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

Before the advent of highly active 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 ERCP and ultrasonography

ERCP provides the diagnosis, identification of the causal organism by small-bowel biopsy, and offers a therapeutic opportunity to relieve strictures. Ultrasonography is noninvasive and very accurate (> 95%). CT and magnetic resonance cholangiopancreatography likely have supportive roles.

Liver biochemistry is consistent with cholestasis, especially a high alkaline phosphatase level.

Treatment

• Endoscopic procedures

Endoscopic sphincterotomy can markedly relieve pain, jaundice, and cholangitis in patients with papillary stenosis. Isolated or dominant strictures can be stented endoscopically. Although the cause is an infectious agent, antimicrobial therapy alone does not relieve the biliary tract damage or its sequellae. 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 December 2007 by Eldon A. Shaffer, MD