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Gastrointestinal Manifestations of HIV Infection Anthony J

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HIV Curriculum for the Health Professional Gastrointestinal Manifestations of HIV Infection Anthony J. Garcia-Prats, MD George D. Ferry, MD Nancy R. Calles, MSN, RN, PNP, ACRN, MPH Objectives HIV-infected patients. Others include vomiting, wasting, hepatitis, esophagitis, malabsorption, jaundice, and 1. Review specific subjective and objective information failure to thrive. Most of these GI problems are related important in the assessment of nausea, to infections and may be caused by HIV itself or other vomiting, and diarrhea in patients with human viruses such as cytomegalovirus (CMV) and hepatitis B immunodeficiency virus (HIV)/AIDS. and C; by bacteria such as Mycobacterium avium complex 2. Discuss the possible causes of, types of, and (MAC), Salmonella, and Shigella; by parasites such as management approaches to diarrhea in patients with Cryptosporidium and Giardia; and by fungi such as HIV/AIDS. Candida. This module will discuss the causes of the most 3. Classify the signs of dehydration in relation to their common GI manifestations in HIV-infected patients and level of severity. approaches to the assessment and treatment of these 4. Identify the appropriate rehydration plan for use conditions. with patients experiencing dehydration. 5. Describe the specific symptoms associated with Nausea and Vomiting wasting syndrome in patients with HIV/AIDS. 6. Describe the symptoms and causes of hepatitis in Nausea and vomiting are common physical complaints HIV-infected children. with many causes. Causes include infection and/or inflammation of the GI tract, gastroesophageal reflux, Key Points an overfilled stomach, protein intolerance, urinary tract infection, pregnancy, increased intracranial 1. Patients with HIV/AIDS are at high risk of having pressure, meningitis, hepatitis, biliary tract disease, gastrointestinal complications. pancreatitis, malignancies, mechanical obstruction, 2. Careful assessment using subjective and objective sepsis, food poisoning/toxins, and altered metabolism. information is important when evaluating patients Many medications can also cause nausea and vomiting, with HIV/AIDS who are experiencing nausea, including antiretroviral agents, drugs used to treat or vomiting, or diarrhea. prevent opportunistic infections, and antineoplastic 3. Patients with diarrhea and/or vomiting should be (anticancer) drugs. (Please refer to the chapter on monitored for signs and symptoms of dehydration. antiretroviral treatment for a list of specific medications 4. Oral rehydration fluids should be used to prevent that may cause nausea and vomiting, hepatitis, or and treat dehydration. pancreatitis as side effects.) Determining the exact cause 5. Wasting syndrome is a severe form of weight loss of an individual patient’s nausea and vomiting will often associated with HIV/AIDS. be difficult. 6. Hepatitis B and C are common coinfections in HIV- infected patients. Assessment The assessment of a patient with nausea and vomiting Overview should include both subjective and objective data. Most People infected with human immunodeficiency virus episodes of nausea and vomiting are self-limited and not (HIV) have a high likelihood of developing gastro- dangerous. The assessment should focus on determining intestinal (GI) complications at some point during their the hydration status of the patient and evaluating for illness. Diarrhea is the most common GI manifestation in the presence of danger signs that might indicate a 206 206 Gastrointestinal Manifestations of HIV Infection serious cause of the patient’s symptoms. Some danger section discusses the types of fluids. Patients should be signs include bilious (dark green) emesis, hematemesis instructed to drink fluids frequently, small volumes at a (vomit with blood), jaundice, severe headache, altered time; eat five to six small meals a day; avoid greasy, high- mental status, focal neurologic signs, and severe flank or fat foods; and eat food at room temperature. abdominal tenderness on exam. In addition to restoring and maintaining adequate Subjective data include the following: hydration, treatment should be directed at the underlying • Onset of vomiting, quantity of emesis, presence of cause of nausea and vomiting if appropriate. Antiemetic blood or bile medications can be sedating and may be harmful in the • Relationship of vomiting to meals, time of day, pediatric setting and are not recommended for children. activities, or medications • History of trauma or ill contacts Diarrhea • Presence of associated signs and symptoms, such Overview as diarrhea, fever, pain, dysuria, flank or abdominal Diarrhea remains one of the most common causes of pain, vision changes, headache, seizures, high- death worldwide among