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December 1986 Volume 204, Number 6 Annals of Surgery Abdominal Pain in Patients with Acquired Immune Deficiency Syndrome JAMES E . BARONE, M.D., F.A.C.S. BRUCE S . GINGOLD, M.D., F.A.C.S. MICHAEL L . ARVANITIS, M.D. T h e patient with acquired immune deficiency syndrome (AIDS) a n d abdominal pain presents the surgeon ith a difficult chal- lenge. T h e pain m ay be due t o a n opportunistic infection, ileus, organomegaly, or a true surgical emergency. T h e hospital records of 23 5 patients with AIDS were reviewed. O f t he 2 9 patients with abdominal pain, 12 had infectious diarrhea, eight were d i - agnosed a s having ileus o r organomegaly, an d nine h a d miscel- laneous causes for their pain. Only five patients underwent lap- arotomy. T w o patients were operated o n f o r pain associated with bleeding (Meckel's diverticulum a n d intestinal Kaposi's sar- coma); o n e h a d a perforated duodenal ulcer a n d on e h ad severe ileitis. O ne patient w a s electively operated o n f o r Burkitt's lym- phoma. Laparotomy f o r abdominal pain is no usually necessary i n patients with AIDS. Specific recommendations f o r evaluation a n d management o f these patients a r e offered. R THOUSANDS O F YEARS, physicians have been called upon t o evaluate patients with abdominal . 1 pain. Guidelines f o r diagnosis o f most types o f abdominal pain a r e generally well established. However, a ne w disease complex, acquired immune deficiency syn- drome (AIDS), h a s recently appeared, making previously Presented a t t h e N e w York Surgical Society Meeting, February 1 2 , 1986. Reprint requests a n d correspondence: James E . Barone, M.D., F.A.C.S., Director o f Surgery, St . Francis Medical Center, 6 0 1 Hamilton Avenue, Trenton, N J 08629. Submitted f o r publication: Ma y 1 2 , 1986. THOMAS F . NEALON, JR., M.D., F.A.C.S. From t h e Department of Surgery, S t . Vincent's Hospital an d Medical Center o f N e w York, N e w York, N e w York unusual illnesses, such a s Kaposi's sarcoma (KS) a n d Pneumocystis carinii pneumonia (PCP), commonplace. More than 15,000 cases o f AIDS have been reported.' More frequently, surgeons a re being asked t o assess a b - dominal pain i n patients with AIDS. T h e experience o f o n e institution regarding t h e presentation, diagnosis, a n d management o f abdominal pain i n a large series o f patients with AIDS has not been described before. Patient Data Base T h e medical records of 235 patients with AIDS w h o were admitted to S t . Vincent's Hospital a n d Medical Center of N ew York from M a y 1 , 1982, throughOctober 15, 1985, were screened. T h e diagnosis o f AIDS w a s con- firmed b y standard criteria, including presence o f proven KS, PCP, or multiple other opportunistic infections.2 T h e charts o f t he patients w h o had abdominal pain docu- mented i n t h e physician's progress notes f o r 2 o r more consecutive days were reviewed f o r this report. Results There were 2 9 patients (12.3% o f t h e total population reviewed) wh o had abdominal pain. Twenty-eight patients 6 1 9
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December 1986V o l u m e 2 0 4 , N u m b e r 6
Annals of
Surgery
Pain in P a t i e n t s w i t h AcquiredImmune Deficiency Syndrome
E . BARONE, M . D . , F . A. C . S . BRUCE S . GINGOLD, M . D . , F . A . C . S .
MICHAEL L . A R V A N I T I S , M . D .
