Biliary Problems in People with HIV Disease

Acute cholecystitis in a patient with HIV infection represents a difficult diagnostic problem. With improved antiretroviral therapy, many of the biliary problems we have seen in these patients are identical to those in nonimmunosuppressed patients (ie, they are largely caused by gallstones). The indication for cholecystectomy is usually right upper quadrant abdominal pain that has been persistent for weeks to months. Although cholecystectomy will result in pain relief in many patients, the presence of coexisting HIV cholangiopathy in about half these patients increases the likelihood of ongoing symptoms. Patients should be counseled that postoperative endoscopic retrograde cholangiopancreatography (ERCP) may be necessary and that some of the variants of HIV cholangiopathy do not respond to endoscopic therapy. The high perioperative mortality in these patients is not related to biliary tract disease but is rather a manifestation of severe underlying disease associated with advanced HIV infection. HIV cholangiopathy represents a complication of severe immunosuppression. Patients are generally in poor condition and often have coexisting infections or malignancies. The decision regarding how aggressively to approach a patient with suspected HIV cholangiopathy, a nonfatal condition, is best made with consideration of the degree of pain being reported. All patients should undergo an abdominal ultrasound, with ERCP being offered to those with severe or debilitating pain and who are found to have dilated bile ducts suggesting papillary stenosis. Should this finding be confirmed at cholangiography, sphincterotomy is effective palliation for abdominal pain in most cases. ERCP is considerably less useful in patients who have elevated liver enzyme levels without symptoms; there is only a small likelihood of identifying an infection not previously recognized or better diagnosed noninvasively. These patients do not generally benefit from sphincterotomy. The regular use of ERCP in patients with HIV for the evaluation of elevated liver enzyme levels is to be discouraged, because the very limited potential benefit of the procedure does not outweigh the risks.