Evaluation of the HIV-infected patient with hepatobiliary complaints
- C Mel Wilcox, MD
C Mel Wilcox, MD
- Professor of Medicine
- University of Alabama at Birmingham
The era of potent antiretroviral therapy (ART) has been associated with a marked decrease in morbidity and mortality in HIV-infected patients.
However, those who present with advanced immunosuppression are at risk for a wide variety of opportunistic infections (OIs), such as Cryptosporidium, Isospora, Microsporidium, Mycobacterium avium complex (MAC), and cytomegalovirus (CMV) and hepatobiliary complications, such as acalculous cholecystitis and AIDS-related cholangiopathy . Those patients who undergo therapy are also at risk for treatment-related adverse events, such as lactic acidosis, hepatic steatosis, and drug-induced hepatotoxicity. Finally, a significant proportion of patients are infected with hepatitis B and/or C virus, due to shared routes of transmission.
This topic will discuss a guided approach to the evaluation of the HIV-infected patient with hepatobiliary complaints. More detailed information regarding viral hepatitis B and hepatitis C infections and AIDS cholangiopathy are found elsewhere. (See "Evaluation of the HIV-infected patient with chronic hepatitis C virus infection" and "Epidemiology, clinical manifestations, and diagnosis of hepatitis B in the HIV-infected patient" and "AIDS cholangiopathy".)
Chronic viral hepatitis — The most common cause of hepatomegaly in HIV-infected patients is chronic viral hepatitis with either hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infections . End-stage liver disease is a major cause for inpatient admissions and mortality in the era of antiretroviral therapy (ART) [3,4]. In patients with chronic HBV or HCV infection, concomitant HIV infection is associated with higher rates of morbidity and mortality related to liver disease. (See "Epidemiology, clinical manifestations, and diagnosis of hepatitis B in the HIV-infected patient" and "Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-infected patient".)
Depending on the risk group studied, it is estimated that approximately 30 to 80 percent of patients with HIV have concomitant hepatitis C and approximately 5 to 10 percent have chronic hepatitis B. There are few data on the seroprevalence of multiple hepatitides, such as hepatitis B and C combined; one study of 423 HIV-infected patients in Spain found that approximately 5 percent of patients had HBV, HCV, and delta virus infections  The most common risk factor for acquisition of HCV is injection drug use, while HBV can be acquired both sexually and parenterally. However, there are emerging data on acute HCV infection among men who have sex with men (MSM) who report sex with trauma or in association with other genital ulcer disease [6,7].
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- HEPATOBILIARY COMPLICATIONS
- Chronic viral hepatitis
- Infiltrative liver disease
- Opportunistic infections
- Hepatic steatosis
- Drug-induced liver injury
- AIDS cholangiopathy
- Atazanavir-associated cholelithiasis
- HISTORY AND PHYSICAL EXAMINATION
- DIAGNOSTIC STUDIES
- Liver function tests
- Blood cultures
- Skin testing
- - Ultrasound
- - CT scanning
- - Hepatobiliary scintigraphy
- Endoscopic retrograde cholangiopancreatography
- Laparoscopy with biopsy
- Liver biopsy
- SUMMARY AND RECOMMENDATIONS