h e p a t i e n t w i t h a c q u i r e d i m m u n e d e f i c i e n c y s y n d r o m e ( A I D S )
n d a b d o m i n a l p a i n p r e s e n t s t h e s u rg e o n w i t h a d i f f i c u l t c h a l -e n g e . T h e p a i n may b e d ue t o a n o p p o r t u n i s t i c i n f e c t i o n , i l e u s ,
o r a t r u e s u r g i c a l e m e r g e n c y . T h e h o s p i t a l r e c o r d sf 2 3 5 p a t i e n t s w i t h AIDS w e r e r e v i e w e d . Of t h e 2 9 p a t i e n t si t h a b d o m i n a l p a i n , 1 2 h a d i n f e c t i o u s d i a r r h e a , e i g h t w e r e d i -
a s h a v i n g i l e u s o r o r g a n o m e g a l y , a n d n i n e h a d m i s c e l -a n e o u s c a u s e s f o r t h e i r p a i n . O n l y f i v e p a t i e n t s u n d e r w e n t l a p -
Two p a t i e n t s w e r e o p e r a t e d o n f o r p a i n a s s o c i a t e d w i t h
( M e c k e l ' s d i v e r t i c u l u m a n d i n t e s t i n a l K a p o s i ' s s a r -o n e h a d a p e r f o r a t e d d u o d e n a l u l c e r a n d o n e h a d s e v e r e
One p a t i e n t w a s e l e c t i v e l y o p e r a t e d o n f o r B u r k i t t ' s l y m -
L a p a r o t o m y f o r a b d o m i n a l p a i n i s n o t u s u a l l y n e c e s s a r y
n p a t i e n t s w i t h A I D S . S p e c i f i c r e c o m m e n d a t i o n s f o r e v a l u a t i o nn d m a n a g e m e n t o f t h e s e p a t i e n t s a r e o f f e r e d .
R THOUSANDS OF Y E A R S , p h y s i c i a n s h av e b e e n
c a l l e d u p o n t o e v a l u a t e p a t i e n t s w i t h a b d o m i n a l
. 1 p a i n . G u i d e l i n e s f o r d i a g n o s i s o f m o s t t y p e s o f
p a i n a r e g e n e r a l l y w e l l e s t a b l i s h e d . H o w e v e r ,
ne w d i s e a s e c o m p l e x , a c q u i r e d immune d e f i c i e n c y s y n -( A I D S ) , h a s r e c e n t l y a p p e a r e d , m a k i n g p r e v i o u s l y
P r e s e n t e d a t t h e Ne w Y o r k S u r g i c a l S o c i e t y M e e t i n g , F e b r u a r y 1 2 ,9 8 6 .
R e p r i n t r e q u e s t s a n d c o r r e s p o n d e n c e : J a m e s E . B a r o n e , M . D . ,
D i r e c t o r o f S u r g e r y , S t . F r a n c i s M e d i c a l C e n t e r , 6 0 1 H a m i l t o n
T r e n t o n , NJ 0 8 6 2 9 .
S u b m i t t e d f o r p u b l i c a t i o n : May 1 2 , 1 9 8 6 .
THOMAS F . NEALON, J R . , M . D . , F . A . C . S .
From t h e D e p a r t m e n t o f S u r g e r y , S t . V i n c e n t ' s H o s p i t a l and
M e d i c a l C e n t e r o f N e w Y o r k , N e w Y o r k , N e w Y o r k
u n u s u a l i l l n e s s e s , s u c h a s K a p o s i ' s s a r c o m a ( K S ) a n d
P n e u m o c y s t i s c a r i n i i p n e u m o n i a ( P C P ) , c o m m o n p l a c e .
M o r e t h a n 1 5 , 0 0 0 c a s e s o f AIDS h a v e b e e n r e p o r t e d . 'M o r e f r e q u e n t l y , s u r g e o n s a re b e i n g a s k e d t o a s s e s s a b -
d o m i n a l p a i n i n p a t i e n t s w i t h A I D S . T h e e x p e r i e n c e o f
o n e i n s t i t u t i o n r e g a r d i n g t h e p r e s e n t a t i o n , d i a g n o s i s , a n d
m a n a g e m e n t o f a b d o m i n a l p a i n i n a l a r g e s e r i e s o f p a t i e n t sw i t h AIDS h as n o t b e e n d e s c r i b e d b e f o r e .
P a t i e n t D a t a B a s e
T h e m e d i c a l r e c o r d s o f 2 3 5 p a t i e n t s w i t h AIDS who
w e r e a d mi tt ed t o S t . V i n c e n t ' s H o s p i t a l a n d M e d i c a l
C e n t e r o f N e w Y o r k f r o m May 1 , 1 9 8 2 , t hr ou g h O c t o b er
1 5 , 1 9 8 5 , w e r e s c r e e n e d . T h e d i a g n o s i s o f AIDS w a s c o n -
f i r m e d b y s t a n d a r d c r i t e r i a , i n c l u d i n g p r e s e n c e o f p r o v e n
K S , P C P , o r m u l t i p l e o t h e r o p p o r t u n i s t i c i n f e c t i o n s . 2 T h e
c h a r t s o f t h e p a t i e n t s who h a d a bd o m i n a l p a i n d o c u -
m e n t e d i n t h e p h y s i c i a n ' s p r o g r e s s n o t e s f o r 2 o r m o r e
c o n s e c u t i v e d a y s w e r e r e v i e w e d f o r t h i s r e p o r t .
