Long-term follow-up of endoscopic retrograde cholangiopancreatography sphincterotomy for patients with acquired immune deficiency syndrome papillary stenosis

Magnetic Resonance Cholangiopancreatography (MRCP) Findings in a Patient With AIDS Cholangiopathy and Cryptosporidiosis

AIDS cholangiopathy is a rare condition characterized by intra- and extra-hepatic ductal strictures causing biliary obstruction primarily in individuals with advanced HIV infection and low clusters of differentiation 4 (CD4) count. This case report presents a male patient with a history of HIV, poor adherence to antiretroviral therapy (ART), and chronic cryptosporidiosis infection, who exhibited clinical and radiological findings consistent with advanced immunocompromise and AIDS cholangiopathy. The patient presented with respiratory symptoms, weight loss, renal dysfunction, and elevated liver enzymes. Imaging studies, including ultrasound and magnetic resonance cholangiopancreatography (MRCP), revealed diffuse biliary dilatation and stricturing, indicative of cholangiopathy. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement was performed to manage the biliary obstruction. This case highlights the importance of considering AIDS cholangiopathy in HIV patients with poor ART compliance who present with biliary obstruction symptoms or cholestatic liver enzyme abnormalities. Prompt diagnostic evaluation using MRCP or ERCP can aid in confirming the diagnosis and guiding appropriate therapeutic interventions, including endoscopic management and initiation of ART.

Rapidly Disseminated Kaposi's Sarcoma Despite Initiation of Antiretroviral Therapy

Kaposi's sarcoma (KS) is the most common malignancy in people living with HIV. The reported incidence of AIDS-related KS has been dramatically decreased with the introduction of antiretroviral therapy (ART). Systemic treatment with ART is indicated for patients with AIDS-related KS; however, some patients may develop KS-related immune reconstitution inflammatory syndrome characterized by sudden rapid progression of new or pre-existing KS within the initiation of ART. Here, we present a case of rapidly disseminated KS with widespread visceral involvement despite ART initiation in a 27-year-old African American man with advanced HIV/AIDS.

Role of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Management of Cholestatic Liver Diseases

Cholestatic liver diseases (CLDs) occur as a result of bile duct injury, emanating into duct obstruction and bile stasis. Advances in radiological imaging in the last decade has replaced endoscopic retrograde cholangiopancreatography (ERCP) as the first diagnostic tool, except in certain groups of patients, such as those with ischemic cholangiopathy (IsC) or early stages of primary sclerosing cholangitis (PSC). ERCP provides an opportunity for targeted tissue acquisition for histopathological evaluation and carries a diverse therapeutic profile to restore bile flow. The aim of this review article is to appraise the diagnostic and therapeutic roles of ERCP in CLDs.

The Relationship of Cholangiocarcinoma with Human Immunodeficiency Virus Cholangiopathy and Cytomegalovirus Infection

Human immunodeficiency virus (HIV) is a worldwide disease with an increasing number of cases globally. Initially, HIV cholangiopathy was often observed among such patients but has become rare after three decades because of the availability of new treatment options and potent antiretroviral drugs. Consequently, its occurrence now suggests drug resistance or disease progression. The relationship between cholangiocarcinoma and HIV remains unclear. We report the case of a patient with high-grade dysplasia of the ductus choledochus and uncontrolled disease which was treated with potent antiviral agents and bile duct dilatation.

LEARNING POINTS

HIV cholangiopathy should be kept in mind in an HIV-positive patient even if they are receiving combination antiretroviral therapy (cART); endoscopic retrograde cholangiopancreatography can provide symptomatic relief.Once HIV cholangiopathy is detected, close follow-up for cholangiocarcinoma is required.Opportunistic infections can cause cholangiocarcinoma in HIV-positive patients.

Fungal and Parasitic Infections of the Liver

Hepatosplenic candidiasis and other fungal infections of the liver are uncommon in healthy individuals; however, high index of suspicion is essential in immunocompromised patients with prolonged fever. Parasitic infections are protozoan or helminthic; their distribution and epidemiology are variable among different world regions. Clonorchiasis, opisthorchiasis, fascioliasis, and ascariasis are helminthic infections that commonly involve the biliary systems. Signs and symptoms of cholangitis require prompt management to relieve biliary obstruction; addition of antihelminthic agents is essential. Parasitic infections are mostly transmitted to humans by fecally contaminated food and water. Proper hand and food sanitation measures are essential in preventing disease transmission.

