Patients who have the human immunodeficiency virus (HIV) commonly experience gastrointestinal (digestive) complications, including oral lesions, esophageal lesions, diarrhea, and anorectal diseases (disease that affects the anus and/or rectum).
HIV is a retrovirus that causes AIDS (acquired immune deficiency syndrome). The retrovirus primarily attacks the body's immune system and, as a result, the patient is extremely vulnerable to opportunistic infections.
Opportunistic infections occur in individuals who have weakened immune systems. The organisms (bacteria, fungi, or viruses) that cause these infections do not cause illnesses in patients who have healthy immune systems because they are able to fight off the infection.
HIV primary infects and destroys the CD4 T-cells, which are white blood cells that help coordinate the immune system's response to infection and disease. Healthy individuals have a CD4 cell count between 600 and 1,200 per microliter of blood. HIV patients progress to AIDS when their CD4 cell counts drop to lower than 200 cells per microliter of blood. Individuals with a CD4 cell lower than 200 cells per microliter of blood have the greatest risk of developing opportunistic infections.
HIV patients often suffer from gastrointestinal symptoms because they are vulnerable to bacterial, parasitic, and fungal infections. Gastrointestinal symptoms may also be side effects of antiretroviral therapy (ART), which is used to suppress HIV.
Several body parts, including the mouth, esophagus, stomach, small intestine, large intestine, and anus, make up the gastrointestinal tract. The digestive process begins when food enters the mouth. Digestive enzymes in the saliva break down the food before it is swallowed. The esophagus is a muscular tube that carries food from the mouth to the stomach. The stomach contains harsh enzymes that break down food so it can be absorbed by the body. Food then enters the small intestine, which contains three parts:
the duodenum, jejunum, and ileum. Most of digestion occurs in the small intestine because it is responsible for absorbing nutrients from food. The remaining food then enters the colon, which also has three parts:
the cecum, colon, and rectum. The large intestine absorbs any remaining water from indigestible food matter and eliminates the unusable food matter from the body. The anus is the external opening of the rectum. It allows waste (feces) to be excreted from the body.
Acquired immune deficiency syndrome, acquired immunodeficiency syndrome, AIDS, anorectal lesions, anorectal symptoms, antiretroviral therapy, antiretrovirals, ART, aphthous ulcers, bacterial infection, candidiasis, canker sore, chlamydia, condyloma, colitis, esophageal candidiasis, esophageal lesions, esophagitis, esophagus, fungal infection, gastrointestinal complications, gastrointestinal disease, gastrointestinal disorder, gastrointestinal symptoms, gonorrhea, HAART, herpes simplex virus, highly active antiretroviral therapy, histoplasmosis, HIV, HPV, human immunodeficiency virus, human papillomavirus, immune, immune defense system, immune system, immunocompromised, immunodeficiency, infection, Kaposi's sarcoma, KS, MAC, mycobacterium avium complex, perianal lesions, OHL, oral hairy leukoplakia, oral lesions, oral thrush, salmonella, sarcoma, sexually transmitted disease, sexually transmitted infection, STD, STI, syphilis, viral infection, virus.
Aphthous ulcers (canker sore): HIV patients often suffer from aphthous ulcers, also called canker sores. These sores are usually more severe in HIV patients than in immunocompetent patients. They form single or multiple ulcers in the mouth, which are painful, especially when drinking or eating. They may develop on the tongue, roof of the mouth, inside the cheeks or lips, or on the base of the gums.
The exact cause of canker sores remains unknown, although researchers believe that stress or tissue injury may play a role. Immunocompromised individuals are more likely to have canker sores than healthy individuals.
Minor ulcers generally require no treatment. Pain usually decreases after several days, and canker sores typically heal within one to three weeks. Avoiding acidic foods like tomatoes and citrus foods (like oranges) when ulcers are present may help reduce pain. Painkillers like ibuprofen (Motrin® or Advil®) have been used before meals to relieve pain. Liquid medications like tetracycline (Helidac Therapy®, Sumycin®), with or without or hydrocortisone (corticosteroid used to reduce swelling), have been used to treat canker sores and alleviate pain and swelling.
Candidiasis (oral thrush): Oral candidiasis or oral thrush is an opportunistic infection of the mouth that is caused by the fungus Candida albicans.
