Zambian HIV Guidelines:: Cholangiopathy, HIV

	Zambia HIV National Guidelines
	Introduction HIV Counseling and Testing Sexually Transmitted Infections (STIs) General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents Initial Regimen for ARV Therapy Adherence Baseline evaluation and Monitoring Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance ARV Therapy for Individuals with Tuberculosis Co-Infection Adverse Effects and Toxicity Immune Reconstitution Inflammatory Syndrome (IRIS) Changing or Stopping ART Treatment Failure Stopping ARV Therapy Post Exposure Prophylaxis Cotrimoxazole Prophylaxis WHO Staging in Adults and Adolescents Nutrition Care and Support Palliative Care in HIV and AIDS
	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Cholangiopathy, HIV

Andrea Cox, M.D., Ph.D. and Christopher Hoffmann, M.D., M.P.H.
03-28-2008

Almost no data on epidemiology of HIV cholangiopathy in Zambia or sub-Saharan Africa
Given association between HIV cholangiopathy and organisms prevalent in HIV+ patients in Zambia, (e.g. Cryptosporidium, microsporidia, Cyclospora, and CMV), this disease likely underdiagnosed in Zambia.
ERCP not readily available in Zambia. Ultrasound and lab findings in appropriate clinical scenario may lead to presumptive diagnosis.
Treatment options, besides ART, are limited in Zambia.

Zambia Information Author: Larry William Chang, MD, MPH

PATHOGENS

Syndrome of biliary obstruction resulting from infection-associated strictures of the biliary tract. Has 4 sub-classifications:
- Papillary strictures/stenosis (10%)
- Sclerosing cholangitis-like (20%)
- Papillary stenosis with sclerosing cholangitis (50-60%)
- Extra-hepatic strictures (rare)
CD4 usually <100; can be much higher
Sx: RUQ pain (90%) often sharp & radiating to back (especially if strictures present). Fever (50%), low grade if present. Diarrhea common due to small bowel involvement with infectious agent.
Signs: LFTs suggest cholestasis: mild increase in ALT/AST (2-3x ULN), total bili <2x ULN, alk phos 5-10x ULN. LFTs normal in 20%.
Large intrahepatic ducts most commonly involved; Cryptosporidium and CMV are usual pathogens in such cases.
Idiopathic in ~20% of cases.

Established with ERCP. Sensitivity of ultrasound (US) is 75-97%.
If US positive, ERCP indicated to confirm Dx and treat. If US negative, ERCP if abd. pain is severe or w/ known CMV or Cryptosporidium infection.
OIs (usually CMV, Cryptosporidium, or microsporidium) involved in >50% of cases.

Papillary stenosis

ERCP with sphincterotomy provides relief of Sx, but alk phos often remains high.

Isolated bile duct stricture

Cholangiopathy without papillary stenosis

Ursodeoxycholic acid (ursodiol 300 mg PO tid chronically) used experimentally in HIV cholangiopathy.

ART

Role of ART in managing cholangiopathy is unclear, but overall survival improved by ART.

Pathogen-specific therapy

Treatment directed against underlying pathogen does not influence Sx or cholangiographic abnormalities.
Cryptosporidiosis
Cyclospora cayetanensis
CMV
Microsporidiosis

Differential Diagnosis

Viral hepatitis (HAV, HBV, HCV, HDV)
CMV, HSV, EBV infection
Heptobiliary cryptococcosis
Mycobacterial infection of the liver (TB, MAC)
Fatty infiltration of liver
Drug reaction (TMP-SMX, INH, rifampin, ketoconazole, pentamidine, pyrimethamine, dapsone)
Lymphoma

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Abbreviations