Concomitant AIDS cholangiopathy and Fanconi syndrome as complications of HIV in a single patient

We describe the case of a 50-year-old woman presenting to our acute medicine department with generalised non-specific symptoms on a background of HIV managed on triple therapy (tenofovir, lamivudine and zidovudine). On admission, she was noted to be acidotic with proteinuria, glycosuria, hypophosphataemia and generalised body pain, and was diagnosed with Fanconi's renotubular syndrome secondary to tenofovir. It was also noted that she had elevated liver dysfunction markers, and an MRI of the liver revealed a focal stricture near the ampulla of Vater, resulting in a diagnosis of AIDS cholangiopathy. These two diagnoses are rare complications of HIV, and the presence of both these pathologies in a single patient has never been reported in the literature before, and we therefore believe that this case is the first of its kind.

Sclerosing Cholangitis: Clinicopathologic Features, Imaging Spectrum, and Systemic Approach to Differential Diagnosis

Sclerosing cholangitis is a spectrum of chronic progressive cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts, which can be classified as primary and secondary sclerosing cholangitis. Primary sclerosing cholangitis is a chronic progressive liver disease of unknown cause. On the other hand, secondary sclerosing cholangitis has identifiable causes that include immunoglobulin G4-related sclerosing disease, recurrent pyogenic cholangitis, ischemic cholangitis, acquired immunodeficiency syndrome-related cholangitis, and eosinophilic cholangitis. In this review, we suggest a systemic approach to the differential diagnosis of sclerosing cholangitis based on the clinical and laboratory findings, as well as the typical imaging features on computed tomography and magnetic resonance (MR) imaging with MR cholangiography. Familiarity with various etiologies of sclerosing cholangitis and awareness of their typical clinical and imaging findings are essential for an accurate diagnosis and appropriate management.

Progressive HIV-associated Cholangiopathy in an HIV Patient Treated with Combination Antiretroviral Therapy

We herein describe a case of progressive human immunodeficiency virus (HIV)-associated cholangiopathy despite normalization of laboratory parameters, which had indicated liver dysfunction, after the initiation of combined anti-retroviral therapy (cART). HIV-associated cholangiopathy remains important as a differential diagnosis of bile duct disorders, although it is considered to be a rare disease in the era of cART. Magnetic resonance cholangiopancreatography could thus be a powerful tool for the diagnosis and follow-up of this disease.

Mycobacterium avium complex-associated cholecystitis in AIDS patient: a case description and review of literature

AIDS-related cholangiopathy was common in patients with AIDS prior to the advent of highly active antiretroviral therapy. Mycobacterium avium complex (MAC) is the most common opportunistic bacterial infection seen in AIDS patients and one of many opportunistic pathogens implicated in AIDS cholangiopathy. We describe a case of acute cholecystitis secondary to MAC in a patient with likely AIDS cholangiopathy. The patient, a 37-year-old Hispanic woman with CD4⁺ cell count of 10 cells/mm³ who was previously diagnosed with disseminated MAC, presented with a eight days of diffuse abdominal pain and anorexia. Radiologic imaging suggested acute cholecystitis, so the patient underwent open cholecystectomy. Pathology staining of the gall bladder wall revealed acid-fast bacilli consistent with MAC. The patient had been receiving appropriate therapy as an outpatient for MAC with presumed reliable adherence, but we suggest her burden of disease was high due to her severe immunosuppressive state. A thorough review of the literature showed that there are many infectious and non-infectious aetiologies for AIDS-associated cholangiopathy. Acute cholecystitis can develop in the setting of AIDS cholangiopathy, potentially secondary to the opportunistic infection that initially caused the cholangiopathy. MAC-related gallbladder disease needs to be considered in patients with advanced AIDS who present with evidence of acute cholecystitis.

