AIDS Cholangiopathy

By Ali A. Siddiqui, MD, Thomas Jefferson University Hospital

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Gallbladder and Bile Duct Disorders
Overview of Biliary Function
Acalculous Biliary Pain
AIDS Cholangiopathy
Acute Cholecystitis
Chronic Cholecystitis
Choledocholithiasis and Cholangitis
Cholelithiasis
Postcholecystectomy Syndrome
Primary Sclerosing Cholangitis (PSC)
Sclerosing Cholangitis
Tumors of the Gallbladder and Bile Ducts

AIDS cholangiopathy is biliary obstruction secondary to biliary tract strictures caused by various opportunistic infections.

Before the advent of antiretroviral therapy, cholangiopathy occurred in 25% of patients with AIDS, especially in those with a low CD4 count (< 100/μL). The most common pathogen is Cryptosporidium parvum. Others include cytomegalovirus, microsporidia, and Cyclospora sp. Papillary stenosis or intrahepatic or extrahepatic sclerosing cholangitis develops in most patients. Over half have both.

Common symptoms include right upper quadrant and epigastric pain and diarrhea. A few patients have fever and jaundice. Severe pain usually indicates papillary stenosis. Milder pain suggests sclerosing cholangitis. The diarrhea reflects small-bowel infection, often cryptosporidiosis.

Diagnosis

Usually ultrasonography and ERCP

Imaging usually begins with ultrasonography, which is noninvasive and very accurate (> 95%). However, ERCP is usually necessary. ERCP provides the diagnosis, enables clinicians to take a sample for small-bowel biopsy for identification of the causative organism, and provides a therapeutic opportunity to relieve strictures. CT and magnetic resonance cholangiopancreatography likely have supportive roles.

Abnormal liver function test results (especially a high alkaline phosphatase level) are consistent with cholestasis.

Treatment

Endoscopic procedures

Endoscopic sphincterotomy, often done during ERCP, can markedly relieve pain, jaundice, and cholangitis in patients with papillary stenosis. Isolated or dominant strictures can be stented endoscopically. Antimicrobial therapy is given to treat the infection but alone does not reduce the biliary tract damage or relieve symptoms.

Because of its use in primary sclerosing cholangitis, ursodeoxycholic acid may have a role in treating intrahepatic ductal sclerosis and cholestasis.

Last full review/revision August 2016 by Ali A. Siddiqui, MD