Common surgical problems in hiv/aids patients

1. Surgical Aspects of HIV
Dr A Bharath

2. • Introduction
• WHO staging of HIV infection
• Surgical aspects
•Perianal conditions
•GIT involvement
•Tumors
•CNS involvement
• Perioperative care
• Occupational exposure
• Post Exposure Prophylaxis

3. HIV Structure

4. HIV Lifecycle

5. Transmission
• Blood - 90-95%
• Perinatal - 20-24%
• Intercourse 0.1-10%
• IV drug abuse - 0.6%
• Needle stick injury - 0.3%

6. At risk fluids
•Blood
•Semen
•Vaginal secretions
•CSF
•Pleural / Peritoneal / Pericardial
fluids
•Amniotic fluid
Not at risk
•Tears
•Sweat
•Salaiva
•Urine & Faeces

7. WHO clinical staging of HIV/AIDS
Clinical Stage 1
•Asymptomatic
•Persistent generalized lymphadenopathy

8. Clinical Stage 2
•Moderate unexplained weight loss (<10% of presumed or measured
body weight)
•Recurrent URTI
•Herpes zoster
•Angular cheilitis
•Recurrent oral ulceration
•Papular pruritic eruptions
•Seborrheic dermatitis
•Fungal nail infections

9. Clinical Stage 3
•Unexplained severe weight loss (>10% of presumed or measured body
weight)
•Unexplained chronic diarrhea for >1 month
•Unexplained persistent fever for >1 month (>37.6°C, intermittent or
constant)
•Persistent oral candidiasis (thrush)
•Oral hairy leukoplakia
•Pulmonary tuberculosis

10. • Severe bacterial infections (pneumonia, empyema, pyomyositis, bone
or joint infection, meningitis, bacteremia)
• Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
• Unexplained anemia (hemoglobin <8 g/dL)
• Neutropenia (neutrophils <500 cells/µL)
• Chronic thrombocytopenia (platelets <50,000 cells/µL)

11. Clinical Stage 4 / AIDS
•Pneumocystis pneumonia
•Recurrent severe bacterial pneumonia
•Chronic herpes simplex infection (at any site)
•Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs)
•Extrapulmonary tuberculosis
•Kaposi sarcoma
•Cytomegalovirus infection
•Central nervous system toxoplasmosis
•HIV encephalopathy

12. • Cryptococcosis, extrapulmonary (including meningitis)
• Disseminated nontuberculosis mycobacteria infection
• Progressive multifocal leukoencephalopathy
• Chronic cryptosporidiosis
• Chronic isosporiasis
• Disseminated mycosis (e.g., histoplasmosis, coccidioidomycosis, penicilliosis)
• Recurrent nontyphoidal Salmonella bacteremia
• Non Hodgkins Lymphoma
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy
• Symptomatic HIV-associated cardiomyopathy

13. Surgical Aspects
• Perianal conditions
• GI presentation
• Tumors assosciated with HIV

14. Perianal conditions
Most common indication for surgery in HIV positive patients
Perianal / Anorectal Abscess
•Presentation may vary depending on immune status of the patient
•May be well localised abscess or extensive poorly localised perineal
necrotising infection
•Treatment is by Incision - Drainage / Debridement with Antibiotic
coverage

15. Fistula in ano
•Can present with single / multiple peri anal fistulas
•Treatment is similar - Fistulectomy / Seton
Anal fissures
•Traumatic or Idiopathic
•Stool softeners, 2% Diltiazem oint, Botulinum injection
•Lateral spincterotomy after accounting for continence and Diarrhoea

16. HIV assosciated Anal ulcers
•Presentation similar to fissure but pain not much related to bowel
movements
•Differentiated from fissure in being broad based and present proximal
to dentate line
•Can be caused due to infection from CMV, HSV, MAC, Cryptococcus,
Chlamydia or malignancy
•Hence should always be sent for biopsy
•Treatment is dependent on causative organism
•Surgical intervention is for deroofing of cavities if ulcer deepens across
tissue planes

17. Anal warts / Condyloma
•Caused by HPV
•HPV infection is silent in most immunocompetent people
•Majority of condylomas are caused by HPV 6, 11
•In HIV positive patients tend to be multiple, aggressive and dysplastic
•Surgical excision is useful for symptomatic relief and for HPE
•Topical podophyllin / 5FU is not effective
•Topical 5% IMIQUIMOD is used in isolation or in combination with
surgical excision

18. Anal Carcinoma
•Squamous cell carcinoma assosciated with HPV
•Dysplasia can progress to Carcinoma insitu and invasive Ca
•But not commonly found as progression is slow
•Treatment is by Chemo - radiation
•Surgical treatment is considered if CD4 > 200, APR is done

19. GI involvement
• Diarrhoea / HIV enteropathy
• Acute abdominal pain
• GI bleeding
• Dysphagia / Esophagitis
• Before HAART, 50-90% patients had GI symptoms

20. Diarrhoea
• Diarrhoea is most common GI symptom in HIV positive patient
• Can be due to Oppurtunistic pathogens, Bacterial overgrowth or can
be drug induced
• Diarrhoea unrelated to any microorganism except for HIV is
increasingly recognised
• Due to GP120 induced enterocyte apoptosis resulting in mucosal
ulceration, villous atrophy and malabsorption

