Prevalence and etiology of gastroduodenal ulcer in HIV-positive patients: a comparative study of 497 symptomatic subjects evaluated by endoscopy.

OBJECTIVE: In 497 HIV-positive (+) patients with upper digestive tract symptoms, 23 (5%) had gastroduodenal ulcers (GDU) at upper endoscopy. METHODS: To establish the causes of GDU in this setting, 16 of these patients who had had comprehensive histological evaluation (group I) were compared with 20 HIV+ subjects with upper gastrointestinal symptoms but without ulcer (group II), and with 16 seronegative patients with GDU (group III). Eighty-one percent of group I subjects and 90% of group II patients had C3 AIDS. The presence of gastritis and Helicobacter pylori, fungi, mycobacteria, viruses (especially cytomegalovirus [CMV] and herpes simplex [HSV]), and parasites was determined in all three groups by histopathological and microbiological studies. RESULTS: The prevalence of chronic active gastritis was 13/16 (81%) in group I, 12/20 (60%) in group II, and 15/16 (94%) in group III. It was associated with H. pylori in group III, and with opportunistic pathogens in groups I and II and with none in group III. H. pylori was detected in 5/16 patients (31%) in group I, in 12/20 (60%) in group II, and 11/16 (69%) in group III. Cytomegalovirus was histologically diagnosed in 8/16 patients (50%) in group I and in 1/20 (5%) in group II. This virus was the only factor shown to be significantly associated with GDU in these cases (p = 0.0046). Cryptosporidium was found in 2/16 (12.5%) patients in group I, in 1/20 (5%) in group II, and in none in group III. Differences between groups I and II were not statistically significant. No other organisms were observed in the three groups. CONCLUSIONS: Gastroduodenal ulcers were infrequent in HIV+ subjects with upper digestive tract symptoms and CMV was the only organism significantly associated with GDU in HIV+ patients. Among HIV+ patients, H. pylori was an uncommon cause of ulcer. Among HIV+ subjects with ulcer, chronic active gastritis was more common than H. pylori and it was associated with other pathogens. Finally, HIV+ patients with GDU should have endoscopic biopsies to detect opportunistic infections, especially CMV, because H. pylori infection is uncommon.

Patologia esofagica en pacientes con virus del sida: etiologia y diagnostico / Esophageal pathology in patients with the virus of AIDS: etiology and diagnosis

Sobre 180 pacientes seguidos por infección por el virus de inmunodeficiencia humana durante un año, 17 casos (9,44%) enviados para pesquisar patología esofágica, fueron analizados prospectivamente con fibroscopia, radiología, biopsias para histopatología, virología y micología y cepillado citológico. Los síntomas más observados fueron disfagia, odinofagia y dolor retrosternal, generalmente asociados, no permitiendo orientación diagnóstica precisa. La causa más frecuente de los síntomas fue la candidiasis esofágica (64,70%), y en segundo lugar las úlceras por virus herpes simplex (HSV) tipo 2 (23,52%). También se halló patología por reflujo (11,76%). No se encontró presencia de citomegalovirus ni otras infecciones oportunistas ni tumores. De los 11 casos con cándida, 7 (64%) presentaban candidiasis oral. De los 6 pacientes con úlceras esofágicas, 4 (66%) eran herpéticas de las mismas, 2 (50%) presentaron úlceras orales y 1 (25%) vesículas herpéticas periorales. El aspecto endoscópico orientó el diagnóstico en casi todos los casos. La endoscopia de la candidiasis mostró placas blanquecinas aisladas o confluentes de diversa intensidad. Las úlceras herpéticas, únicas o múltiples, eran profundas y presentaban bordes levemente elevados. La radiología fue de escasa utilidad diagnóstica (50%) sobre todo frente a lesiones múltiples. La citología tuvo una alta sensibilidad y especificidad, ambas del 90,9% y sugirió etiología viral en el 100% de los pacientes con HSV, con una especificidad del 80%. La histopatología fue menos sensible que la endoscopia y que la citología (73% en candidiasis y sólo 1 caso sin úlcera, para HSV). Tanto la citología como la histopatología informaron presencia de coilocitosis en pacientes' con infección herpética...

