December 1986 Volume 204, Number 6

Annals of Surgery

Abdominal Pain in Patients with Acquired

Immune Deficiency Syndrome
JAMES E. BARONE, M.D., F.A.C.S.

BRUCE S. GINGOLD, M.D., F.A.C.S. MICHAEL L. ARVANITIS, M.D.

THOMAS F. NEALON, JR., M.D., F.A.C.S.

The patient with acquired immune deficiency syndrome (AIDS) and abdominal pain presents the surgeon with a difficult challenge. The pain may be due to an opportunistic infection, ileus, organomegaly, or a true surgical emergency. The hospital records of 235 patients with AIDS were reviewed. Of the 29 patients with abdominal pain, 12 had infectious diarrhea, eight were diagnosed as having ileus or organomegaly, and nine had miscellaneous causes for their pain. Only five patients underwent laparotomy. Two patients were operated on for pain associated with bleeding (Meckel's diverticulum and intestinal Kaposi's sarcoma); one had a perforated duodenal ulcer and one had severe ileitis. One patient was electively operated on for Burkitt's lymphoma. Laparotomy for abdominal pain is not usually necessary in patients with AIDS. Specific recommendations for evaluation and management of these patients are offered.
R THOUSANDS OF YEARS, physicians have been called upon to evaluate patients with abdominal .1 pain. Guidelines for diagnosis of most types of abdominal pain are generally well established. However, a new disease complex, acquired immune deficiency syndrome (AIDS), has recently appeared, making previously

From the Department of Surgery, St. Vincent's Hospital and Medical Center of New York, New York, New York

unusual illnesses, such as Kaposi's sarcoma (KS) and Pneumocystis carinii pneumonia (PCP), commonplace. More than 15,000 cases of AIDS have been reported.' More frequently, surgeons are being asked to assess abdominal pain in patients with AIDS. The experience of one institution regarding the presentation, diagnosis, and management ofabdominal pain in a large series of patients with AIDS has not been described before.

Presented at the New York Surgical Society Meeting, February 12, 1986. Reprint requests and correspondence: James E. Barone, M.D., F.A.C.S., Director of Surgery, St. Francis Medical Center, 601 Hamilton Avenue, Trenton, NJ 08629. Submitted for publication: May 12, 1986.

Patient Data Base The medical records of 235 patients with AIDS who were admitted to St. Vincent's Hospital and Medical Center of New York from May 1, 1982, through October 15, 1985, were screened. The diagnosis of AIDS was confirmed by standard criteria, including presence of proven KS, PCP, or multiple other opportunistic infections.2 The charts of the patients who had abdominal pain documented in the physician's progress notes for 2 or more consecutive days were reviewed for this report.
Results There were 29 patients (12.3% of the total population reviewed) who had abdominal pain. Twenty-eight patients

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TABLE 1. Causes ofAbdominal Pain

BARONE AND OTHERS

Ann. Surg. * December 1986

No. of Patients

Gastrointestinal infection Cryptosporidium Campylobacterjejuni Giardia lamblia Ileus and/or hepatosplenomegaly Miscellaneous Intestinal Kaposi's sarcoma Pentamidine pancreatitis Meckel's diverticulum Perforated duodenal ulcer Burkitt's lymphoma Duodenitis

9* 2 I 8

3** 2 I I I I

* Includes 2 patients with multiple opportunistic enteric pathogens. ** One patient also had cryptosporidia in stool.

were male homosexuals. The other patient was a female intravenous drug user. Their average age was 36 years, with a range of 22-51 years. The diagnosis of AIDS was established in the following manner: 16 patients had biopsy-proven PCP; four had biopsy-proven KS; three had both PCP and KS; five had multiple opportunistic infections other than PCP; and one had Burkitt's lymphoma. The cause of abdominal pain in the 29 patients could be divided into three major categories: gastrointestinal infection, ileus and/or hepatosplenomegaly, and miscellaneous (Table 1). To date 23 (79.3%) of the 29 patients in this series have died. The three groups of patients will be discussed separately.

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FIG. 1. Possible inflammation or spasm of small intestine (arrow).

