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Author's Name : Harshad Devarbhavi, Teena Sebastian, Sandeep M. Seetharamu and Dheeraj Karanth

Article Title : HIV/AIDS cholangiopathy: Clinical spectrum, cholangiographic features and outcome in 30 patients. 

Journal Name : Journal of Gastroenterology & Hepatology
1)   BIBLIOGRAPHY

Devarbhavi H., Sebastian T., Seetharamu S. M. & Karanth D. (2010). HIV/AIDS cholangiopathy: Clinical spectrum, cholangiographic features and outcome in 30 patients. Journal of Gastroenterology & Hepatology, 25(10): 1656–1660, doi:10.1111/j.1440-1746.2010.06336.x
2)  PURPOSE OF THE ARTICLE

The purpose of this article was to  describe the clinical profile and natural history of patients with
AIDS cholangiopathy and compare it with that reported in Western
literature and determine differences.
3)   BRIEF DESCRIPTION OF PROCEDURE AND FINDINGS/RESULTS

           Patients with HIV cholangiopathy underwent a detailed evaluation including risk factors, complete blood count, liver biochemical tests, HIV by ELISA, CD 4 counts, stool tests, urine tests, chest X-ray and ultrasonography of the abdomen, endoscopic retrograde cholangio-pancreatography (ERCP) or magnetic resonance cholangio-pancreatography (MRCP) or both. Ampullary biopsy was obtained (n-26) during ERCP and bile was aspirated (n-27) and sent for microbiological tests for Cryptosporidiosis, Microsporidia and Cyclospora. Past and present histories of opportunistic infections, treatment with anti-retroviral drugs, were noted. Follow up was available for all except three patients. Patients with abdominal pain and papillary stenosis underwent sphincterotomy. Sphincterotomy was not carried out in patients who had no pain or were asymptomatic. ERCP abnormalities or HIV cholangiopathies were classified into four types as previously described which include:

  • Type 1: papillary tenosis
  • Type 2: sclerosing cholangitis 
  • Type 3: combined papillary stenosis and sclerosing cholangitis 
  • Type 4: long extrahepatic strictures 

Sclerosing cholangitis was defined as bile duct dilatation with irregular margins either in the intrahepatic or extrahepatic ducts a picture similar to those seen in patients with primary sclerosing cholangitis.

           The findings shows that from Jan 1999 to May 2009, 30 patients (27 men) with AIDS cholangiopathy were seen. The most common mode of transmission was heterosexual (n = 28) followed by blood transfusion (n = 2). Abdominal pain (n = 20) of biliary origin, was the commonest manifestation followed by an asymptomatic group (n = 6) and a third group (n = 3) with pain due to pancreatitis. Ultrasonography of the abdomen was abnormal in all patients. Papillary stenosis (n = 23) was the most common cholangiographic feature followed by sclerosing cholangitis (n = 5). Abdominal pain resolved reliably and promptly after endoscopic sphincterotomy. Cholangiographic abnormalities regressed during follow up on antiretroviral therapy in 10 patients. Seven patients on anti retroviral therapy developed de novo cholangiopathy, with a precipitous drop in CD4 count of whom two had a worse prognosis. None had Kaposi’s sarcoma.
4)   CONCLUSIONS AND COMMENTS

The results from the investigation shows that, HIV cholangiopathy was seen predominantly in patients who acquired HIV by heterosexual transmission which is in contrast to Western literature. De novo development of cholangiopathy on antiretroviral therapy may indicate the occurrence of resistance. Papillary stenosis is the most common feature. Abdominal pain resolved with sphincterotomy. Regression of cholangiographic abnormality occurred with anti retroviral medications. Median survival following cholangiopathy diagnosis was 34 months, higher than reported in previous studies.
5)   OPINION OF THE ARTICLE

I thought this article provides very useful information regarding the AIDS cholangiopathy disease. The natural of the disease and patient's infected are also well described. Furthermore, it gives a better understanding of how AIDS cholangiopathy is diagnosed, what is affected and how it is treated.


APPEARANCE OF PATHOLOGY ON RADIOGRAPHS/IMAGES 







Figure 1: Ultrasonography demonstrates dilatation of common bile duct.


Figure 2: ERCP (endoscopic retrograde cholangio-pancreatography) showing 
massive dilatation of the common bile ducts and hepatic ducts 
secondary to papillary stenosis.

Figure 3: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrating 
dilatation of the common bile duct and mild pancreatic duct 
dilatation secondary to papillary stenosis.

Figure 4: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrates 
massive dilatation of common bile duct and pancreatic duct.

Figure 5: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrating
irregularity of intrahepatic ducts and common bile duct suggestive of
sclerosing cholangitis with common bile duct dilatation.
Figure 6: ERCP (endoscopic retrograde cholangio-pancreatography) demonstrating
common hepatic duct stricture with massive upstream dilatation.