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.