Chronic liver disease in the human immunodeficiency virus patient

There are an estimated 40 million HIV infected individuals worldwide, with chronic liver disease being the 2nd leading cause of mortality in this population. Elevated liver functions are commonly noted in HIV patients and the etiologies are varied. Viral hepatitis B and C, fatty liver and drug induced liver injury are more common. Treatment options for viral hepatitis C are rapidly evolving and are promising, but treatments are limited for the other conditions and is primarily supportive. Opportunistic infections of the liver are now uncommon. Irrespective of etiology, management requires referral to specialized centers and with due diligence mortality can be reduced.

Secondary sclerosing cholangitis: pathogenesis, diagnosis, and management

Secondary sclerosing cholangitis (SSC) is an aggressive and rare disease with intricate pathogenesis and multiple causes. Understanding the specific cause underlying each case of SSC is crucial in the clinical management of the disease. Radiologic imaging can help diagnose SSC and hence institute management in a timely manner. Management may encompass simple interventions, such as supportive therapy, antibiotics, and monitoring, or more serious measures, such as surgery, endoscopic intervention, or liver transplantation. Patients with AIDS cholangiopathy have limited therapeutic options and worsened survival. The disease should always be highly suspected in patients with primary sclerosing cholangitis with questionable diagnosis.

Co-occurrence of cytomegalovirus-induced vanishing bile duct syndrome with papillary stenosis in HIV infection

Jaundice in patients with AIDS can be a result of diverse conditions ranging from opportunistic infections to drug-related hepatotoxicity. With the advent of antiretroviral therapy (ART), the prevalence of AIDS cholangiopathy as a cause of jaundice has decreased; on the other hand, ART-related hepatotoxicity has become one of the commonest causes of jaundice in these patients. AIDS cholangiopathy is a rare condition of extrahepatic biliary obstruction in patients with advanced HIV infection, usually due to opportunistic infections. Vanishing bile duct syndrome (VBDS) is an acquired disorder characterized by progressive destruction and loss of interlobular bile ducts causing intrahepatic cholestasis. Herein, we report co-occurrence of fatal cytomegalovirus (CMV)-induced VBDS along with papillary stenosis, as a component of AIDS cholangiopathy, which to the best of our knowledge has not been documented earlier. This is perhaps the third case of VBDS in a patient with AIDS, and the second in association with CMV infection. VBDS in AIDS has a poor outcome, and liver transplantation may be considered only in a suitable candidate.

Endoscopic management of benign biliary strictures

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

Klatskin-like lesions

Hilar cholangiocarcinoma, also known as Klatskin tumour, is the commonest type of cholangiocarcinoma. It poses unique problems in the diagnosis and management because of its anatomical location. Curative surgery in the form of major hepatic resection entails significant morbidity. About 5-15% of specimens resected for presumed Klatskin tumour prove not to be cholangiocarcinomas. There are a number of inflammatory, infective, vascular, and other pathologies, which have overlapping clinical and radiological features with a Klatskin tumour, leading to misinterpretation. This paper aims to summarise the features of such Klatskin-like lesions that have been reported in surgical literature.

Evolving concepts in primary sclerosing cholangitis

Patients suffering from primary sclerosing cholangitis (PSC) show considerable differences regarding clinical manifestations (i.e. large duct versus small-duct PSC, presence or absence of concomitant inflammatory bowel disease), disease progression, risk for malignancy and response to therapy, raising the question whether PSC may represent a mixed bag of diseases of different aetiologies. The growing list of secondary causes and diseases 'mimicking' or even overlapping with PSC (e.g. IgG4-associated sclerosing cholangitis), which frequently causes problems in clear-cut discrimination from classic PSC and the emerging knowledge about potential disease modifier genes (e.g. variants of CFTR, TGR5 and MDR3) support such a conceptual view. In addition, PSC in children differs significantly from PSC in adults in several aspects resulting in distinct therapeutic concepts. From a clinical perspective, appropriate categorization and careful differential diagnosis are essential for the management of concerned patients. Therefore, the aim of the current review is to summarize current and evolving pathophysiological concepts and to provide up-to-date perspectives including future treatment strategies for PSC.