Patologia esofagica en pacientes con virus del sida: etiologia y diagnostico / Esophageal pathology in patients with the virus of AIDS: etiology and diagnosis

Sobre 180 pacientes seguidos por infección por el virus de inmunodeficiencia humana durante un año, 17 casos (9,44%) enviados para pesquisar patología esofágica, fueron analizados prospectivamente con fibroscopia, radiología, biopsias para histopatología, virología y micología y cepillado citológico. Los síntomas más observados fueron disfagia, odinofagia y dolor retrosternal, generalmente asociados, no permitiendo orientación diagnóstica precisa. La causa más frecuente de los síntomas fue la candidiasis esofágica (64,70%), y en segundo lugar las úlceras por virus herpes simplex (HSV) tipo 2 (23,52%). También se halló patología por reflujo (11,76%). No se encontró presencia de citomegalovirus ni otras infecciones oportunistas ni tumores. De los 11 casos con cándida, 7 (64%) presentaban candidiasis oral. De los 6 pacientes con úlceras esofágicas, 4 (66%) eran herpéticas de las mismas, 2 (50%) presentaron úlceras orales y 1 (25%) vesículas herpéticas periorales. El aspecto endoscópico orientó el diagnóstico en casi todos los casos. La endoscopia de la candidiasis mostró placas blanquecinas aisladas o confluentes de diversa intensidad. Las úlceras herpéticas, únicas o múltiples, eran profundas y presentaban bordes levemente elevados. La radiología fue de escasa utilidad diagnóstica (50%) sobre todo frente a lesiones múltiples. La citología tuvo una alta sensibilidad y especificidad, ambas del 90,9% y sugirió etiología viral en el 100% de los pacientes con HSV, con una especificidad del 80%. La histopatología fue menos sensible que la endoscopia y que la citología (73% en candidiasis y sólo 1 caso sin úlcera, para HSV). Tanto la citología como la histopatología informaron presencia de coilocitosis en pacientes con infección herpética...(AU)

[Esophageal pathology in patients with the AIDS virus. Etiology and diagnosis]. / Patología esofágica en pacientes con virus del SIDA. Etiología y diagnóstico.

From 180 patients infected with human immunodeficiency virus (HIV) and followed-up for one year, 17 cases (9.44%) were referred to detect oesophageal pathology. They were prospectively analyzed through fibroscopy, radiology, biopsies for histopathology, virology and mycology and brush cytology. Most frequent symptoms were dysphagia. Odynophagia and retrosternal pain, usually associated, and not providing an accurate diagnostic clue. The most common causes of symptoms were oesophageal candidiasis (47.70%), and herpetic ulcers (23.52%) caused by herpes simplex virus (HSV) type 2. Reflux pathology was also found (11.76%). Cytomegalovirus, other opportunistic infections and tumors were not detected. Seven (64%) of the eleven patients with oesophageal candidiasis also had oral involvement. Four (66%) of six oesophageal ulcers were herpetic; two of them (50%) showed oral ulcers too, and one (25%) had perioral herpetic blisters. Almost in every case endoscopic features allowed diagnosis. Endoscopy in candidiasis showed isolated or confluent white plaques of variable grade. Herpetic ulcers, alone or multiple, were deep with slightly elevated borders. Radiology yielded a poor diagnostic profit (50%), specially in case of multiple lesions. Cytology was highly specific and sensitive (both 90.9%) and suggested viral etiology in 100% of HSV patients. Histopathology was less sensitive than endoscopy and cytology (73% in candida and one HSV non-ulcer case). Both, cytology and histopathology showed koilocytosis in herpetic virus infected patients. The studies performed allowed to change the HIV disease stage in ten patients (62.5%) and to diagnose AIDS in seven (43.75%). In every case medical behavior was oriented or changed by these studies.

PIP: 16 HIV seropositive patients among the 180 treated at the Hospital Muniz and the Hospital Posadas in Buenos Aires between December 1988 and December 1989 were referred to the Hospital Posadas Endoscopy Service for esophageal studies. The 16 patients were prospectively studies by means of fiberoscopy, radiology, biopsies, virology, mycology, and brush cytology. Early treatment is of utmost importance because opportunistic infections may aggravate the general condition, increase immune system effects, and probably permit greater replication of HIV, in addition to producing symptoms. 14 patients were male and 2 female. Ages ranged from 18 to 41 and averaged 32 years. 10 were male homo- or bisexuals and the other 6 were intravenous drug users. 14 of the patients consulted because of specifically esophageal symptoms. 12 reported dysphagia, 8 odynophagia, and 6 retrosternal pain. 9 patients presented various symptoms. 15 of the 16 symptomatic patients had some pathology related to HIV. The remaining case presented a small submucus tumor and gastroesophageal reflux. The symptoms had appeared between 10 days and 1 year prior to study. Symptoms did not provide accurate diagnostic clues. 11 cases of esophageal candidiasis were diagnosed endoscopically by isolated or confluent white plaques. 3 patients classified as grade 1 or 2 on the basis of the intensity and density of plaques had mild symptoms, and 8 classified as grade 3 or 4 had more severe symptoms. 7 of the 11 patients also had oral candidiasis. 4 of 6 patients presenting ulcerative pathology were diagnosed virologically with herpes simplex virus type 2. Herpetic ulcers were single or multiple and were deep with slightly raised edges. No ulcers attributable to cytomegalovirus were diagnosed. 4 of the 11 patients with candidiasis also had ulcers, in 2 cases herpetic. The studies indicated a change in the stage of HIV infection following Centers for Disease Control criteria in 10 cases. AIDS was diagnosed in 7 cases based on esophageal findings. Endoscopic study and the samples obtained guided treatment in the 16 patients. In 1 case a repeat endoscopy led to a change in treatment. It is recommended that endoscopy be performed in all patients with esophageal symptoms. Radiology was relatively ineffective, with 50% of diagnoses in error. Histopathology required multiple biopsies and was less sensitive than endoscopy and cytology. Cytology was highly specific and sensitive.