Gastrointestinal Infection
The 12 patients with gastrointestinal infection had diffuse abdominal pain accompanied by profuse, watery
TABLE 2. Factors Related to Abdominal Pain

Infection Diarrhea Diffuse tenderness Local tenderness Rebound tenderness Diminished bowel sounds Nausea/vomiting
Fever

Ileus or Organomegaly

Miscellaneous
5 4 4
1 5 4 2 1 3 6

11 10 2 1
1 5 1 4 2 2 7

3 2 1 3
3 2 2
4

Elevated WBC Decreased WBC Hyperamylasemia Hypoalbuminemia

diarrhea. Localized and rebound tenderness were uncommon. Other symptoms, signs, and laboratory results were nonspecific (Table 2). Only one patient in this group underwent laparotomy. This patient had diarrhea, exquisite generalized abdominal pain with fever, and rebound tenderness, which became more pronounced with repeated examinations. Abdominal x-ray results were suggestive of spasm or inflammation of the small intestine (Fig. 1). Because of progression of symptoms, laparotomy was performed. At surgery, severe inflammation of the terminal ileum was found. No resection was performed. Stool cultures obtained before operation eventually grew Campylobacterjejuni, which responded to erythromycin. This patient recovered and left the hospital after a 10-day course of the antibiotic. Eight of the nine patients with cryptosporidiosis died without responding to any antibiotics or supportive measures such as total parenteral nutrition. One patient with cryptosporidiosis and disseminated candidiasis was noted to have a perforation of the colon at postmortem examination. He died of multiple system failure, malnutrition, and disseminated intravascular

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FIG. 3. Arteriogram showing site of bleeding (arrow) in patient with Meckel's diverticulum.

FIG. 2.

Note "string sign" in nonspecific ileitis (arrows).

coagulopathy. The colonic perforation appeared to have been a premorbid event.

Ileus and/or Hepatosplenomegaly

and died 6 months later of PCP. The patient with a bleeding Meckel's diverticulum had cramps and a massive lower gastrointestinal bleeding episode requiring 16 units of packed red cells. Diagnosis was made by arteriography (Fig. 3) and the diverticulum was resected. The pathologic report confirmed the presence of an inflamed diverticulum with evidence of recent bleeding. Bleeding recurred 6 weeks later requiring 2 units of packed red cells. Extensive diagnostic studies did not establish a definite bleeding site, although nonspecific enterocolitis was seen on barium enema. The patient died several months later of inanition. The patient with duodenitis was diagnosed by upper gastrointestinal endoscopy and successfully treated conservatively. Two of the three patients with intestinal KS had severe malnutrition. Figure 4 depicts a duodenal KS lesion seen on upper gastrointestinal series. Massive lower gasgery

Categorization of the eight patients with ileus and/or hepatosplenomegaly was by exclusion as well as physical findings. These patients were all treated conservatively with complete resolution of their abdominal symptoms. Three of these seven patients eventually died of AIDSrelated illnesses during the same hospitalization.

Miscellaneous
The nine patients in the miscellaneous group were both the easiest and most difficult to diagnose. The patient with -duodenal ulcer perforation was believed to have perforation of previously diagnosed ileitis, presumably secondary to an AIDS-related infectious disease (Fig. 2). The patient had a rigid abdomen and free intra-abdominal air on x-ray 6 months after the original presentation of nonspecific ileitis. He recovered from the ulcer plication sur-

FIG. 4. KS of duodenum (arrow).

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Bacterial

BARONE AND OTHERS

Ann. Surg. * December 1986

TABLE 3. Intra-abdominal Infections Seen in Patients with AIDS

Parasitic

Fungal Candida sp. Cryptococcus neoformans

Viral Cytomegalovirus

Mycobacterium tuberculosis Mycobacterium avium-intracellulare Campylobacterjejuni Listeria monocytogenes Salmonella sp.

Cryptosporidium Isospora belli Giardia lamblia Entamoeba histolytica

trointestinal bleeding was a terminal event in both patients. The third patient had a successful resection of a bleeding small intestinal KS lesion. Pancreatitis secondary to the administration of pentamidine for PCP was noted in two patients. Resolution of the abdominal pain and gradual return to normal of the serum amylase value followed discontinuation of the drug. The patient with Burkitt's lymphoma of the stomach underwent attempted elective resection but the lesion was too extensive to remove safely. Only five (17%) of 29 patients with abdominal pain and AIDS underwent laparotomy. Of the four emergency procedures, two were for massive hemorrhage, one was for progressive severe ileitis due to an infectious agent, and one was for a perforated duodenal ulcer. Discussion

Patients with abdominal pain and AIDS are susceptible

to multiple types of infection (Table 3). Cryptosporidia were present in nine of 12 patients with infection. It was the most common pathogenic organism in our series. Severe diarrhea was almost always present. When cryptosporidiosis is suspected, fresh, undiluted stool must be

