Evaluation of Findings of Upper Gastrointestinal Endoscopy in HIV Positive Patients with Special Reference of Helicobacter Pylori

INTRODUCTION: HIV – AIDS has been the recent infectious disease of great interest, due to its extreme immunosuppressive effect in humans. Of late many studies have been conducted on HIV and its manifestations of various organ system disorders. The most dreaded complications of HIV infection are due to the opportunistic infections following severe immunosuppression, rather than the virus itself, such as pneumocystis carinii pneumonia, tuberculous and cryptococcal meningitis. Gastro intestinal infections are also increased in patients with HIV. Various organisms not usually found in immunocompetent persons colonise the GIT in HIV patients, such as CMV, Isospora, Cryptospora, Herpes etc. But H.pylori has been shown to take a different scenario in HIV infected patients in many studies. While H.pylori has been found to be the most common organism in peptic ulcer disease and even in non ulcer dyspepsia in the general population, its incidence in HIV positive patients in some studies has been low. Hypochlorhydria has been postulated to be one of the causes for this decreased incidence. But still there are some studies that have shown no difference from the general population. Such studies in Indian population are also very few. Many methods of diagnosis are available both non invasive and invasive to detect H.pylori infection, such as serological methods, stool antigen tests, rapid urease tests and biopsy based tests. Among these the ultra rapid urease tests gives the immediate diagnosis and is relatively cheaper and easier to perform. Establishing the extent of prevalence of H.pylori infection in HIV positive patients is important, due to the complications associated with chronic H.pylori infection such as adenocarcinoma of stomach, gastric lymphomas, peptic ulcer associated complications such as perforation and bleeding. AIM AND OBJECTIVES: 1. To evaluate the findings of upper gastrointestinal tract in HIV positive patients. 2. To study the prevalence of Helicobacter pylori in HIV positive patients. 3. To compare the prevalence of Helicobacter pylori among HIV positive patients according to their immunity status assessed by CD4 count. MATERIALS AND METHODS: Place of Study: Department of medicine Madurai medical college Type of Study: Cross sectional study. Case Selection: The inclusion criteria were: 1) Patients aged 18 yrs and above, 2) Patients with complaints of dyspeptic symptoms, 3) Patients confirmed HIV positive, 4) HIV negative patients for controls. Criteria for exclusion were: 1) Intake of antibiotics metronidazole or PPI within a period of 2 weeks, 2) Patients on NSAIDS, 3) Patients with severe systemic illness, 4) Acute GI bleed, 5) Pregnancy. The patients were divided into two groups, the study cases included the HIV positive patients (101) and the controls included the HIV negative patients (106). The HIV positive patients were again divided into four groups based on their CD4 + T Cell counts, as group CD1, including patients with CD4 counts less than 100 cells /μl, group CD2 with counts 100-200 cells /μl, group CD3 with counts 200-500 cells /μl and group CD4 with CD4 counts >500 cells /μl. METHODS: A detailed history and clinical examination was taken for every patient. Baseline investigations were done to rule out major systemic illness. HIV status was confirmed with ELISA and CD4 estimation was done with flow cytometry. Endoscopy was done in patients after obtaining informed consent and an over night fast. OGD was done using flexible fibreoptic endoscope. Three mucosal samples were obtained from stomach. Two from antrum and one from body of stomach. One of the samples from antrum was used for RUT test. The other two samples were sent for HPE, using haematoxylin and eosin stains. Separate biopsy forceps were used in HIV patients. The scope and biopsy forceps were sterilised with gluteraldehyde and washed with distilled water after every procedure. SUMMARY: The study “EVALUATION OF FINDINGS OF UPPER GASTROINTESTINAL ENDOSCOPY IN HIV POSITIVE PATIENTS WITH SPECIAL REFERENCE TO HELICOBACTER PYLORI”, was a cross sectional study of 101 HIV patients and 106 HIV negative control patients admitted with complaints of dyspepsia, at Government Rajaji Hospital, Madurai. After detailed history, physical examination and basic investigations, all patients underwent endoscopy and gastric mucosal samples were analysed for rapid urease tests and histology. There was decreased prevalence of Helicobacter pylori in HIV positive patients and the prevalence was directly related to CD4+ T cell counts in HIV patients. No significant influence with ART was seen. Esophageal moniliasis was found to be the most common upper GI disease in HIV patients. Possible cause for this decreased prevalence of H.pylori in HIV patients could be the hypochlorhydria in HIV patients which prevents colonisation of H.pylori. CONCLUSION: 1. In the endoscopic findings the most common opportunistic infection in HIV positive patients was esophageal candidiasis. 2. There is decreased positivity of H.pylori in HIV patients when compared to controls. This is consistent with literature reported world wide. 3. Amongst the HIV patients, those whose CD4+ T cell counts were 500 cells / μl. 4. Prevalence of H.pylori did not seem to be altered with ART. 5. The histology of the gastric mucosa was no different in H.pylori positive or negative subjects with HIV.