The Candida albicans fungus is found almost everywhere in the environment. Most people have small amounts of Candida albicans present in their mouths and/or vagina (in women) at any given time, but healthy individuals are able to prevent the fungus from multiplying and causing an infection.
Oral candidiasis usually develops in HIV patients once their CD4 cell count drops below 350. HIV infects and destroys the CD4 cells, which are white blood cells that make up the immune system. Candidiasis causes an inflammation and thick white coating and lesions on the mucous membranes of the mouth, including the cheeks, roof of the mouth, gums, tonsils, and tongue. The lesions are often painful and may bleed slightly when rubbed or scraped. While oral thrush is the least serious of the fungal infections associated with HIV, it may indicate that a patient's HIV condition is worsening. The oral infection can progress to esophageal candidiasis, which occurs when thrush spreads to the esophagus.
Candidiasis infections are treatable. HIV patients who have candidiasis infections usually receive treatment with antifungals to clear the infection. Amphotericin B, fluconazole, ketoconazole, and nystatin are the drugs most commonly used to treat oral and esophageal candidiasis. Treatment generally tests 10 to 14 days. Some of these medications may cause liver damage. Therefore, blood tests should be performed regularly during treatment.
Human papillomavirus (HPV): The human papillomavirus (HPV) is a term used to describe more than 100 types of the virus. HPV can cause warts on the lips, mouth, or genitals. These warts, which are either flat or cauliflower shaped, are generally painless. Patients typically experience multiple warts at once.
Lesions will clear up without treatment. However, patients can choose to have them removed. A healthcare provider may use a scalpel, electrosurgery, laser ablation, or liquid nitrogen to remove the warts. Surgical removal of the warts does not prevent future outbreaks.
In June 2006, the U.S. Food and Drug Administration (FDA) approved the first HPV vaccine called Gardasil®. However, the safety and effectiveness of Gardasil® in HIV patients have not been determined. The drug, developed by Merck & Co. Inc., is a recombinant vaccine (contains no live virus) that is given as three injections over the course of six months. However, patients will not be protected if they have been infected with the HPV type(s) prior to vaccination, and the drug does not protect against less common types of HPV.
Kaposi's sarcoma: Kaposi's sarcoma (KS), a type of cancer that develops in connective tissues like bone, cartilage, fat, blood vessels, muscle, tendons, or ligaments, may also affect the gastrointestinal tract of HIV patients. KS causes tumors to form in the tissues below the skin or face or in the mucous membranes of the nose, mouth, or anus.
Researchers believe a herpes virus called human herpes virus 8 (HHV-8) causes HIV-related Kaposi's sarcoma. However, not everyone who has HIV and HHV-8 develops KS.
Common symptoms include skin lesions that may erupt at many places on the body, including on the skin (raised lumps that may be purple, brown or red), in the mouth, on the lymph nodes, and other organs (especially organs in the gastrointestinal tract, lungs, liver, and spleen). Most patients experience enlarged lymph nodes and unexplained fever or weight loss. Sometimes patients experience painful swelling, especially in the legs, groin area, or skin around the eyes.
While the skin lesions may be disfiguring, they are not usually life threatening. In some cases, the lesions may be painful or cause swelling. If KS develops in the lungs, liver, or gastrointestinal tract, however, the disease may be life threatening, causing internal bleeding or difficulty breathing. During a diagnosis, a healthcare provider will determine how far the disease has spread. The patient's response to treatment is then monitored.
Highly active antiretroviral therapy (HAART), which involves combinations of antiretrovirals, has been shown to reduce the risk of fatality in patients who have AIDS-related KS. Local therapies, including radiation therapy, intralesional vinblastine, cryotherapy (use of cold temperatures to treat disease), and vitamin A have been used to treat patients who experience lesions that are limited to one particular area. However, local therapy does not prevent the development of new lesions. Systemic therapies (therapies used to treat multiple body areas), including interferon-alpha and chemotherapy, are used when multiple organs are involved.
With new treatments for AIDS, including HAART, as well as greater awareness of HIV, the number of KS cases due to HIV infection has decreased about 85% to 90%, according to researchers. Before HAART was available, an estimated 90% of patients who had AIDS-related KS died from the disease. Today, researchers estimate that in areas where antiretroviral therapy is available, 47% of patients who have AIDS-related KS die.
