Hepatobiliary abnormalities of AIDS.

Liver disease, although usually asymptomatic, is a frequent accompaniment of AIDS. Hepatomegaly and macrosteatosis are prevalent but non-specific findings. Evidence of remote hepatitis B virus infection is extremely common; however, the HBsAg carrier state, chronic active hepatitis, or cirrhosis occur no more frequently in AIDS patients than in the general population. Opportunistic intrahepatic infections (such as MAI, fungi, and CMV) or neoplasms (such as lymphoma or KS) usually reflect a disseminated process; liver involvement generally does not directly cause morbidity or result in death. Although biochemical liver tests are commonly elevated in the AIDS population, alkaline phosphatase has proved to be the most specific enzyme for infiltrative processes. Percutaneous liver biopsy has a high diagnostic yield, although the treatment options are currently limited. Acalculous cholecystitis and biliary tract obstruction have been recently described and probably result from CMV and/or cryptosporidial infection. Radiologic features of papillary stenosis and/or sclerosing cholangitis have been demonstrated. In contrast to hepatic parenchymal disease, these entities may be amenable to surgical or endoscopic therapeutic maneuvers.

Hepatic disease in patients with the acquired immune deficiency syndrome (AIDS).

The spectrum of liver disease in patients with acquired immune deficiency syndrome (AIDS) and the clinical impact of diagnostic percutaneous liver biopsy in this population were evaluated by a retrospective review of hepatic histology, clinical features and laboratory data in 85 patients (26 biopsies, 59 autopsies). Only 1 (3.8%) biopsy and 9 (15%) postmortem livers were histologically normal. Macrosteatosis and nonspecific portal inflammation were the most common histologic abnormalities. Intrahepatic AIDS-specific opportunistic infections or malignancies were detected in 42% of both biopsy and autopsy groups, with Mycobacterium avium-intracellulare the most frequent pathogen seen. Kaposi's sarcoma, although not detected on biopsy, was the most common postmortem AIDS-related hepatic finding. Intrahepatic lymphoma, cytomegalovirus hepatitis and hepatic mycoses were less frequently observed. In general, hepatic involvement represented part of a previously diagnosed, widely disseminated disease process, and liver biopsy led to new AIDS-specific diagnoses in only two patients. We conclude that while liver biopsy is a useful diagnostic tool in selected patients with AIDS, the information provided by biopsy rarely influences therapy or leads to improved survival.

Papillary stenosis and sclerosing cholangitis in the acquired immunodeficiency syndrome.

Eight homosexual men with the acquired immunodeficiency syndrome (AIDS) presented with clinical, biochemical, and radiologic features of stenosis of the papilla of Vater and sclerosing cholangitis. This newly recognized complication of AIDS produces abdominal pain, nausea, and vomiting and may predispose patients to superimposed bacterial cholangitis. Marked elevation of serum alkaline phosphatase levels and lesser changes in hepatic aminotransferase levels are common. Although abdominal ultrasonography and computed tomography detect ductal abnormalities, endoscopic retrograde cholangiography best shows precise ductal irregularities and provides therapeutic intervention. Prompt relief of symptoms follows endoscopic sphincterotomy, often with resolution of biochemical evidence of cholestasis. Biliary tract infection with cytomegalovirus or cryptosporidia and resultant viral or coccidial cholangitis are the proposed pathophysiologic mechanisms.

Intestinal ischemia and infarction associated with oral contraceptives.

PIP: The authors analyze 41 cases of temporary intestinal ischemia (15) or frank infarction (26) reported in the literature among oral contraceptive users. Like women with other thromboembolic diseases, duration of pill use was not a factor: these women had been taking orals for 10 days to 10 years, mean 2.2 years. Reversible ischemia resolved in days or weeks after discontinuing oral contraceptives, with supportive treatment. The best diagnostic tool was barium contrast radiogaphy. Neither arteriography or colonoscopy were helpful. Lesions were continuous, narrow, spastic, often with "thumbprinting", sometimes with proximal dilation. Intestinal infarction, usually determined at laparotomy, was fatal in 31%. Resection was necessary for gangrenous, pale or edematous small or large intestine or both. Most often the superior mesenteric artery or vein were involved. 42% needed a second laparotomty. Only 2 women developed ischemia or necrosis after oral contraceptives had been discontinued: both had documented arterial occlusion in all 3 major vascular trunks. The physiological cause of oral contraceptive-related ischemia or infarction is controversial. Several mechanisms including blood clotting factors, lipoproteins, platelet activity are reviewed. The evidence for the pill being involved in these cases is the young age and lack of preexisting risk factors, and especially resolution of the condition on stopping the pill, in the affected women.^ieng