HIV/AIDS cholangiopathy: clinical spectrum, cholangiographic features and outcome in 30 patients

BACKGROUND AND AIMS

AIDS cholangiopathy is presently considered rare and has been reported mainly from the West. With the HIV epidemic in India, we have encountered an increasing number of patients. We aimed to study these patients and determine differences from earlier experiences.

METHODS

We describe the clinical presentation, cholangiographic features, and outcome and determine differences reported in Western literature.

RESULTS

From Jan 1999 to May 2009, 30 patients (27 men) with AIDS cholangiopathy were seen. The most common mode of transmission was heterosexual (n = 28) followed by blood transfusion (n = 2). Abdominal pain (n = 20) of biliary origin, was the commonest manifestation followed by an asymptomatic group (n = 6) and a third group (n = 3) with pain due to pancreatitis. Ultrasonography of the abdomen was abnormal in all patients. Papillary stenosis (n = 23) was the most common cholangiographic feature followed by sclerosing cholangitis (n = 5). Abdominal pain resolved reliably and promptly after endoscopic sphincterotomy. Cholangiographic abnormalities regressed during follow up on antiretroviral therapy in 10 patients. Seven patients on anti retroviral therapy developed de novo cholangiopathy, with a precipitous drop in CD4 count of whom two had a worse prognosis. None had Kaposi's sarcoma.

CONCLUSIONS

In contrast to Western literature, HIV cholangiopathy was seen predominantly in patients who acquired HIV by heterosexual transmission. De novo development of cholangiopathy on antiretroviral therapy may indicate the occurrence of resistance. Papillary stenosis is the most common feature. Abdominal pain resolved with sphincterotomy. Regression of cholangiographic abnormality occurred with anti retroviral medications. Median survival following cholangiopathy diagnosis was 34 months, higher than reported in previous studies.

Mimics of cholangiocarcinoma: spectrum of disease

Cholangiocarcinoma is the second most common primary malignant hepatobiliary neoplasm, accounting for approximately 15% of liver cancers. Diagnosis of cholangiocarcinoma is challenging and the prognosis is uniformly poor, with recurrence rates of 60%-90% after surgical resection. A wide spectrum of neoplastic and nonneoplastic conditions of the biliary tract may masquerade as cholangiocarcinoma, adding to the complexity of management in patients suspected to have cholangiocarcinoma. Mimics of cholangiocarcinoma constitute a heterogeneous group of entities that includes primary sclerosing cholangitis, recurrent pyogenic cholangitis, acquired immunodeficiency syndrome cholangiopathy, autoimmune pancreatitis, inflammatory pseudotumor, Mirizzi syndrome, xanthogranulomatous cholangitis, sarcoidosis, chemotherapy-induced sclerosis, hepatocellular carcinoma, metastases, melanoma, lymphoma, leukemia, and carcinoid tumors. These entities demonstrate characteristic histomorphology and variable clinicobiologic behaviors. The imaging findings of these disparate entities are protean and may be indistinguishable from those of cholangiocarcinoma. In most cases, a definitive diagnosis can be established only with histopathologic examination of a biopsy specimen.

Sclerosing cholangitis: a focus on secondary causes

Secondary sclerosing cholangitis (SSC) is a disease that is morphologically similar to primary sclerosing cholangitis (PSC) but that originates from a known pathological process. Its clinical and cholangiographic features may mimic PSC, yet its natural history may be more favorable if recognition is prompt and appropriate therapy is introduced. Thus, the diagnosis of PSC requires the exclusion of secondary causes of sclerosing cholangitis and recognition of associated conditions that may potentially imitate its classic cholangiographic features. Well-described causes of SSC include intraductal stone disease, surgical or blunt abdominal trauma, intra-arterial chemotherapy, and recurrent pancreatitis. However, a wide variety of other associations have been reported recently, including autoimmune pancreatitis, portal biliopathy, eosinophillic and/or mast cell cholangitis, hepatic inflammatory pseudotumor, recurrent pyogenic cholangitis, primary immune deficiency, and AIDS-related cholangiopathy. This article offers a comprehensive review of SSC.