Oral hairy leukoplakia (OHL): Oral hairy leukoplakia (OHL) occurs when fuzzy, white patches form on the gums, inside of the cheeks, and sometimes, the tongue. The Epstein-Barr virus, also known as infectious mononucleosis, causes the condition. Although OHL is not an AIDS-defining illness (the development of OHL does not mean that the patient has progressed to AIDS), it may indicate that HIV is worsening.
Treatment may include antiviral medications like acyclovir (Zovirax®) or valacyclovir (Valtrex® Caplets). In addition, research has shown that OHL responds well to highly active antiretroviral therapy (HAART), which suppresses HIV and helps restore the immune system.
Esophageal candidiasis: Esophageal candidiasis is the most common infection that affects the esophagus of HIV patients. This is the result of an overabundance of the fungus whose scientific name is Candida albicans. Patients typically have oral thrush first, which spreads to the esophagus. Esophageal candidiasis typically occurs when the HIV patient's CD4 cell counts are 200 or less. According to the U.S. Centers for Disease Control and Prevention (CDC), esophageal candidiasis is considered an AIDS-defining illness. This means that when HIV-infected patients develop esophageal candidiasis, they have progressed from HIV to AIDS.
Common symptoms of esophageal candidiasis include pain or difficulty swallowing and a sensation of food sticking to the throat. The pain may be so severe that it is difficult to eat. A fever may indicate that the infection has spread beyond the esophagus to areas such as the heart, brain, eyes, or joints.
Candidiasis infections are treatable. HIV patients who have candidiasis infections usually receive treatment with antifungals to clear the infection. Amphotericin B, fluconazole, ketoconazole, and nystatin are the drugs most commonly used to treat oral and esophageal candidiasis. Treatment generally tests 10 to 14 days. Some of these medications may cause liver damage. Therefore, blood tests should be performed regularly during.
Esophageal herpes simplex virus: HIV patients are also vulnerable to developing the herpes simplex virus (HSV) because they have weakened immune systems. When HSV infects the esophagus, it causes fluid-filled blisters to form. Common symptoms include painful swallowing, difficulty swallowing, pain behind the breastbone, nausea, and vomiting.
Untreated patients can develop tracheoesophageal fistulas, which are abnormal openings between the esophagus and trachea. The infection may also kill cells in the esophagus, cause the esophagus to narrow and may lead to internal bleeding.
HIV patients with esophageal HSV typically receive intravenous antiviral treatment with acyclovir (Zovirax®).
General: Bacterial, viral, or parasitic infections and certain medications can cause diarrhea in HIV patients. Individuals with advanced HIV are vulnerable to many opportunistic infections that may cause diarrhea. Opportunistic infections occur in individuals who have weakened immune systems.
Serious complications are associated with diarrhea, making it the most common cause of death among HIV patients worldwide. Complications of diarrhea may include weight loss, dehydration, malnutrition, and poor absorption of medication (including antiretrovirals).
Antiretroviral side effects: Diarrhea is a common side effect of antiretrovirals (drugs used to suppress HIV). The most common antiretrovirals that cause diarrhea are nelfinavir (Viracept®), ritonavir (Norvir®), didanosine (Videx®), and tipranavir (Aptivus®).
Bacterial causes: The most common causes of diarrhea in HIV patients living in the United States are bacteria called salmonella, Clostridium difficile, mycobacterium avium complex (MAC), and shigella.
Domestic and wild animals, including poultry, cattle, and pets, can transmit salmonella infections to human. However, it usually occurs after an individual drinks unpasteurized milk or eats undercooked poultry or poultry products (like eggs). Kitchen counters and cooking utensils should be washed thoroughly with soap and water after they come into contact with raw meat. Common symptoms include headache, fever, abdominal pain, diarrhea, nausea, and vomiting. Salmonella can be treated with medications such as TMP/SMX (Bactrim®, Septa®) or azithromycin (Zithromax®).
Clostridium difficile infection causes diarrhea and it has also been associated with colitis, a condition where inflammation of the large intestine occurs. Common symptoms include high fever (temperature of 102-104 degrees Fahrenheit), severe diarrhea with blood (more than 10 watery stools a day), severe abdominal pain, and tenderness. The bacteria are often found in healthcare facilities and nursing homes. Patients who have received antibiotics like clindamycin (Cleocin®, Cleocin® Vaginal Ovules, Clinda-Derm®, Clindagel®, Clindets® Pledgets), ampicillin (Principen®), amoxicillin (Amoxil®, Prevpac®, Trimox®), and cephalosporins (Keflex®) are also vulnerable to infection. HIV patients who develop Clostridium difficile infections typically receive treatment with metronidazole (Flagyl®) for about 10-14 days.