Patología esofágica en pacientes con virus del SIDA. Etiología y diagnóstico. / [Esophageal pathology in patients with the AIDS virus. Etiology and diagnosis]

From 180 patients infected with human immunodeficiency virus (HIV) and followed-up for one year, 17 cases (9.44

) were referred to detect oesophageal pathology. They were prospectively analyzed through fibroscopy, radiology, biopsies for histopathology, virology and mycology and brush cytology. Most frequent symptoms were dysphagia. Odynophagia and retrosternal pain, usually associated, and not providing an accurate diagnostic clue. The most common causes of symptoms were oesophageal candidiasis (47.70

), and herpetic ulcers (23.52

) caused by herpes simplex virus (HSV) type 2. Reflux pathology was also found (11.76

). Cytomegalovirus, other opportunistic infections and tumors were not detected. Seven (64

) of the eleven patients with oesophageal candidiasis also had oral involvement. Four (66

) of six oesophageal ulcers were herpetic; two of them (50

) showed oral ulcers too, and one (25

) had perioral herpetic blisters. Almost in every case endoscopic features allowed diagnosis. Endoscopy in candidiasis showed isolated or confluent white plaques of variable grade. Herpetic ulcers, alone or multiple, were deep with slightly elevated borders. Radiology yielded a poor diagnostic profit (50

), specially in case of multiple lesions. Cytology was highly specific and sensitive (both 90.9

) and suggested viral etiology in 100

of HSV patients. Histopathology was less sensitive than endoscopy and cytology (73

in candida and one HSV non-ulcer case). Both, cytology and histopathology showed koilocytosis in herpetic virus infected patients. The studies performed allowed to change the HIV disease stage in ten patients (62.5

) and to diagnose AIDS in seven (43.75

). In every case medical behavior was oriented or changed by these studies.

[Emergency endoscopy in upper digestive tract hemorrhage]. / Endoscopía de urgencia en hemorragia digestiva alta (H.D.A.).

The experience in upper G.I. tract hemorrhage accumulated during the first 30 months in the Emergency Hemorrhage Unit at the Hospital Posadas is here reported over a total of 428 endoscopies, we found 518 lesions. Ninety one (21%) presented with active bleeding, and 317 (76%) were considered as the probable cause of the bleeding. In 37 cases (8.6%) the site of bleeding was detected, but the diagnosis wasn't done. The most frequent lesions were erosive gastritis (21.2%), gastric ulcer (20%), erosive duodenitis (12.6%), duodenal ulcer (12.15%) and esophageal varices (12.12%) the diagnosis was normal 14.7% of the cases. One hundred and sixty one patients were admitted to the hospital; on 143 (88.82%) patients the original diagnosis was confirmed but it was modified in 18 patients (11.18%) by surgery or repeated endoscopy. During the last 20 months of the period the accuracy diagnostic of the endoscopy increased 95%. When compared with the first 10 months (76%) this fact shows, the importance of the experience acquired by the endoscopist. Most of the patients received medical treatment with a mortality of 9.02% and 25 patients received surgical treatment with a mortality of 28%.

Endoscopía de urgencia en hemorragia digestiva alta (H.D.A.). / [Emergency endoscopy in upper digestive tract hemorrhage]

The experience in upper G.I. tract hemorrhage accumulated during the first 30 months in the Emergency Hemorrhage Unit at the Hospital Posadas is here reported over a total of 428 endoscopies, we found 518 lesions. Ninety one (21

) presented with active bleeding, and 317 (76

) were considered as the probable cause of the bleeding. In 37 cases (8.6

) the site of bleeding was detected, but the diagnosis wasnt done. The most frequent lesions were erosive gastritis (21.2

), gastric ulcer (20

), erosive duodenitis (12.6

), duodenal ulcer (12.15

) and esophageal varices (12.12

) the diagnosis was normal 14.7

of the cases. One hundred and sixty one patients were admitted to the hospital; on 143 (88.82

) patients the original diagnosis was confirmed but it was modified in 18 patients (11.18

) by surgery or repeated endoscopy. During the last 20 months of the period the accuracy diagnostic of the endoscopy increased 95

. When compared with the first 10 months (76

) this fact shows, the importance of the experience acquired by the endoscopist. Most of the patients received medical treatment with a mortality of 9.02

and 25 patients received surgical treatment with a mortality of 28

.