Clinicians should evaluate patients with gastrointestinal (GI) complaints for non-human immunodeficiency virus (HIV)-related illness, non-GI-related illness, adverse effects of medications, possible opportunistic infections (OIs), and HIV-associated neoplasms.
Clinicians should not routinely dismiss GI complaints in HIV-infected pregnant women.
Gastrointestinal Diseases and Syndromes
Esophageal Disease
Treatment
Initial Empiric Therapy
Clinicians should prescribe an oral azole antifungal (fluconazole loading dose of 200 mg, followed by 100 to 200 mg/day) as initial empiric treatment for patients with suspected esophagitis. If no improvement is seen after 7 to 10 days, diagnostic endoscopy should be performed.
Esophagitis in Patients Receiving Antifungal Therapy
When a patient receiving antifungal therapy presents with esophagitis, clinicians should assess for the following:
- A defect in drug absorption (common with itraconazole and ketoconazole)
- The development of resistance to the drug by the initial infecting fungus
- Development of a fungal superinfection with a resistant strain
- Development of a non-fungal etiology
Cytomegalovirus (CMV) Esophagitis
Clinicians should treat CMV esophagitis with oral valganciclovir or intravenously administered ganciclovir or foscarnet at induction doses for 3 to 6 weeks.
An ophthalmologic examination should be performed at the time of diagnosis to assess for the presence of concurrent CMV retinal disease.
Herpes Simplex Virus (HSV) Esophagitis
Clinicians should treat mild or moderate HSV esophagitis orally for 2 weeks (if absorption is not an issue) with standard treatment doses of acyclovir, valacyclovir, or famciclovir.
Clinicians should treat severe HSV esophagitis with intravenously administered acyclovir for 2 weeks. Foscarnet should be used when acyclovir-resistant HSV is suspected.
Gastroesophageal Reflux Disease (GERD)
Clinicians should treat GERD primarily with proton pump inhibitors (omeprazole, lansoprazole), possibly in combination with pro-motility agents (metoclopramide).
Aphthous Ulcers
Clinicians should use topical corticosteroids to manage aphthous ulcers; however, caution should be taken because steroid use may result in candidal overgrowth.
Gastric Disease
Diagnosis
Clinicians should perform endoscopy in patients with recalcitrant symptoms or disease and/or acute events, such as hematemesis.
Clinicians should discuss with HIV-infected patients who are initiating antiretroviral (ARV) therapy the possible GI side effects associated with ARV medications. The patient should be informed that the duration of symptoms is generally limited to 2 weeks and that symptomatic treatment can be prescribed.
Treatment
Because of the high incidence of diarrhea in HIV-infected patients, magnesium-containing antacids should be avoided, and aluminum- or bismuth-based antacids should be used.
Clinicians should prescribe short courses of the oral or suppository form of prochlorperazine or promethazine with or without metoclopramide for symptomatic relief of medication-associated nausea and vomiting.
Liver Disease
Diagnosis
When a patient has elevated serum transaminase, the clinician should assess for use of any possible hepatotoxic medications or alternative therapies (herbal therapies), alcohol abuse, and viral hepatitis. Refer to Table 2 in the original guideline document for information on hepatotoxicity of ARV drugs. For recommendations regarding hepatitis A, B, and C management, see the New York State Department of Health (NYSDoH) guideline on Viral Hepatitis.
Treatment
The clinician should avoid using any potentially hepatotoxic non-essential drugs in the setting of new or worsening abnormal serum liver enzyme levels.
When one of the highly active antiretroviral therapy (HAART) agents is suspected as the cause for the hepatotoxicity, the clinician should substitute an equally potent agent. If the clinical situation does not permit the initiation of an alternative agent, the discontinuation of all the components of the HAART regimen is recommended. Therapy with the alternative HAART regimen should be initiated after the abnormal laboratory values have returned to the patient's baseline values.
Clinicians should initiate standard treatment for pathogens found in the liver, such as fungi and mycobacteria.
Diarrhea
Diagnosis
Clinicians should assess the following in HIV-infected patients with diarrhea:
- A careful dietary history, including lactose and fat intake
- Medication history to assess whether diarrhea is medication-induced
- Travel history
- Alcohol use
- Sexual activity
- Weight loss
Clinicians should perform endoscopy in the setting of moderate to severe diarrhea if stool studies for pathogens are negative and medication is not a suspected etiology.