AIDS cholangiopathy

AIDS is an advanced disease with systemic and infectious complications that can be fatal. When a patient with AIDS presents with right upper quadrant or midepigastric pain, cholestasis, and symptoms of cholangitis, AIDS cholangiopathy should be suspected and appropriate diagnostic and therapeutic interventions should be initiated. Opportunistic infections such as Cryptosporidium and cytomegalovirus are the most common cause of AIDS cholangiopathy. Four distinct cholangiographic abnormalities have been demonstrated by endoscopic retrograde cholangiopancreatography, the most common being papillary stenosis with sclerosing cholangitis. Antimicrobial therapy is often ineffective. Highly active antiretroviral therapy may enhance immune function and offers the best medical therapy to clear the opportunistic infections. Ursodeoxycholic acid has a limited benefit in patients with sclerosing cholangitis and cholestasis. Endoscopic sphincterotomy has been shown to relieve pain and biliary obstruction in patients with papillary stenosis. Balloon dilation of strictures and stent placement decompress the biliary system and may be helpful. Cholecystectomy is recommended to treat acalculous cholecystitis, and celiac plexus block may be offered to patients with terminal disease and intractable abdominal pain.

Cholestasis in HIV-infected patients

Cholestasis is frequently observed in the HIV-infected population and can be caused by drugs, such as highly active antiretroviral therapy (HAART) and antimicrobial agents, and by opportunistic infections of the liver. Less common causes such as HIV-related malignancies or biliary tract disease are also encountered. Most disorders respond to medical management, but patient outcome was often dictated by the stage of the HIV infection and concomitant illnesses in the pre-HAART era. Prompt recognition and specific treatment may improve the outcome for these patients in the HAART era.

The AIDS patient with abdominal pain: a new challenge for the emergency physician

As the prevalence of HIV infection continues to increase, EPs will be called upon to evaluate increasing numbers of AIDS patients who have abdominal pain, some of whom will require emergent surgical intervention. In addition to the myriad causes of abdominal pain in the nonimmunocompromised patient, the differential diagnosis in the AIDS patient includes a wide variety of opportunistic infections and neoplasms (Table 5). Evaluation frequently requires extensive laboratory studies and cultures and advanced imaging (CT, ultrasound, and so forth). A low threshold for surgical and other subspecialty consultation should be in place because of the often subtle presentation of surgical emergencies in AIDS patients.

Prognostic factors for the survival of patients with AIDS cholangiopathy

OBJECTIVES

AIDS cholangiopathy, once considered to have extremely poor prognosis, is now rarely fatal. This study was designed to assess the survival of patients with AIDS cholangiopathy and investigate prognostic variables, especially in the era of highly active antiretroviral therapy (HAART).

METHODS

Ninety-four patients with AIDS cholangiopathy were diagnosed at the San Francisco General Hospital from 1983 to 2001. The mortality status, demographic and clinical variables, and ERCP results were collected through death certificates, chart review, and endoscopic reports.

RESULTS

The median survival time from the diagnosis of AIDS and AIDS cholangiopathy was 23 and 9 months, respectively. HAART significantly improved the mortality of patients with AIDS cholangiopathy (hazard ratio [HR] = 0.08, 95% confidence interval [CI] = 0.02-0.35). The presence or history of any opportunistic infection involving the digestive tract, lung, eye, nervous system, skin, or systemic involvement at the time when AIDS cholangiopathy was diagnosed was an indicator of poor prognosis (HR = 3.24, 95% CI = 1.45-7.26); this was especially true for cryptosporidial infection (HR = 2.05, 95% CI = 1.24-3.38). Patients with high serum ALP levels, especially greater than 1000 IU/L or eight times the normal value (HR = 2.69, 95% CI = 1.10-6.60), tended to have a shorter life expectancy than those with normal or slightly elevated serum ALP levels. CD4 lymphocyte counts, type of cholangiopathy, and the performance of sphincterotomy were not correlated with the survival of patients with AIDS cholangiopathy.

CONCLUSIONS

HAART administration most likely accounts for the recent dramatic improvement in survival of patients with AIDS cholangiopathy. Underlying immunosuppressive status, reflected by the presence or history of any opportunistic infections, is associated with a worse outcome. Serum ALP levels might be a good clinical indicator for the prognosis of patients with AIDS cholangiopathy.