R e s u l t s
T h e r e w e r e 2 9 p a t i e n t s ( 1 2 . 3 % o f t h e t o t a l p o p u l a t i o n
r e v i e w e d ) who h a d a b do m i na l p a i n . T w e n t y - e i g h t p a t i e n t s
6 1 9
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ABD OMINAL PAIN AND AIDS
F I G . 3 . A r t e r i o g r a m s h o w i n g s i t e o f b l e e d i n g ( a r r o w ) i n p a t i e n t w i t h
M e c k e l ' s d i v e r t i c u l u m .
F I G . 2 . N o t e " s t r i n g s i g n " i n n o n s p e c i f i c i l e i t i s ( a r r o w s ) .
T h e c o l o n i c p e r f o r a t i o n a p p e a r e d t o h a v e
a p r e m o r b i d e v e n t .
a n d / o r H e p a t o s p l e n o m e g a l y
C a t e g o r i z a t i o n o f t h e e i g h t p a t i e n t s w i t h i l e u s a n d / o r
was b y e x c l u s i o n as w e l l as p h y s i c a lT h e s e p a t i e n t s w e r e a l l t r e a t e d c o n s e r v a t i v e l y
c o m p l e t e r e s o l u t i o n o f t h e i r a b d o m i n a l symptoms.
o f t h e s e s ev en p a t i e n t s e v e n t u a l l y d i e d o f A I D S -i l l n e s s e s d u r i n g t h e same h o s p i t a l i z a t i o n .
T h e n i n e p a t i e n t s i n t h e m i s c e l l a n e o u s group w e r e b o t h
e e a s i e s t a n d most d i f f i c u l t t o d i a g n o s e . T h e p a t i e n t w i t h
u l c e r p e r f o r a t i o n was b e l i e v e d t o h a v e p e r f o -o f p r e v i o u s l y d i a g n o s e d i l e i t i s , p r e s u m a b l y s e c o n d -
y t o an A I D S - r e l a t e d i n f e c t i o u s d i s e a s e ( F i g . 2 ) . The
h a d a r i g i d a b d o m e n a n d f r e e i n t r a - a b d o m i n a l a i r
x - r a y 6 m o n t h s a f t e r t h e o r i g i n a l p r e s e n t a t i o n o f non-
i l e i t i s . He r e c o v e r e d f r o m t h e u l c e r p l i c a t i o n s u r -
gery a n d d i e d 6 m o n t h s l a t e r o f P C P . The p a t i e n t w i t h a
b l e e d i n g M e c k e l ' s d i v e r t i c u l u m h a d c r a m p s a n d a m a s s i v e
l o w e r g a s t r o i n t e s t i n a l b l e e d i n g e p i s o d e r e q u i r i n g 1 6 u n i t so f p a c k e d r e d c e l l s . D i a g n o s i s w as made b y a r t e r i o g r a p h y( F i g . 3 ) a n d t h e d i v e r t i c u l u m was r e s e c t e d . The p a t h o l o g i cr e p o r t c o n f i r m e d t h e presence o f an i n f l a m e d d i v e r t i c u l u m
w i t h e v i d e n c e o f r e c e n t b l e e d i n g . B l e e d i n g r e c u r r e d 6
w e e k s l a t e r r e q u i r i n g 2 u n i t s o f p a c k e d r e d c e l l s . E x t e n s i v e
d i a g n o s t i c s t u d i e s d i d n o t e s t a b l i s h a d e f i n i t e b l e e d i n g s i t e ,
a l t h o u g h n o n s p e c i f i c e n t e r o c o l i t i s w as s e en on b a r i u menema. T h e p a t i e n t d i e d s e v e r a l m o n t h s l a t e r o f i n a n i t i o n .
T h e p a t i e n t w i t h d u o d e n i t i s was d i a g n o s e d b y up p e r g a s -
t r o i n t e s t i n a l e n d o s c o p y a n d s u c c e s s f u l l y t r e a t e d conser-
v a t i v e l y . Two o f t h e t h r e e p a t i e n t s w i t h i n t e s t i n a l KS h a d
s e v e r e m a l n u t r i t i o n . F i g u r e 4 d e p i c t s a d u o d e n a l KS l e s i o n
s e en o n up p e r g a s t r o i n t e s t i n a l s e r i e s . M a s s i v e l o w e r g a s -
F I G . 4 . KS o f duodenum ( a r r o w ) .