Mycobacterium avium complex (MAC), or mycobacterium avium intracellulare (MAI), is a bacterial infection that is caused by one of two bacteria whose scientific names are Mycobacterium avium and Mycobacterium intracellulare. These bacteria are very common. However, a healthy immune system will prevent the bacteria from causing an infection. Since HIV/AIDS patients have weakened immune systems, they have an increased risk of developing MAC infections. MAC infections typically occur in patients with advanced AIDS (CD4cell count of less than 50 cells per microliter of blood). Common symptoms of MAC include weight loss, fever, chills, night sweats, swollen glands, abdominal pain, diarrhea, inflamed muscles, and overall weakness. MAC usually affects the intestines and inner organs first. In general, MAC infection is treated with two or three antimicrobials for life in order to prevent the infection from recurring. Commonly prescribed antimicrobials include clarithromycin (Biaxin®), ethambutol (Myambutol®), and azithromycin (Zithromax®).
Shigella is also a common bacterial infection that affects HIV patients. The bacteria are generally transmitted through feces. Humans can contract the virus by eating contaminated food or drinking contaminated water. This infection is especially common in areas of poor sanitation. Common symptoms include bloody diarrhea, fever, nausea, vomiting, and cramps. People with mild infections usually recover within a few days without special treatment. Severe infections may require antibiotics.
Fungal infections: The Histoplasma capsulatum fungus causes histoplasmosis. The fungus is commonly found in damp soil that is rich in organic material. Individuals may be exposed to the fungus while gardening or by eating produce that is grown in soil. All produce should be washed thoroughly before eating to prevent exposure to disease-causing organisms. Symptoms of histoplasmosis typically develop about 17 days after exposure. When the infection involves the gastrointestinal tract, symptoms typically include diarrhea, fever, pain, and weight loss. Histoplasmosis is usually treated with antifungals like amphotericin B (Abelcet®) or itraconazole (Sporanox®). Treatment is generally lifelong in order to prevent the infection from recurring.
Parasitic infections: A parasite called Cryptosporidium parvum can cause diarrhea, especially in HIV patients. Animals that are infected with the parasite excrete parasitic eggs in their feces. Humans typically develop the infection after drinking water or eating produce items that are contaminated with these eggs. Cryptosporidium parvum can survive extreme temperatures and can withstand exposure to chlorine. HIV patients who become infected with the parasite may be sick for several months and often suffer from severe diarrhea that can lead to dehydration and electrolyte disturbances. Patients generally receive a drug called paromomycin (Humatin®), which kills the parasite. Treatment generally lasts from five to 10 days.
Many parasites of the Microsporidia species have been shown to cause infections in HIV patients. Microsportia organisms, including Encephalitozoon intestinalis and Enterocytozoon bieneusi, may cause severe diarrhea and weight loss in HIV patients. These organisms typically cause long-term, debilitating infections if not treated. Patients typically receive treatment with a drug called albendazole (Albenza®), which kills the parasites.
Another parasite called Entamoeba histolytica can lead to diarrhea in HIV patients. The eggs of this parasite are found in animal feces. Humans are usually exposed to the parasite after coming into contact with contaminated food or water or after handling contaminated soil (e.g. gardening). Only about 10% of people who are infected with the parasite experience symptoms, researchers estimate. However, some patients may experience abdominal pain, diarrhea, bloody stools, and painful bowel movements. A diagnosis can be made after detecting the organism in the patient's stools or after a blood test. Patients who experience symptoms typically receive treatment with a drug called metronidazole (Flagyl®) for about ten days. Healthcare providers disagree whether or not treatment is beneficial in patients who excrete the eggs in their feces but experience no symptoms of infection. These patients may receive a drug called iodoquinol (Yodoxin®) for about three weeks to kill the parasite.
Giardia lamblia is among the most common parasites throughout the world. The parasite causes an infection called giardia, which results in severe diarrhea. Animals that are infected with the parasite excrete the parasite's eggs in their feces. Humans become infected if they ingest food or water that is contaminated with these eggs. Most humans will not become infected after ingesting the eggs. Patients who do develop an infection may or may not experience symptoms. Symptoms typically include severe diarrhea, gas, and weight loss, which may lead to dehydration and electrolyte disturbances. A diagnosis is made after the eggs are detected in a patient's stool. Once diagnosed, patients typically receive treatment with a drug called metronidazole (Flagyl®) for about five days.