21. Acute abdomen
Acute appendicitis
•More common in HIV positive patients than general population
•But presentation is usually late due to lack of proper immune
response
•Appendicular perforation is more common
•White cell counts are not as raised as in immnocompetent individual
•Treatment is Appendicectiomy

22. Bowel obstruction
•Can result from tumor mass or stricture
•Intussusception is uncommon
•Treatment is same as with normal individuals
Perforation
•Can result due to obstruction from a tumor mass
•Due to lysis of tumor following chemoradiation
•Due to CMV enteritis, usually terminal ileum or colon

23. Peritonitis
•Can result from Bowel perforation
•Infectious non specific peritonitis not assosciated with perforation
•Can be caused due to CMV, Histoplasma, MAC, Toxoplasma,
Cryptococcus and Vibrio
•Treatment depends on etiology

24. Acute Pancreatitis
•Pancreatitis has typical presentation with pain abdomen and elevated
amylase and lipase
•Can be of varied etiology
•Drug induced (MC),
•Infective - CMV, HSV, MAC, Cryptococcus
•Pancreatic infiltration with lymphoma / Kaposi sarcoma
•In advanced stages severe pancreatitis is mostly fatal

25. GI bleeding
Seen in < 1%, but can be due to various causes
•Peptic / Stress related ulcers
•Variceal hemorrhage
•Inflammatory Bowel Disease
•Diverticulosis
•Polyps, Ulcerated Tumor mass
Rare causes include
•CMV vasculitis
•Diffuse Hemorrhagic esophagitis (HSV)
•Severe erosive Candidiasis

26. Dysphagia / Esophagitis
• Dysphagia is very common in early stages of HIV infection
• Most common cause is Candidial esophagitis / Oral thrush
• Not all patients with esophagitis are symptomatic
• Other causes include HSV, CMV, malignancies or idiopathic ulceration
• Diagnosis is by Upper GI endoscopy
• Treatment is dependent on the cause
• Emperically HIV patients with dysphagia can be given Fluconazole /
Itraconazole 200mg/day

27. Hepatobiliary involvement
• Hepatic involvement is usually seen as a part of disseminated disease
in advanced stages of HIV/AIDS
• Hepatic involvement can present as elevated LFTs, Hepatomegaly or
Jaundice
• Any Liver lesions discovered are either oppurtunistic infections or
secondaries from tumors
• Co infection with HBV is very common but progression to HCC is not
usually seen
• Approach is complicated because systemic symptoms are dominant
and liver involvement as it is, is not fatal

28. Peliosis hepatis
•AIDS assosciated syndrome caused by Bartonella henselae
•Infection is linked with exposure to cats
•Present with fever, RUQ pain, elevated liver enzymes, mild elevation
of bilirubin and cutaneous bacillary angiomatosis
•CT scan reveals multiple dilated blood filled hepatic sinusoids
•Histologically multiple blood filled cystic spaces in liver parenchyma
not lined by endothelium
•Treatment is by Erythromycin / Ciprofloxacin and Doxycycline

29. Biliary tract disorders
• HIV positive patients mostly present with conditions unrelated to HIV,
most common is cholelithiasis
• HIV assosciated conditions include Acute Acalculous Cholecystitis and
HIV Cholangiopathy
• Acalculous Cholecystitis also presents with Fever and RUQ pain but
mostly indicates systemic debilitating illness
• May require Cholecystectomy depending on condition of patient
• Palliative stent placement or Percutaneous cholecystostomy is
considered in poor surgical candidates

30. HIV Cholangiopathy
•Seen in young patients who present with RUQ pain
•No icterus clinically
•Imaging shows dilated intra and/or extra hepatic biliary tree in 80%
•ERCP shows Papillary Stenosis (28%) or Sclerosing Cholangitis (12%) or
both (49%) or Isolated extra hepatic bile duct strictures (10%)
•Treatment is only symptomatic

31. Tumors in HIV
• HIV by means of its immunosuppression enables tumor growth
especially of viral etiology
• Most common to come across are -
• Kaposi Sarcoma
• Non Hodgkins Lymphoma
• Primary CNS Lymphoma

32. Kaposi Sarcoma
•Caused by HHV8, usually in immunosuppressed
•Lesions can be found over skin, oral cavity, GIT, Lymph nodes and any
solid organ
•Usually be asymptmatic, can cause symptoms based on its location
•Its name is a misnomer
•Arises from lymphatic endothelium. Ca cells are Spindle cells which
form slits filled with RBC
•Not curable, but treatable by treating the cause of
immunosuppression

33. Non Hodgkins Lymphoma
•Almost all are of B cell origin
•GI involvement is found in >50%
•Tumors are usually high grade, very aggressive and present early
•Presenting features depend on its location
•Biopsy is essential for diagnosis
•Treatment is chemotherapy but use of immunosuppressives is
conflicted
•Of particular concern is the risk of inducing perforation by tumor lysis
following treatment of bulky luminal lesions