Jaundice caused by a clinically undetectable T-cell lymphoma infiltrating the sphincter of Oddi

Malignant lymphoma rarely presents with jaundice. We describe a patient who had a unique etiology for painless jaundice, dilated ducts, and a normal ampulla of Vater. A Whipple's procedure was performed for the suspicion of pancreatic cancer, and initial pathological review detected only mild focal chronic pancreatitis. Seven months later, the patient developed ascites, retroperitoneal mass, and splenomegaly caused by a T-cell lymphoma. Reevaluation of the Whipple's specimen revealed previously unrecognized microscopic infiltration and fibrosis of the sphincter of Oddi by atypical T-lymphocytes. Obstructive jaundice caused by a clinically undetectable primary duodenal T-cell lymphoma has not been previously reported and is contrasted with other causes of jaundice associated with malignant lymphoma and ampullary lesions.

Biliary giardiasis in a patient with human immunodeficiency virus

A 41-year-old man with human immunodeficiency virus (HIV) (CD4 count, 446/mm3) developed a protracted course of abdominal pain, weight loss, and increasing liver function tests after undergoing a metronidazole treatment regimen for Giardia enteritis. Three months later, endoscopic retrograde cholangiography (ERCP) showed dilated common and intrahepatic bile ducts and luminal irregularities of the common bile duct. Seven months after the onset of his acute diarrhea, a repeat ERCP with aspiration demonstrated many Giardia trophozoites and cysts in the bile and continued structural abnormalities consistent with cholangiopathy. A 10-day course of high-dose intravenous metronidazole did not resolve these signs or symptoms. A gallbladder ultrasound showed a thickened wall. Laparoscopic cholecystectomy led to resolution of abdominal pain and normalization of serum alkaline phosphatase over an 8-month period. Gallbladder histopathology revealed chronic cholecystitis, but no parasites were seen on hematoxylin and eosin staining or with Giardia antigen enzyme immunoassay testing of the gallbladder. The patient refused to undergo a follow-up ERCP, but a right upper quadrant ultrasound and computed tomography of the abdomen were normal.

Pruritus in patients with chronic human immunodeficiency virus, hepatitis B and C virus infections

AIM

The prevalence of pruritus was prospectively determined in 310 patients of whom 119 had hepatitis C virus infection, 91 hepatitis C virus and human immunodeficiency virus, 51 human immunodeficiency virus infection alone, 31 hepatitis B virus and human immunodeficiency virus coinfection and 18 were HBsAg carriers.

RESULTS

Patients in the first three groups were more likely to complain of itching (22%, 28% and 25%, respectively) than HBsAg carriers (8.2%, p=0.01. Laboratory data were not different between groups, except for the human immunodeficiency virus group, whose alkaline phosphatase levels were highest, and CD4 counts were lowest (median 30 cells/mm3). Patients with hepatitis C, including those with human immunodeficiency virus, had similar hepatitis C virus RNA levels in patients with or without pruritus. There was no difference in hepatic inflammation or fibrosis between those with and those without pruritus.

CONCLUSION

20% of patients with chronic hepatitis C and 8% of hepatitis B patients complain of pruritus. Patients with pruritus have laboratory and histologic parameters comparable to those without.

Microsporidial AIDS cholangiopathy due to Encephalitozoon intestinalis: case report and review

Microsporidia are increasingly recognized as opportunistic infections in immunodeficient patients, predominantly patients with AIDS. The two microsporidia most commonly associated with disease in AIDS patients are Enterocytozoon bieneusi and Encephalitozoon intestinalis (previously known as Septata intestinalis). The most common clinical presentation of microsporidiosis in AIDS patients is diarrhea, most commonly caused by the Enterocytozoon bieneusi species. Encephalitozoon intestinalis is a recently described species that has been reported to cause disseminated human infection including cholangitis. We report a case of AIDS cholangiopathy that presented with abdominal pain and cholestatic liver tests. Ultrasound examination and ERCP revealed a picture of sclerosing cholangitis. Bile samples obtained at ERCP were negative for microsporidia; stool studies for microsporidia and cryptosporidia were also negative. No organisms were identified on routine light microscopy of the biopsy specimens from the duodenum, ampulla, and bile duct. E. intestinalis spores were demonstrated in the bile duct biopsies, by methylene blue and azure 11 staining and confirmed by electron microscopy. Albendazole therapy was successful in eradicating E. intestinalis with clinical improvement and improvement in CD4 count. However, the cholangiographic picture did not improve and repeat cholangiography revealed progressive bile duct injury. Albendazole therapy was delayed and may have been too late to prevent bile duct damage; the drug had to be approved by the US Food and Drug Administration for compassionate use. This is an unusual case of sclerosing cholangitis caused by an unusual organism and requiring biliary sphincterotomy and stent placement for progressive stricturing despite eradication of the infection.

