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 Table of Contents  
CASE SERIES
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 58-59

Endoscopic retrograde cholangiopancreatography findings in HIV cholangiopathy patients: Tripoli Central Hospital experience


Department of Medical, Tripoli Central Hospital, Tripoli, Libya

Date of Submission11-Sep-2022
Date of Acceptance29-Nov-2022
Date of Web Publication02-Jan-2023

Correspondence Address:
Dr. Marwan Taher Alsari
Tripoli Central Hospital, Tripoli
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ljms.ljms_35_22

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  Abstract 


HIV infection and its related opportunistic infections increasing the risk of having HIV-related cholangiopathy, especially those who had low CD4 counts. In this case series, we assessed the findings of endoscopic retrograde cholangiopancreatography and the interventions required in those patients who underwent this procedure at Tripoli Central Hospital between January 2007 and December 2020, comparing them with previous studies conducted in other centers. Our study concluded that common bile duct strictures are more frequent finding than papillary stenosis, and accordingly most of those patients managed by placing common bile duct stent rather than sphincterotomy only.

Keywords: Acquired immunodeficiency syndrome, cholangiopathy, cholestasis, endoscopic retrograde cholangiopancreatography, HIV, opportunistic


How to cite this article:
Alsari MT, Elfaghih S, Tumi A. Endoscopic retrograde cholangiopancreatography findings in HIV cholangiopathy patients: Tripoli Central Hospital experience. Libyan J Med Sci 2022;6:58-9

How to cite this URL:
Alsari MT, Elfaghih S, Tumi A. Endoscopic retrograde cholangiopancreatography findings in HIV cholangiopathy patients: Tripoli Central Hospital experience. Libyan J Med Sci [serial online] 2022 [cited 2023 Feb 7];6:58-9. Available from: https://www.ljmsonline.com/text.asp?2022/6/2/58/366078




  Introduction Top


HIV cholangiopathy is often diagnosed while searching for the cause of cholestasis in HIV patients. Patients with the right upper quadrant pain with raised alkaline phosphatase and minimal elevation in bilirubin or high liver enzymes are usually evaluated for obstructive causes.[1] In patients who have a low CD4 count of (<100/mm3), 94% of intrahepatic duct involvement is mainly related to HIV coinfection, such as cryptosporidium (57%) and cytomegalovirus (28%).[2],[3] The way these patients have the infection does not seem to play a role in the development of cholangiopathy, as it is shown in one study that heterosexual-acquired HIV infection has a higher risk of developing cholangiopathy.[2] Another study showed that 80% of homosexual men developed cholangiopathy.[3] Furthermore, if it occurs in a patient who is already taking highly active antiretroviral therapy (HAART) may indicate resistance.[4]

The pathogenesis is not well known, but the disease behaves like primary sclerosing cholangitis.[2] The presence of cholestasis in biochemistry, alterations in the bile ducts shown on ultrasound, and magnetic resonance cholangiopancreatography (MRCP) are all required to diagnose HIV cholangiopathy. These changes are the main indications of endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic and therapeutic procedure. It was reported that papillary stenosis was present in 64% of HIV patients with cholangiopathy;[3] hence, endoscopic papillotomy was conducted to relieve the symptoms, especially abdominal pain.[5],[6]

The prognosis for HIV cholangiopathy is bleak; 1 year following diagnosis, only 14% of patients survived.[3] Ursodeoxycholic acid therapy had no positive effects on cholestasis or sclerosing cholangitis in such patients. At the same time, cholecystectomy is a favorable alternative, especially for acalculous cholecystitis.[1],[2],[3],[4],[5],[6],[7] Biliary stenting or balloon dilatation may be effective,[7] and celiac plexus block has proved helpful in reducing the discomfort of patients with advanced HIV stages and persistent abdominal pain.[7] On the other hand, HAART may be used to reduce cholangitis and enhance the radiological image.[7] Furthermore, they increase the median survival time up to 34 months.[4]

In this case series, we reported the findings of ERCP and the interventions required in HIV patients who underwent this procedure at Tripoli Central Hospital, Libya, and comparing them with previous studies conducted in other centers.