Patients with ileus or pain from hepatic or splenic enlargement did not have any characteristic findings to distinguish them from the infection or miscellaneous groups. One patient had sepsis secondary to Listeria monocytogenes, causing hepatosplenomegaly. This patient died long after the resolution of listeriosis. Since diarrhea was common in patients with ileus it may be that infection was present in the stool but simply not detected in spite of numerous specimens examined. Patients in the miscellaneous group varied from the most obvious of presentations (intra-abdominal free air) to the most unusual (bleeding Meckel's diverticulum and intestinal KS). A series of case reports of five AIDS patients by Potter et al.6 described a patient with abdominal pain due to hepatomegaly confirmed by laparotomy and another with mesenteric nodal enlargement secondary to M. aviumintracellulare infection. Also mentioned was a case of perforated ileal lymphoma. Intra-abdominal, extranodal non-Hodgkin's lymphoma has been noted in such sites as bowel, liver, and gallbladder.7 Colonic perforation due to cytomegalovirus has been the subject of two case reassociated with pentamidine has been previously reported.8 Symptoms resolve when the drug is discontinued, and no apparent long-term sequelae have been noted. In summary, laparotomy in the AIDS patient appears to be necessary infrequently. However, the surgeon should be familiar with the diverse manifestations of AIDS. The problem of the patient with AIDS and abdominal pain should be approached in the following manner: (1) Obtain a thorough history and perform a complete physical examination. (2) If diarrhea is present, diligently search for an infectious cause and observe the abdomen closely. Laparotomy should not be necessary in these patients, unless symptoms progress with an uncertain diagnosis. (3) Consider organomegaly or ileus as a possible cause of abdominal pain in patients whose physical findings are
nonspecific.

ports.' Pancreatitis
8,9

examined. Special stains, such as the three-step stool examination (iodine wet mount, modified Kinyoun acidfast, and Sheather's sugar cover-slip flotation), should be used.3 Mucosal biopsy may be necessary if stool examination is inconclusive. Only one of the nine patients with cryptosporidiosis has survived to date. This patient recovered without treatment. One patient had a transient response to intravenous trimethoprim-sulfamethoxazole. Although not effective in this series, spiramycin may be of benefit in treating cryptosporidiosis.4 Infection with C. jejuni may produce panenteritis and colitis associated with fever, cramps, and diarrhea that is usually bloody. Stool culture is the method of diagnosis. The illness responds to erythromycin in almost all cases.5 The severe campylobacter ileitis seen in the patient undergoing laparotomy was accompanied by multiple large mesenteric nodes. Node biopsy and culture were performed to rule out other possible causes of infection such as Mycobacterium avium-intracellulare.

(4) Remember that AIDS patients

may

rotomy for conditions not related to AIDS

require lapaor when a

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623

serious complication, such as perforation of a viscus due to an AIDS-related disease, cannot be ruled out. (5) If laparotomy reveals only enteritis, mesenteric node excision for biopsy and culture should be done. (6) Isolation protocols for patients and specimens should be established according to the Centers for Disease Control guidelines, which continue to be updated.
References
1. Recommendations for assisting in the prevention of perinatal transmission of human t-lymphotropic virus type III/lymphadenopathy virus and acquired immunodeficiency syndrome. MMWR 1985; 34:721-726. 2. Revision of the case definition of acquired immunodeficiency syndrome for national reporting: United States. MMWR 1985; 34: 373-375.

3. Ma P, Soave R. Three-step stool examination for cryptosporidiosis in 10 homosexual men with protracted watery diarrhea. J Infect Dis 1983; 147:824-828. 4. Portnoy D, Whiteside M, Buckley E, MacLeod C. Treatment of cryptosporidiosis with spiramycin. Ann Intern Med 1984; 101: 202-204. 5. Nolan C, Johnson K, Coyle M, Faler K. Campylobacter jejuni enteritis: efficacy of antimicrobial and antibacterial drugs. Am J Gastroenterol 1983; 78:621-626. 6. Potter DA, Danforth DN, Macher AM, et al. Evaluation of abdominal pain in the AID.%patient. Ann Surg 1984; 199:332-339. 7. Ziegler JL, Beckstead Jk, Volberding PA, et al. Non-Hodgkin's lymphoma in 90 homosexual men. N Engl J Med 1984; 31:565570. 8. Frank D, Raicht RF. Intestinal perforation associated with cytomegalovirus infection in patients with AIDS. Am J Gastroenterol 1984; 79:201-205. 9. Kram HB, Hino ST, Cohen R, et al. Spontaneous colonic perforation secondary to cytomegalovirus in a patient with acquired immune deficiency syndrome. Crit Care Med 1984; 12:469-471.