34. CNS involvement
Intra Cranial Toxoplasmosis
•Caused by Toxoplasma gondii, oppurtunistic pathogen
•Most common cause of Cerebral abscess in immunosuppressed
•Symptoms are usually vague due to absence of inflammatory response
•Development of new neurological symptoms, altered consciousness
level should bring suspiscion
•Treatment is conservative - Pyrimethamine

35. AIDS assosciated Primary CNS Lymphomas
•Should be differentiated from CNS involvement in systemic
lymphomas
•Assosciated with EBV infection
•Tend to be multifocal, heterogenous (necrotic) in
immunocompromised individuals
•Usually assosciated with severe cerebral edema
•Treatment is mainly with IV steroids
•Methotrexate based chemotherapy is also available

36. Perioperative Care
Pre operative assessment
•Similar to normal individuals in assessing nutritional and general status
of patient and obtaining proper consent for risks of surgical procedure
•Laboratory investigatons to rule out any organ dysfunction
•Specifically in HIV patients Duration of HIV infection, ART status and
Duration of ART has to be noted
•Preoperatively Viral load and CD4 counts are evaluated, but should
not be taken as sole indicators of surgical outcome

37. • ART drugs are known to have many adverse effects and drug
interactions
• Hepatic dysfunction can result from either ART drugs or HBV infection
• Also result in dyslipidemias whic increase risk for CAD
• Renal dysfunction may be present
• Patients are at higher risk for pneumonia and other opp. infections
• H/o MRSA infection/colonisation should be elicited if possible

38. • ART drugs are notorious for causing mitochondrial toxicity which
usually presents as lactic acidosis
• Propofol use is discouraged as it can exacerbate lactic acidosis
• ART drugs interfere with metabolism of all the inhalational
anaesthetics due to their effect on CYT p450 3A
• Protease inhibitors are known to interact with sedatives/anxiolytics,
PPI and H2 blockers

39. • But, despite their adverse effects efforts should be made to continue
HAART throughout the operative period
• Previously stopping ART was considered when patient had to be kept
NPO
• But with availablity of parenteral drugs, stopping ART is not
considered
• Patients receiving Cotrimoxazole prophylaxis also have to continue
the drug, if necessary parenterally
• If cotrimoxazole is c/i, Pentamidine can be used

40. • Post operatively patient is mobilised as early as possible
• There may be delay in wound healing
• Wound should be disturbed as minimal as possible
• Drains are placed only if necessary and removed as early as possible
• Suture removal can be delayed upto 2 weeks to promote proper
healing

41. • Diagnosis of post operative infections are difficult as inflammatory
response is decreased
• Very few signs are clinically evident if present
• High degree of suspicion is needed to avoid diagnostic delay
• Thorough microbiological surveillance is needed especially for
atypical organisms
• Chest radiographs can be taken in case of suspicion for pneumonia

42. • Emperical treatment is started in case of suspicion of post op
infection
• Aminoglycoside + Broad spectrum cephalosporin
• Meropenem alone or in combination with broad spectrum
cephalosprin
• Metronidazole is added if anaerobic infection is suspected
• Treatment is continued until cultures are negative
• Despite aggressive antibiotic therapy if patient doesnt improve,
fungal infection is suspected

43. Occupational Exposure
• Health care professionals like surgeons, nurses, lab technicians are at
a high risk of exposure to at risk fluids
• Extent of risk depends on - Prevalence of HIV in patient population,
No. of procedures done by the surgeon and Duration of procedures
• Most common source of infection is by Needle stick injury (0.3%)
• Risk increases with hollow needle (10 times) and with visible blood on
the needle
• Other possible sources are - exposure of mucosal surfaces or broken
skin to at risk fluids (0.1%)

44. HIV infection risk depends on many factors
•Stage of HIV infection
•Sero status of the patient
•ART status of patient
•Body fluid exposed
•Type of exposure
•Duration of exposure

45. Universal precautions
•Disposable water proof aprons and drapes
•Using impermeable Overboots
•Full face shield or protective spectacles
•Using Double gloves
•Only necessary staff are allowed inside theatre
•Minimising movement in the theatre
•Safe handling of Sharps, at risk fluids, contaminated linen

46. • Minimising blood loss and reducing time in theatre
• Fill suction bottles with 2% Glutaraldehyde solution
• Using disposable instruments wherever possible
• Cleaning the theatre, equipment and instruments with
gluteraldehyde or 1% hypochlorite solution
• Proper disposal of contaminated mops and linen for incineration

47. Steps to be taken After exposure
•Thorough washing of exposed surface with running water
•Counseling
•Risk assessment
•Baseline HIV testing and repeating after 12 weeks
•Depending on the risk assessment, the provision of short term (4
weeks) of antiretroviral drugs (PEP)
•Follow up and support

48. PEP regimens
•Zidovudine (AZT) 300mg bd
•Stavudine (d4T) 30 mg bd
•Lamivudine (3TC) 150mg bd
•2 drug regimen - AZT + 3TC or d4T + 3TC
•3 drug regimen - a protease inhibitor is added
•PI- Lopinavir 400mg / Ritonavir 100mg bd

49. THANK YOU