Report of the endoscopic retrograde cholangiopancreatography findings of the cases

ERCP was performed in seven patients who have had HIV infection and referred from HIV clinic due to suspected cholangiopathy. All these patients were investigated for liver biochemistry and radiological findings "ultrasound or MRCP" prior the ERCP. The constellation of clinical, biochemical, and radiological findings justifies ERCP in this hospital.

The mean age of the patients was 55 years. Only one patient was coinfected with the hepatitis C virus, and four patients discovered that they had esophageal candidiasis during ERCP. Two patients had abnormal papilla (28.5%), one had papillary narrowing, and another patient had his papilla hidden inside a duodenal diverticulum, which may have been explained by his age (80 years). This low percentage may explain by the patient's age (80 years). Three patients had filling defects on their ERCP cholangiograms, and three patients had common bile duct (CBD) stricture or cutoff. [Figure 1] shows cholangiopathy papillary stenosis found in ERCP of one of the HIV patients of this case series.
Figure 1: ERCP in a patient with HIV cholangiopathy (papillary stenosis is present). ERCP: Endoscopic retrograde cholangiopancreatography

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Cholestasis has been detected biochemically in four individuals. Only one had a cholecystectomy, whereas three patients had gallbladder stones. Four patients (57%) developed esophageal moniliasis, indicating a disturbance in their immune system and an elevated risk of cholangiopathy. Two of them have had CBD strictures, one for distal cystic duct stone compressing CBD "Mirizzi syndrome," and the last two patients for pancreatic head tumor. Five patients (71.4%) needed CBD plastic stenting to maintain their CBDs patency. One patient has had a CBD stone retrieved by an extraction balloon after sphincterotomy. The last patient has double pathology (stone and CBD stricture).


  Discussion Top


In this report, we described the ERCP findings observed in seven HIV patients with cholangiopathy in our center. It is worth to mention that there were no enough data available about their immunity state and CD4 counts because the patients were referred from HIV clinics without full details about their immunity state. Furthermore, most patients had no follow-up, for their cholangiopathy probably due to the social stigma related to their primary disease (HIV), and they preferred to follow their doctors in HIV clinics. All these factors contribute to the lack of enough data. Furthermore, differentiation between CBD stricture causes, whether malignant or benign, was not achieved due to the unavailability of the designed ERCP tools needed for the differentiation. The literature published on this topic was very little and old-dated, and most case series contained a minimal number of patients.


  Conclusion Top


As opposed to stones or papillary stenosis, which may be caused by HIV infection, opportunistic infections, or nonadherence to antiretroviral therapy, most of our patients' ERCP findings were obstructions unrelated to papillary stenosis as is typically seen in HIV cholangiopathy. As a result, the primary method of treating their symptoms and cholestasis was the implantation of CBD stents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathology, Diagnosis, Management. Saunders: Elsevier Inc; 2016.  Back to cited text no. 1
    
2.
Mahajani RV, Uzer MF. Cholangiopathy in HIV-infected patients. Clin Liver Dis 1999;3:669-84, x.  Back to cited text no. 2
    
3.
Bouche H, Housset C, Dumont JL, Carnot F, Menu Y, Aveline B, et al. AIDS-related cholangitis: Diagnostic features and course in 15 patients. J Hepatol 1993;17:34-9.  Back to cited text no. 3
    
4.
Devarbhavi H, Sebastian T, Seetharamu SM, Karanth D. HIV/AIDS cholangiopathy: Clinical spectrum, cholangiographic features and outcome in 30 patients. J Gastroenterol Hepatol 2010;25:1656-60.  Back to cited text no. 4
    
5.
Dolmatch BL, Laing FC, Ferderle MP, Jeffrey RB, Cello J. AIDS-related cholangitis: Radiographic findings in nine patients. Radiology 1987;163:313-6.  Back to cited text no. 5
    
6.
Walden DT. Biliary problems in people with HIV disease. Curr Treat Options Gastroenterol 1999;2:147-53.  Back to cited text no. 6
    
7.
Yusuf TE, Baron TH. AIDS cholangiopathy. Curr Treat Options Gastroenterol 2004;7:111-7.  Back to cited text no. 7
    


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