Cholangiopathy in HIV-infected patients

HIV cholangiopathy is a disease of advanced-stage AIDS that presents with biliary symptoms and anicteric cholestasis. An abnormal ultrasound examination in a patient with low CD4 count is evaluated by endoscopic retrograde cholangiopancreatography, which demonstrates the characteristic cholangiographic abnormalities. Besides being the gold standard for diagnosis, it offers therapeutic intervention and possible pain relief in the presence of papillary stenosis. An infectious pathogen is identifiable in a majority of patients, suggesting infection-related damage to the biliary tree. Anti-infective therapy, however, usually is ineffective, and prognosis is related to the underlying stage of AIDS.

Biliary Problems in People with HIV Disease

Acute cholecystitis in a patient with HIV infection represents a difficult diagnostic problem. With improved antiretroviral therapy, many of the biliary problems we have seen in these patients are identical to those in nonimmunosuppressed patients (ie, they are largely caused by gallstones). The indication for cholecystectomy is usually right upper quadrant abdominal pain that has been persistent for weeks to months. Although cholecystectomy will result in pain relief in many patients, the presence of coexisting HIV cholangiopathy in about half these patients increases the likelihood of ongoing symptoms. Patients should be counseled that postoperative endoscopic retrograde cholangiopancreatography (ERCP) may be necessary and that some of the variants of HIV cholangiopathy do not respond to endoscopic therapy. The high perioperative mortality in these patients is not related to biliary tract disease but is rather a manifestation of severe underlying disease associated with advanced HIV infection. HIV cholangiopathy represents a complication of severe immunosuppression. Patients are generally in poor condition and often have coexisting infections or malignancies. The decision regarding how aggressively to approach a patient with suspected HIV cholangiopathy, a nonfatal condition, is best made with consideration of the degree of pain being reported. All patients should undergo an abdominal ultrasound, with ERCP being offered to those with severe or debilitating pain and who are found to have dilated bile ducts suggesting papillary stenosis. Should this finding be confirmed at cholangiography, sphincterotomy is effective palliation for abdominal pain in most cases. ERCP is considerably less useful in patients who have elevated liver enzyme levels without symptoms; there is only a small likelihood of identifying an infection not previously recognized or better diagnosed noninvasively. These patients do not generally benefit from sphincterotomy. The regular use of ERCP in patients with HIV for the evaluation of elevated liver enzyme levels is to be discouraged, because the very limited potential benefit of the procedure does not outweigh the risks.

Hepatobiliary and pancreatic infections in AIDS: Part II

In the first part of our review, we discussed the general evaluation and clinical presentation of the various hepatic infections occurring in patients with AIDS. In addition, we focused on specific hepatic parenchymal infections. In this article, we will discuss the major clinical syndromes arising from opportunistic infections affecting the gallbladder (acalculous cholecystitis), biliary tree (AIDS-cholangiopathy), and pancreas (pancreatitis). Acalculous cholecystitis can develop in patients with AIDS who have not experienced the severe precipitating physiologic stresses normally required in patients without AIDS. The most common presentation is with right upper quadrant (RUQ) pain and tenderness. The diagnosis is a clinical one since there is no standard test, other than surgery. Cholecystectomy is the treatment of choice. The most common AIDS-associated infective complication of the biliary tree is AIDS-cholangiopathy. This is best viewed as a form of secondary sclerosing cholangitis resulting from a variety of opportunistic infections within the biliary tree. Affected persons present with RUQ pain and have marked elevations in the canalicular enzymes, alkaline phosphatase, and gamma-glutamyl transferase. Morphologic abnormalities are identified by endoscopic retrograde cholangiopancreatography. These include stricturing, dilatation, and beading of the biliary tract. Endoscopic sphincterotomy of the papilla of Vater may provide symptomatic relief for patients with papillary stenosis. Opportunistic infections within the pancreas gland have been documented in both pre- and postmortem studies. However, the true incidence of pancreatitis related to infections is unknown. The presentation is similar to that of pancreatitis from other causes. A computerized tomogram of the abdomen is the investigation of choice. Tissue aspiration or biopsy of the pancreas is required to demonstrate the presence of an opportunistic infection. The management is usually supportive, as it is rare that a specific infection is identified and treated.

