HIV-related cholangiopathy is biliary obstruction secondary to biliary tract strictures caused by various opportunistic infections. Treatment is antiretroviral therapy, antibiotics, and sometimes endoscopic sphincterotomy.
(See also Overview of Biliary Function.)
Before the advent of antiretroviral therapy, cholangiopathy occurred in > 25% of patients with late-stage HIV (formerly called AIDS), especially in those with a low CD4 count (< 100/mcL) (1). The most common pathogen is Cryptosporidium parvum. Others include cytomegalovirus, microsporidia, and Cyclospora species. The majority of patients have papillary stenosis, and many have intrahepatic or extrahepatic sclerosing cholangitis (1).
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.
Reference
1. Naseer M, Dailey FE, Juboori AA, et al. Epidemiology, determinants, and management of AIDS cholangiopathy: A review. World J Gastroenterol. 2018;24(7):767-774. doi:10.3748/wjg.v24.i7.767
Diagnosis of HIV-related Cholangiopathy
Usually ultrasound and magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP)
Laboratory testing
Imaging usually begins with ultrasound, which is noninvasive and very accurate (> 95%) (1). However, MRCP or ERCP is usually necessary. Either can be used for diagnostic purposes. MRCP carries less procedural risk, while ERCP enables clinicians to take a biliary and small bowel samples for identification of the causative organism, and provides a therapeutic opportunity to relieve strictures (1).
Abnormal liver test results (especially a high alkaline phosphatase level) are consistent with cholestasis.
Diagnosis reference
1. Naseer M, Dailey FE, Juboori AA, et al. Epidemiology, determinants, and management of AIDS cholangiopathy: A review. World J Gastroenterol. 2018;24(7):767-774. doi:10.3748/wjg.v24.i7.767
Treatment of HIV-related Cholangiopathy
Antiretroviral therapy
Endoscopic procedures
Antimicrobial therapy
Sometimes ursodeoxycholic acidSometimes ursodeoxycholic acid
The preferred treatment is antiretroviral therapy to restore normal immune functions, which can both treat and prevent the opportunistic infections that cause HIV-related cholangitis (1).
Endoscopic sphincterotomy, often performed during endoscopic retrograde cholangiopancreatography, can markedly relieve pain, jaundice, and cholangitis in patients with papillary stenosis. Stents can be placed endoscopically for isolated or dominant strictures. Antimicrobial therapy is given to treat the infection but alone does not reduce the biliary tract damage or relieve symptoms.
The causative organism, when identified, is treated with antimicrobial therapy.
Ursodeoxycholic acid may have a role in treating intrahepatic ductal sclerosis and cholestasis.Ursodeoxycholic acid may have a role in treating intrahepatic ductal sclerosis and cholestasis.
Treatment reference
1. Naseer M, Dailey FE, Juboori AA, et al. Epidemiology, determinants, and management of AIDS cholangiopathy: A review. World J Gastroenterol. 2018;24(7):767-774. doi:10.3748/wjg.v24.i7.767
Drugs Mentioned In This Article
