بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم GASTROINTESTINAL MANIFESTATIONS OF AIDS In : Medical, health and social aspects of HIV/AIDS Salimi. G. M.D 2003

2. Gastrointestinal Complications of AIDS • Diarrhea Acute diarrhea with primary HIV-1 SYNDROM Chronic diarrhea with other stages of infection • Abdominal pain CMV disease, Lymphoma, Pancreatitis, typhlitis • Hepatobiliary Dis. Acalculus cholecystitis,papillary stenosis , sclerosing cholangitis • Pancretitis Drugs(Pentamidine, dideoxyinosine); infection neoplasm( lymphoma, kaposi sarcoma) • GI Bleeding upper GI: HSV, esophagitis, GI Lymphoma,MAC Lower GI:CMV, Lymphoma • Opprtunistic infections esophagus, stomach, intestine,

3. Chronic diarrhea Odynophagea Dysphagea Abdominal pain Jaundice Anorectal disease The commonest symptoms

4. Primary GI evidence of AIDS • Esophageal Candida • Cryptosporiodosis>1 month • Cytomegalovirus>1 month • Herpes ulcer / Esophagitis>1 month • Kaposi,s sarcoma in patient<60 Y.Old • Mycobacterium avium or kansasii, disseminated

5. CMV-Assoclated organ Disease in the Gastrolntestinal Tract in HIV-1-infected Persons

6. Oral complications of AIDS • Oral candidiasis • Oral Hairy Leukoplakia • HSV Infection • Aphthous like Ulcers • Kaposi sarcoma

8. Esophageal Complications of AIDS Frequency(%) CD4 count • Candida 50-70 <200 • CMV 10-20 <50 • HSV 2-5 <200 • Idiopathic 10-20 <300

15. Gastric Complications of AIDS • Gastritis • Peptic ulcer <5% • CMV infection (erosive gastritis) • Kaposi, sarcoma • Lymphoma • Drug-Induced gastritis

16. DIARRHEA • The commonest symptom (50-90%) • The most frostrating and morbid GI. Manifestation • Change in normal mucosal immunity: -Untreatable infection (cryptosporidia) -More virulent clinical course (salmonella,shigella…)

17. Agents of Acute and Chronic Diarrhea in AIDS • Agent Freq.% CD4 /mm3 • Acute Diarrhea --Salmonella 5-15 Any Clostridium 10-15 Any difficile -- Enteric Viruses 15-30 Any -- Idiopathic 25-40 Any

18. Cont…Agens of Chronic Diarrhea Agent Freq.% CD4/mm3 • Cryptosporidium 10-30 <100 • Microsporidia 15-30 <100 • Isospora 1-3 <100 • MAC 10-20 <50 • CMV 15-40 <50 • Idiopathic 20-30 Any

19. Prevalence ofPathogenesinDiarrhea Pathogene % -Cryptosporidia 19.6 -Microsporidia 19.4 -CMV 20.1 -MAC 9.3 Giardia Lamblia 4.9 -Entamoeba Histolitica 2.6 -Campilobacter 3.3 -Salmonella 2.1 -Shigella 1.9 -Closteridium Difficile 1.8 -Isospora belli 1.5 -Enteric viruses 3.8 -Any pathogen isolated 67

24. Evaluation of Diarrhea in AIDS • Drug History • CD4 count • Differentiate Acute Vs. Chronic • Differentiate Colitis Vs. Enteritis

25. Evaluation Of Diarrhea In AIDS • I-In all patients , stool specimen for: 1-Bacterial Culture -Salmonella -Shigella -Campylobacter 2-Stool Smear for -Fecal leukocyte -Ova and Parasite -Acid-Fast bacterial stain -Fat stain

26. Continue of evaluation of diarrhea • II- In patients with Rectal Bleeding, Tenesmus, Fecal Leukocyte -FLEXIBLE SIGMOIDOSCOPYwith BIOPSYof mucosa for: -Pathology( Viruse, protozoa) -Culture of rectal tissue for bacteria( especially campylo- bacter)

27. Cont….. • III-If Diarrhea Persist UPPER GI ENDOSCOPY WITH Aspiration of secretion for ova and parasite bacterial culture - Small bowel mucosal biopsy; electron microscopy if avaleable

28. Causes of Abdominal Pain • CMV Infection and Arteritis • CMV Colitis • Sclerosing Cholangitis • AIDS Cholangiopathy • Acute Surgical Abdomen

29. Dull pain , Diarrhea Naseua , Vomiting Acute severe pain Tenderness RUQ Pain + Abn.LFT Subacute Pain, Severe Naseua/Vomiting =Infectious Enteritis =Perforation/Peritonitis =Cholecystitis ;Hepatitis Cholestasis =Obstruction Abdominal “Pain syndrom” in AIDS

30. Hepatic Parenchymal Disease MAC Drug-Induced( Zidovudine) CMV H.C.V, H.B.V, H.D.V Bacillary Peliosis Hepatis Lymphoma Mycobacterium T.B Cryptococcus Kaposi, sarcoma Microsporidium Biliary Disease Cholangitis caused by CMV Cryptosporidium Microsporidium Lymphoma Kaposi, sarcoma Differential Diagnosis ofJaundice /Hepatomegalyin AIDS

31. ADVOISE

32. Clinical Guidelines • Clinical signs and symptoms alone rarely suggest diagnosis • Likely diagnoses may be predicted on the basis of immunocompromise. • In late-stage HIV infection GI pathogen are usually part of a systemic infection (e.g., CMV , MAC )

33. Clinical Guidelines • Evaluation should proceed from less invasive to more invasive procedures • Multiple infection is common • The clinician,s main goal is to identify treatable disorders • Failure to establish a specific cause is not unusual • Recurrence of opportunistic infection is almost invariable

34. Type ofClinical Presentation And Degree of Immunodefficiency Help to Differential diagnosis

35. DIFFICULTIES

36. Difficulty in decision • Considering the vast number of infection and tumoral or nonspecific concequences of aids at once. • How extensively should investigate GI. Symptoms.

37. Consider: • Patient Discomfort • Invasiveness • Cost of Procedure • Benefit of Procedure • Severity of patient Complaint

38. PREVENTION

39. Approach to Prevention • I-Biological Approach • II-Education Approach • III-Behavorial Approach

40. I-Biological Approach -Vaccination -Blood product & Biological Product Screening -Antiretroviral Treatment -Prevention of Vertical Transmissin -STD & HIV Prevention

41. II-Education Approach -Intervention vs. Education vs. Counceling -Media-Based Efforts

42. III-Behavorial Approach • Behavorial Epidemiology “baseline state” -High Risk Sexual Behavior: -Multi Sexual Partner( Men & Women) >3-6 million adult with 5 partner/year -Low average age( 15.6 year) -Low Condom Use( 12%) -STD -Health-Risk Behaviors: -Smoking, Drug abuse, Alcohol

43. Behavorial Intervention: Objectives • Increasing Knowledge Base • Self Esteem • Communication Skills • Technical Efficacy • Social Norms