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Advances in antiretroviral therapy are changing the nature of HIV disease and affecting many of the gastrointestinal manifestations. Given fewer late-stage immunocompromised patients, clinicians must recognize the shifts in the spectrum of pathogens, recognize the need to maintain good nutrition, and facilitate outpatient management directed at identifying treatable causes and ameliorating symptoms.
Gastrointestinal GI manifestations of HIV disease include diarrhea, dysphagia and odynophagia, nausea, vomiting, weight loss, abdominal pain, anorectal disease, jaundice and hepatomegaly, GI bleeding, interactions of HIV and hepatotropic viruses, and GI tumors Kaposi's sarcoma and non-Hodgkin's lymphoma.
The evaluation of specific gastrointestinal complaints must be based on an assessment of the degree of immunosuppression. Progressive immunocompromise is associated with increasing prevalence of GI symptoms 3 and remains the common endpoint for most individuals infected with HIV.
Consequently, clinicians should investigate all significant GI complaints, using sufficiently objective studies to identify specific treatable infections or neoplasms associated with advanced HIV disease.
A notable exception is esophageal disease, in which empiric therapy for Candida may precede invasive work-up. Multiple GI infections are common, making it important to distinguish between true pathogens and secondary colonization, and to evaluate patients further when initial therapies fail.
Evidence of tissue invasion by an infectious agent is the hallmark of true pathogenicity. Prolonged survival necessitates greater emphasis on maintaining adequate nutritional status and diagnosing and treating chronic co-morbid conditions including hepatitis C virus HCV.
Among the more difficult management issues in the HIV-infected patient is deciding how extensively to investigate GI symptoms.
The clinician must always weigh the discomfort and invasiveness of a procedure against the severity of the patient's complaints and the likelihood of identifying a treatable condition.
Thus, for example, patients who are incapacitated by abdominal pain or diarrhea should be evaluated more extensively with endoscopic or imaging studies than patients whose symptoms do not interfere with daily activities.
In outpatient studies, the prevalence of diarrhea ranged from 0.
Differential Diagnosis Prospective series have implicated a wide variety of protozoal, viral, and bacterial organisms as diarrheal pathogens Table 1. Others, like Cryptosporidium, cause self-limited diarrheal illness in healthy hosts but chronic diarrhea in immunosuppressed patients.
Two studies have reported a dramatic decrease in cryptosporidial diarrhea over the past 5 years.
The diarrhea is often self-limited, lasting less than 2 to 4 weeks from initiation of medication use. Other etiologies of diarrhea include idiopathic colitis, enteropathogenic Escherichia coli, and small bowel bacterial overgrowth.
The morphologic changes reported in patients with small bowel overgrowth include villous atrophy and inflammatory infiltrates similar to the findings in "HIV enteropathy". Intestinal disturbances common in patients with HIV, including gastric hypoacidity, impaired intestinal immunity, or impaired intestinal motility are known to predispose to bacterial overgrowth.
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