PANCREATIC & BILIARY DISORDERS IN HIV

Dr.BujjiBabu ,M.D

Consultant HIV PhysicianDr.Bujjibabu HIV Clinic

Pancreatic Disorders

Acute Pancreatitis

Chronic Pancreatitis(On Autopsy usually)

Pancreatic Neoplasm – Lymphoma Kaposi’s Sarcoma

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

Mechanism

HIV itselfOpportunistic Infections

CMV,HSV,MAC,Crypaococcus, Toxoplasma, Myco.tuberculosis, Candida

Usually involves other organs alsoPancreatic neoplasms:Lymphoma, Kaposi Sarcoma 5% of AIDS; Pancreatitis rareUsually in setting of wide spread diseaseDRUGS

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 months Advanced AIDS & Previous H/o Pancreatitis – high risk

Dose reduction decreases the risk Careful monitoring of glucose

CECT : Acute pancreatitis in HIV

Diagnosis

Clinical features

Elevated amylase & lipase

Imaging (USG & or CT)

Occasionally FNAC for etiology

Acute pancreatitis in HIV

Ac.Panc+HIV(44) Ac. Pancreatitis(44)

Clinical Features Similar SimilarAnemia More Lesshypoalbuminemia More LessLeucopenia More LessFever,Diarrhoea, hepatomegaly

More incidence Less

Drug Induced 18 2Gall stone 2 22Severe course (Prolong stay & death)

22 12

Ranson & Glasgow Poor GoodAPACHE II Good Good

Cappell et al Gut,1995

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

Total No: 73Drug Induce – 46%Idiopathic 26%25% had severe pancreatitis by Atlanta15% Severe hospital course & deathAPACHE –II – Best (Accuracy 75%)Glasgow & Ranson – PoorConclusion: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

Acute pancreatitis in HIV:

Biliary Disorders in HIV Patients

Non HIV associated :

Stones, benign strictures, ascariasis ,neoplasms etc

Acalculus cholecystitis

AIDS cholangiopathy

CBD Stone in an AIDS Patient

Periampullary Ca

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

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)

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

ERCP confirmed cholangiopathy

USG Normal in 10/38 CT Normal in 5/17

ERCP NormalUSG Abnormal - 1/10

CT Abnormal - 0/9

CECT : AIDS Cholangiopathy

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

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

Cryptosporidium & AIDS Cholangiopathy

82 HIV patients acquired cryptosporidiosis in an outbreak in Milwaukee ’93

29% developed biliary symptoms10 had ERCP – All had AIDS

cholangiopathySuggest biliary cryptosporidiosis CD4 < 50 high risk and all died within 1

year Vakil et al;NEJM:1996

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

ERCP : Papillary stenosis in HIV

AIDS Cholangiopathy

TREATMENT

Papillary Stenosis Endoscopic sphincterotomy

Balloon sphincteroplasty

CBD stenting Lymphoma or Kaposi Sarcoma -Chemotherapy

Acalculus cholecystitis - Cholecystectomy

Antiviral drugs if CMV or HSV

AIDS cholangiopathy : Natural history

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

Forbes et al Gut 1993

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 casesHIV cholangiopathy : 2 casesPancreatic pseudocyst : 1 case

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

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