Biliary Tree and Gallbladder Pathology in HIV

Abstract

AIDS cholangiopathy was first described in 1986 (Ko et al., Am J Gastroenterol 98(10):2176–2181, 2003). Patients typically present with right upper quadrant pain, fever, diarrhea, and weight loss, whereas pruritus and jaundice are uncommon features (Benhamou et al., Dig Dis Sci 38(6):1113–1118, 1993; Bouche et al., J Hepatol 17(1):34–39, 1993; Farman et al., Abdominal Imaging 19(5):417–422, 1994). This clinical entity is typically seen in patients with severely suppressed immune systems, and CD4 counts are frequently less than 50 cells/μL (Cello, Am J Med 86(5):539–546, 1989). Workup typically reveals a markedly elevated alkaline phosphatase, out of proportion to mildly elevated transaminases and bilirubin (Bouche et al., J Hepatol 17(1):34–39, 1993; Farman et al., Abdominal Imaging 19(5):417–422, 1994). This entity is associated with opportunistic infections; however, an etiology is discovered in less than half of cases (Cello and Rogers, Tech Gastrointest Endosc 4(2):86–89, 2002). The most commonly encountered etiologies include Cryptosporidium and Cytomegalovirus (Nash and Cohen, Gastroenterol Clin N Am 26(2):323–334, 1997). The frequency of the disease has decreased since the advent of antiretroviral therapy contributing to immune reconstitution (Enns, Am J Gastroenterol 98(10):2111–2112, 2003). ERCP with sphincterotomy is beneficial to relieve pain in many patients; however, it does not impact survival (Enns, Am J Gastroenterol 98(10):2111–2112, 2003). Reconstituting the immune system via ART is the mainstay of therapy. Some protease inhibitors themselves can affect the biliary system; atazanavir is still used frequently today and can place patients at risk for gallstone formation as well as a benign unconjugated hyperbilirubinemia (Jacques et al., Ann Pharmacother 44(1):202–206, 2010; Verdon et al., Clin Infect Dis 35(5):57–59, 2002).