Viral infections: Diarrhea caused by viral infections is generally short-term and usually does not require treatment.
The cytomegalovirus (CMV) can lead to colitis (inflammation of the large intestine) in patients with advanced AIDS (CD4 count lower than 50 cells per microliter of blood). CMV can be transmitted through airborne droplets. People become infected with the virus when they inhale particles of infected sputum from the air. It may also be sexually transmitted through bodily fluids such as blood, semen, vaginal discharge, and breast milk. Most individuals with healthy immune systems will not develop symptoms of infection. However, since HIV patients have weakened immune systems, they are vulnerable to CMV infections. Common symptoms of CMV that affect the gastrointestinal tract include diarrhea, abdominal pain, gastrointestinal bleeding, nausea and vomiting, fever, difficulty or painful swallowing, and weight loss.
In general, HIV patients who have CMV receive drugs like ganciclovir (Cytovene®) or foscarnet (Foscavir®). Highly active antiretroviral therapy (HAART) is also required to prevent the infection from recurring. Patients who receive HAART take a combination of antiretroviral drugs (anti-HIV drugs) from different classes to suppress the virus and help boost the body's immune system.
General: Anorectal (related to the anus and/or rectum) diseases are typically caused by viral infections (like herpes) and sexually transmitted diseases (like gonorrhea, syphilis, and chlamydia).
Condyloma: Condylomas are wart-like growths around the anus, vulva, or tip of the penis. HIV patients who have the human papillomavirus (HPV) typically develop these warts in the perianal region. The warts may be flat or cauliflower shaped. Multiple warts usually develop at the same time. Small warts may spontaneously resolve. Lesions can be removed at a doctor's office with a scalpel, by electrosurgery, laser ablation, or liquid nitrogen. However, surgical removal of the warts does not cure the virus or prevent future outbreaks.
Because certain types of HPV have been associated with anal cancer, a tissue biopsy should be performed in patients who experience extensive lesions and who do not respond to therapy. During the procedure, a small sample of tissue is removed and analyzed for cancerous cells.
In June 2006, the U.S. Food and Drug Administration (FDA) approved the first HPV vaccine called Gardasil®. However, the safety and effectiveness of Gardasil® in HIV-positive people have not been determined. The drug, developed by Merck & Co. Inc., is a recombinant vaccine (contains no live virus) that is given as three injections over the course of six months. However, patients will not be protected if they have been infected with the HPV type(s) prior to vaccination and the drug does not protect against less common types of HPV.
Gonorrhea, syphilis, and chlamydia: Gonorrhea, syphilis, and chlamydia are sexually transmitted diseases that often cause anorectal symptoms in HIV patients. Patients who are infected with gonorrhea or chlamydia may experience symptoms such as anal discharge, pain, straining to have a bowel movement, and bleeding. Patients typically receive one dose of ceftriaxone (Rocephin®), followed by either azithromycin (Zithromax®) or doxycycline (Doryx®, Doxy 100®, Monodox®, Vibramycin®, Calcium Syrup, Vibramycin®, Hyclate, Vibramycin® Monohydrate, Vibra-Tabs®).
Syphilis can also cause sores around the anus or rectum, which may or may not be painful. Sores may also develop in other areas of the body, including the vulva, clitoris, opening of the urethra, cervix, penis, and mouth. Patients receive an antibiotic called penicillin to kill the bacteria that causes syphilis.
Herpes simplex virus: Another sexually transmitted disease called the herpes simplex virus (HSV) often causes anorectal disease in HIV patients. There are two types of HSV: type 1 (HSV1) and type 2 (HSV2). Both types cause similar symptoms, which may include blisters and sores near the mouth, nose, genitals, and anus. These small blisters may burst to form ulcers, which then crust over. When HSV affects the anus, it may cause ulcers or fissures (tears) in the perianal region. Ulcers typically last about 12 days.
Patients are generally given oral antivirals like acyclovir (Zovirax®) or valacyclovir (Valtrex® Caplets) for 10 to 14 days. However, since the virus may remain but become dormant in the body, relapses are common. Acyclovir has been used daily to prevent recurrent outbreaks.