Pain as a complication of HIV disease

Pain as a symptom is common to many pathologic conditions. At its most elementary level, it is a signal from peripheral nerves with specialized receptors that there is a change in the local environment, such as pressure, pH, temperature, or some other noxious stimulus, that can be detrimental to function. Pain is particularly prevalent in patients with HIV infection. The assessment, evaluation, and treatment of pain should be an integral part of comprehensive patient care.

An assessment of the use of costs and quality of life as outcomes in endoscopic research

BACKGROUND

Costs and quality of life are increasingly important study outcomes. We quantitatively and qualitatively assessed their use in recent endoscopic research.

METHODS

All Medline-retrieved 1985 to 1995 published gastrointestinal endoscopic research using cost and/or quality of life as outcomes were analyzed.

RESULTS

Sixty-eight (1.2%) of an estimated 5568 publications discussed costs and/or quality of life as endoscopic outcomes (24 quality of life, 37 cost-effectiveness, 7 cost-benefit). Their use did not increase with time. Cost or quality of life was infrequently a primary study outcome. Twenty of 24 (83%) quality of life papers used an objective scale. However, of these, 15 of 20 (75%) used symptom indexes, performance scales, or other nonvalidated quality of life instruments. Two of 24 (8%) evaluated quality of life in nonmalignant disease. Eight of 40 (20%) papers claimed endoscopy was cost-effective, with no evidence of formal cost assessment. Ten of 32 (31%) substituted charges for costs. Of 21 papers reporting cost data, 4 (19%) specified cost type (e.g., direct vs other), 6 (29%) specified cost perspective, and 9 (43%) reported sensitivity analysis. Sixteen of 27 (59%) cost-effectiveness papers did not correlate costs with changes in a health outcome.

CONCLUSIONS

The overall cost and quality of life assessment in endoscopic research has been limited and must be improved. Accurate cost and quality of life assessment will require cooperation between gastroenterologists and experts in these fields.

Gallbladder and biliary tract disease in AIDS

Biliary disease occurs in a subset of AIDS patients with CD4 counts of less than 100 per mm3. These patients present with right upper quadrant and epigastric pain, cholestasis, and usually abnormal findings on imaging. In 75% of patients, an associated opportunistic infection can be identified. In patients with biliary disease, pain is often relieved following endoscopic sphincterotomy, whereas cholecystectomy provides pain relief in patients with acalculous cholecystitis.

Cryptosporidiosis in Houston, Texas. A report of 95 cases

Cryptosporidiosis is an important cause of diarrhea. We identified 95 patients with cryptosporidiosis over a 6-year period in our county hospital system, including 9 children and 86 adults infected with the human immunodeficiency virus (HIV). Risk factors included male-to-male sexual practices and Hispanic race. Diarrhea, weight loss, and gastrointestinal complaints were the most common symptoms at presentation. Among the HIV-infected adults, 20 (23%) developed biliary tract disease. Biliary involvement was associated with low CD4 counts. Treatment with paromomycin and antimotility agents was effective in reducing diarrheal symptoms in 54 of 70 (77%) patients with the acquired immunodeficiency syndrome (AIDS), although there was a high rate of relapse. Paromomycin did not prevent the development of biliary disease. Biliary disease responded to cholecystectomy or sphincterotomy with stent placement. Though often a cause of morbidity, cryptosporidiosis was only rarely the cause of death, even among patients with HIV. Cryptosporidiosis continues to be an important medical problem even in developed-countries. Current methods of prevention and treatment are suboptimal.