children younger than 5 years. pitched cry (especially in an infant), jaundice, It is also one of the most common manifestations of irritability, behavior changes, polydipsia, polyuria, advanced HIV disease in both adults and children, and polyphagia, or anorexia in Africa it is estimated that 60%-97% of children with • Changes in patterns or quantity of urination and AIDS suffer from diarrhea at some point. Diarrhea is amount of oral intake an excessive loss of fluid and electrolytes in the stool resulting in three or more loose stools in a 24-h period. Objective data include the following: The consistency of the stools is the most important • Patient’s current weight and last known weight. factor, and frequent passage of soft or well-formed stools • Volume of intake and output, as well as vital should not be considered diarrhea. signs (temperature, heart rate, blood pressure, respiration rate). Infections, toxins, medications, anatomic abnormalities • Assessment of skin turgor (skin pinch), mucous such as tumors, and dietary intolerance can cause membranes, and the presence or absence of tears. diarrhea. Infectious causes of diarrhea are the most • Nuchal rigidity; level of consciousness; and any common. These may be of bacterial, viral, fungal, or behavioral changes, such as irritability or lethargy. parasitic origin. Infections can be classified as causing • When laboratory studies can be obtained, a predominantly watery, large-volume diarrhea due complete blood count, serum pH, electrolytes, to a small-bowel infection or bloody, small-volume blood urea nitrogen, creatinine, AST (aspartate dysentery due to a predominant colonic infection. aminotransferase), ALT (alanine aminotransferase), Pathogens that infect the GI tract are similar worldwide, bilirubin, amylase, lipase, urine analysis, and urine but the likelihood of infection depends on the patient’s culture may be helpful in determining the cause of age, immune status, geographic location, and nausea/vomiting and degree of dehydration. exposure history. Agents such as rotavirus, Norwalk virus, adenoviruses, enteroviruses, Vibrio cholerae, Clinical Considerations enterotoxigenic Escherichia coli, Giardia, and Crypto­ Considerations for patients with nausea and vomiting sporidium commonly cause watery diarrhea. See this include restoring and/or maintaining adequate hydration module’s section on dysentery for common causes of and identifying the cause of nausea and vomiting. The bloody diarrhea. Campylobacter spp., Salmonella, Shigella, patient and family should be educated about the signs and MAC are particularly common bacterial causes of of dehydration and the importance of maintaining diarrhea in the setting of AIDS. Diarrhea caused by adequate fluid intake. The patient’s weight, intake, and enteric viruses is no more common among children with output should be assessed daily. Intake should include AIDS than in the general population, although CMV and all oral and intravenous fluids; output should include herpes simplex virus may cause opportunistic infection. urine, stool, and emesis. Hydration fluids should be Candida albicans can infect the GI tract of people with administered as available. This module’s rehydration 207 HIV Curriculum for the Health Professional AIDS, and parasites such as Cryptosporidium and Assessment Isospora are more likely to cause chronic diarrhea in an Assessment of a patient with diarrhea should include immunosuppressed host. both subjective and objective information. The focus of the assessment should be twofold: to determine the Food- or waterborne pathogens may cause diarrheal degree of dehydration and to determine the type of infections in immunocompromised hosts at a smaller diarrhea (acute, dysentery, persistent, or with severe inoculum than that needed to infect healthy hosts; they acute malnutrition). may also cause opportunistic infections. Opportunistic AIDS-defining diarrheal illnesses include chronic Subjective data include the following: Cryptosporidium (lasting >14 days in children or >1 month • Onset, duration, amount, frequency, odor, and in adolescents and adults), CMV disease, histoplasmosis, appearance of stool—presence of mucus or blood isosporiasis, MAC, and septicemia from Salmonella. (The • Presence of any associated symptoms, such as module on opportunistic infections gives more details fever, pain, vomiting, cramping, flatus, abdominal regarding these infections and their treatment.) distension, tenesmus • Dietary changes that might correlate with the Bacterial toxins present in food may also cause increase in the amount of stool acute diarrhea, usually in association with vomiting. • Family members with similar illness or other GI Staphylococcus aureus, Bacillus cereus, and Clostridium diseases and any unusual exposure history (travel, perfringens can cause
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