Clinicians should perform colonoscopy in patients with bloody diarrhea or diarrhea with tenesmus when bacterial stool cultures are negative, obtaining multiple biopsies from both abnormal and normal-appearing segments of bowel. Pathologists should be specifically instructed to seek specific organisms. Refer to Table 3 of the original guideline document for information on evaluation of diarrhea based on CD4 count.
Clinicians should perform distal duodenal biopsy in patients with large volume diarrhea (>2L/24hr) of suspected small bowel origin. If microsporidia is suspected, electron microscopy or polymerase chain reaction (PCR) should be used to confirm and identify the microsporidia.
Clinicians should include invasive enteric disease (bacterial, viral) or disseminated mycobacterial infection in the differential diagnosis in patients who present with fever and diarrhea.
Treatment
Clinicians should provide symptomatic treatment for all patients with diarrhea to prevent volume depletion and wasting and to maximize comfort and functional status (see the table below).
Clinicians should counsel patients with diarrhea about the effects of diet, advocating a low-fat, lactose-free diet if these are found to be etiologic.
Clinicians should treat parasitic and bacterial pathogens with standard regimens.
Clinicians should treat CMV colitis with intravenous ganciclovir, valganciclovir, or foscarnet for 3 to 6 weeks with induction doses. Maintenance therapy remains controversial but should be used in the setting of a low CD4 count (<100 cells/mm3). An ophthalmologic examination should be performed at the time of diagnosis to assess for the presence of concurrent CMV retinal disease.
Table: Symptomatic Treatment for Patients with Diarrhea
| Agent |
Indications |
| Loperamide |
Moderate to severe antiretroviral (ARV)-related diarrhea; should only be used after bacterial or amoebic etiology has been excluded |
| Diphenoxylate |
Moderate to severe ARV-related diarrhea; should only be used after bacterial or amoebic etiology has been excluded |
| Paregoric |
Moderate to severe ARV-related diarrhea; should only be used after bacterial or amoebic etiology has been excluded |
| Deodorized tincture of opium |
Moderate to severe ARV-related diarrhea; should only be used after bacterial or amoebic etiology has been excluded |
| Bismuth subsalicylate |
Mild, non-infectious diarrhea |
| Aluminum antacids |
Mild, non-infectious diarrhea |
| Cholestyramine |
Mild, non-infectious diarrhea |
| Fiber supplement |
Mild, non-infectious diarrhea |
| Calcium carbonate pills* |
ARV-related diarrhea |
| Glutamine supplementation* |
ARV-related diarrhea |
*Anecdotally noted to be useful for ARV-related diarrhea.
Biliary Disease
Diagnosis
Clinicians should perform an abdominal ultrasound to establish a diagnosis of biliary disease.
Clinicians should confirm acalculous cholecystitis by hepatoiminodiacetic acid (HIDA) scan.
If stool tests and radiologic studies are unrevealing, clinicians should perform an endoscopic evaluation of the biliary tree and small bowel with or without biopsies to identify the pathogen.
Treatment
Clinicians should treat the underlying pathogen(s) isolated from the biliary tract or stool.
Clinicians should treat jaundice and pruritus with ursodeoxycholic acid and symptomatic treatments such as doxepin. Pain should be treated when indicated.
Clinicians should use appropriate antimicrobial therapy with or without cholecystectomy to treat acalculous cholecystitis.
Pancreatic Disease
Diagnosis
Clinicians should obtain serum lipase levels in patients suspected of having acute pancreatitis; serum lactate levels should also be obtained to exclude lactic acidosis.
Clinicians should obtain abdominal ultrasound or computed tomography (CT) scans both to delineate possible non-infectious etiologies or complications of pancreatitis, such as perforating gastric ulcers or pancreatic pseudocyst, as well as to follow the degree of inflammation and response to treatment over time. Endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for the evaluation of ductal lesions.
Treatment
Clinicians should provide vigorous intravenous hydration and pain control for patients with severe pancreatitis. These patients should be kept "nothing by mouth" (NPO).
The clinician should discontinue the use of all known or suspected pancreatotoxic agents. If one ARV agent is to be discontinued and another ARV agent cannot be expediently substituted to maintain effective HAART, then all ARV agents should be withheld to circumvent the development of resistance.
If an infectious etiology is present or suspected, the clinician should initiate appropriate antimicrobial therapy.
