specificity) - CT Scan • TREATMENT: Supportive (John G. Bartlett, Medical Management of HIV Infection, 2003)Regional Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia www.aidsknowledgehub.org

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