Esophageal disease in patients with AIDS: diagnosis and treatment.

Patients with HIV infection often present with symptoms suggesting esophageal disease: these include odynophagia (pain with swallowing), dysphagia (difficulty in swallowing), and retrosternal chest pain. Esophageal symptoms rank second only to diarrhea in frequency of gastrointestinal complaints among patients with AIDS. Also, esophageal opportunistic infections have been associated with a poor outcome, the mean survival after diagnosis being less than 6 months in one study. Such short survival may be explained by the underlying immunosuppression, as well as a decrease in nutritional intake due to difficulty swallowing.

Helicobacter pylori and complicated ulcer disease.

Approximately 20-25% of patients with peptic ulcer disease develop complications--bleeding, perforation, or obstruction. Although the majority of patients with complicated ulcers are infected with Helicobacter pylori, the prevalence of infection appears to be lower in these patients compared with patients with uncomplicated ulcers. Among patients who present with a bleeding ulcer, approximately one-third will develop recurrent bleeding in the following 1-2 years if left untreated after ulcer healing. A number of studies have shown that the recurrence of rebleeding is virtually abolished if patients receive H. pylori eradication therapy. In contrast, the rate of rebleeding in patients receiving maintenance antisecretory therapy is around 10%. Thus, H. pylori infection status must be determined in patients presenting with complicated ulcer disease and, if positive, eradication therapy initiated. Eradication should be documented at least 4 weeks after the end of therapy (by endoscopic biopsy or urea breath test) and maintenance antisecretory therapy discontinued if the infection is cured.

Status evaluation: endoscopic ultrasonography. American Society for Gastroenterology Endoscopy. Technology Assessment Committee.

Endoscopic ultrasound is a new technology that improves the local staging of esophageal, gastric, and rectal carcinomas. In addition, EUS may provide useful information which will affect management in individual patients with subepithelial masses (e.g., varices, leiomyomas) and pancreatic diseases. Other imaging studies such as transcutaneous ultrasonography and CT are still necessary to detect distant metastatic disease. At present, EUS may be best reserved for use by individuals who have sufficient patient materials to provide broad experience with the technique. Physicians at centers where large numbers of patients with gastrointestinal cancer are evaluated may find this technology most useful. Even in patients with malignancy, however, studies are needed to show that the improved local staging by EUS will translate into changes in patient management and improved outcome.

Status evaluation: biliary stents. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee.

Large caliber plastic stents (10 to 11.5 French) have become widely accepted as an alternative to surgery in the treatment of many malignant and benign lesions of the biliary tract. Procedure-related early complications occur at an acceptable rate (8 to 10%) and procedure-related mortality is approximately 2%. Late clogging occurs at a mean of 4 to 6 months. This results in the need to change a clogged stent in 20 to 35% of surviving patients with malignant disease. In benign or malignant disease, when long-term stenting is desired, it is generally recommended to prophylactically replace the stent every 4 to 6 months to avoid clogging. While several mechanisms of clogging have been elucidated, research studies have failed to lead to a clinically available improvement in duration of patency. The role of expandable metal stents in the treatment of malignant and benign biliary strictures has not been established. Despite their large internal diameter, they may be associated with late problems related to stent clogging from tumor ingrowth or overgrowth. Technical difficulties and expense, as well as lack of data from prospective randomized trials, limit current recommendation for their use at this time.