Gastrointestinal symptoms and illnesses are extremely common in the general population and also in patients with human immunodeficiency virus (HIV) infection. When assessing them it is important to assess:-
- Detailed history of presenting symptoms including: onset, severity, site/location, frequency and progression, triggering and relieving factors and associated features such as fevers and weight loss.
- Degree of immunodeficiency: CD4+ T cell count – opportunistic infections such as cytomegalovirus (CMV) colitis occur in advanced immunodeficiency. Duration of CD4+ T cell depletion, as a long duration is likely to be associated with multiple immune defects. Additional immunosuppressive factors (e.g. corticosteroids, immunosuppressant therapy).
- Use of primary and secondary prophylactic therapy for gastrointestinal tract pathogens: azithromycin for Mycobacterium avium complex (MAC), valganciclovir for CMV (including dose and adherence).
- Risk behaviour and activities:
- i) Injecting drug use – increased risk of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and bacterial sepsis.
- ii) Sexual history, particularly for men who have sex with men (MSM) – risk of enteric pathogens and proctitis caused by sexually-transmitted pathogens.
iii) Recent travel – risk of parasitic infections, hepatitis A virus infection and enteric pathogens such as salmonella and campylobacter.
- Past medical history and family history – previous endoscopy/colonoscopy, family history of inflammatory bowel disease and colorectal cancer.
- Medications: prescribed (including antibiotics) and over-the-counter.
- Previous abdominal surgeries – cholecystectomy, appendicectomy or other surgery.
- Gynaecological history in women.
Common symptoms and signs of gastro-intestinal tract disease reported in people with HIV infection and the more common causes are presented in Table 1, along with a number of associated features and differential diagnoses that are particularly important to consider in patients with HIV infection.
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Table 1. Common gastrointestinal symptoms and signs and causes to consider in people with HIV infection |
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Symptoms |
Concerning associated features |
Common causes |
HIV-associated causes |
Investigations to consider |
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Dysphagia/ odynophagia |
Weight loss Rapidly progressive; solids initially and liquids later Iron deficiency anaemia, gastrointestinal bleeding |
Peptic stricture Eosinophilic oesophagitis Oesophageal webs and rings Achalasia and other oesophageal motility disorders Oesophageal cancer Food bolus |
Oesophageal candidiasis Viral oesophagitis –CMV, HSV Oesophageal SCC (HPV-related) |
Upper gastrointestinal endoscopy Barium swallow Mouth swab or gargle for fungal culture Swab of any oral ulcers for HSV and CMV |
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Diarrhoea |
Blood or mucus in the stool Recent travel Recent antibiotics Large volume, watery diarrhoea Weight loss Prolonged symptoms Significant abdominal pain Fevers/rigors |
Viral gastroenteritis Bacterial enterocolitis including campylobacter, salmonella and shigella Clostridium difficile colitis Parasite infections Coeliac disease Inflammatory bowel disease Irritable bowel syndrome |
CMV colitis MAC enterocolitis Crypto-sporidiosis Micro-sporidiosis HIV protease inhibitors Lymphoma Kaposi’s sarcoma HIV enteropathy |
FBC, U+E, LFT, CRP Stool culture microscopy and multiplex PCR Clostridium difficile toxin Blood cultures – for MAC Colonoscopy and colonic biopsy CT scan of the abdomen-pelvis |
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Rectal bleeding |
Weight loss Recent change in bowel habits Tenesmus Family history of colorectal cancer |
Haemorrhoids Anal fissures Proctitis Colorectal tumours STIs, including chlamydia and gonorrhoea |
Anal SCC (HPV-related) |
Digital rectal examination Rectal swab for STI screen (including LGV) Anoscopy Sigmoidoscopy Colonoscopy |
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Abdominal pain |
Weight loss Persistent diarrhoea Rectal bleeding Ascites |
Gastroenteritis Inflammatory bowel disease Irritable bowel syndrome Appendicitis Diverticulitis Cholecystitis Pancreatitis Bowel obstruction |
Opportunistic infections – CMV, MAC Neoplasms – lymphoma, Kaposi’s sarcoma |
CT scan of abdomen Upper abdominal ultrasound Endoscopy and colonoscopy |
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Jaundice |
Fevers Weight loss Substance abuse Ascites Encephalopathy |
Alcoholic hepatitis Viral hepatitis Choledocholithiasis Pancreatic cancer Haemolysis Medications Gilbert’s syndrome Cirrhosis |
Atazanavir therapy Lymphoma HIV-related cholangiopathy |
LFTs, INR, LDH Conjugated and unconjugated bilirubin Ultrasound of biliary tree CT scan of abdomen MRCP ERCP |
CMV: cytomegalovirus; CRP: C-reactive protein; CT: computerised tomographic; ERCP: endoscopic retrograde cholangiopancreatography; FBC: full blood count; HSV: herpes simplex virus; INR: international normalised ratio for prothrombin time; LFT: liver function test; LDH: lactate dehydrogenase; LGV: lymphogranuloma venereum; MAC: Mycobacterium avium complex; MRCP: magnetic retrograde cholangiopancreatography; U+E: urea and electrolytes