6 2 1l . 2 0 4 * N o . 6
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2 0 4 * N o . 6 ABDOMINAL PAIN AND A I D S 6 23
c o m p l i c a t i o n , s u c h a s p e r f o r a t i o n o f a v i s c u s d u e
a n A I D S - r e l a t e d d i s e a s e , c a n n o t b e r u l e d o u t .( 5 ) I f l a p a r o t o m y r e v e a l s o n l y e n t e r i t i s , m e s e n t e r i c
e x c i s i o n f o r b i o p s y a n d c u l t u r e s h o u l d b e d o n e .
( 6 ) I s o l a t i o n p r o t o c o l s f o r p a t i e n t s a n d s p e c i m e n s
b e e s t a b l i s h e d a c c o r d i n g t o t h e C e n t e r s f o r D i s e a s e
g u i d e l i n e s , w h i c h c o n t i n u e t o b e u p d a t e d .
R e f e r e n c e s
. R e c o m m e n d a t i o n s f o r a s s i s t i n g i n t h e p r e v e n t i o n o f p e r i n a t a l t r a n s -m i s s i o n o f h u m a n t - l y m p h o t r o p i c v i r u s t y p e I I I / l y m p h a d e n o p -a t h y v i r u s a n d a c q u i r e d i m m u n o d e f i c i e n c y s y n d r o m e . MMWR1 9 8 5 ; 3 4 : 7 2 1 - 7 2 6 .
. R e v i s i o n o f t h e c a s e d e f i n i t i o n o f a c q u i r e d i m m u n o d e f i c i e n c y s y n -d r o m e f o r n a t i o n a l r e p o r t i n g : U n i t e d S t a t e s . MMWR 1 9 8 5 ; 3 4 :3 7 3 - 3 7 5 .
3 . Ma P , S o a v e R . T h r e e - s t e p s t o o l e x a m i n a t i o n f o r c r y p t o s p o r i d i o s i si n 1 0 h o m o s e x u a l m en w i t h p r o t r a c t e d w a t e r y d i a r r h e a . J I n f e c tD i s 1 9 8 3 ; 1 4 7 : 8 2 4 - 8 2 8 .
4 . P o r tn oy D , W h i t e s i d e M , B u c k l e y E , M a c L e o d C . T r e a t m e n t o f
c r y p t o s p o r i d i o s i s w i t h s p i r a m y c i n . Ann I n t e r n Me d 1 9 8 4 ; 1 0 1 :2 0 2 - 2 0 4 .
5 . N o l a n C , J o h n s o n K , C oy l e M , F a l e r K . C a m p y l o b a c t e r j e j u n i e n -t e r i t i s : e f f i c a c y o f a n t i m i c r o b i a l a n d a n t i b a c t e r i a l d r u g s . Am J
G a s t r o e n t e r o l 1 9 8 3 ; 7 8 : 6 2 1 - 6 2 6 .6 . P o t t e r D A , D a n f o r t h DN, M a c h e r AM, e t a l . E v a l u a t i o n o f a b d o m -
i n a l p a i n i n t h e A I D . % p a t i e n t . Ann S u r g 1 9 8 4 ; 1 9 9 : 3 3 2 - 3 3 9 .7 . Z i e g l e r J L , B e c k s t e a d J k , V o l b e r d i n g P A , e t a l . N o n - H o d g k i n ' s
l y m p h o m a i n 9 0 h o m os e x u al m e n . N E n g l J Me d 1 9 8 4 ; 3 1 : 5 6 5 -
5 7 0 .8 . F r a n k D , R a i c h t R F . I n t e s t i n a l p e r f o r a t i o n a s s o c i a t e d w i t h c y t o -
m e g a l o v i r u s i n f e c t i o n i n p a t i e n t s w i t h A I D S . Am J G a s t r o e n t e r o l1 9 8 4 ; 7 9 : 2 0 1 - 2 0 5 .
9 . Kram H B , H i n o S T , C o h e n R , e t a l . S p o n t a n e o u s c o l o n i c p e r f o r a t i o ns e c o n d a r y t o c y t o m e g a l o v i r u s i n a p a t i e n t w i t h a c q u i r e d i m m u n ed e f i c i e n c y s y n d r o m e . C r i t C a r e Me d 1 9 8 4 ; 1 2 : 4 6 9 - 4 7 1 .
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