var title_f0_3_48="Management and outcome of atrioventricular (AV) canal defects";

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" Management and outcome of atrioventricular (AV) canal defects",
" </div>",
" <div id=\"topicContributors\">",
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" Authors",
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" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/3/48/contributors\">",
" Craig E Fleishman, MD",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/3/48/contributors\">",
" Aykut Tugertimur, MD",
" </a>",
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href=\"UTD.htm?0/3/48/contributors\">",
" Section Editors",
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0/3/48/contributors\">",
" John K Triedman, MD",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/3/48/contributors\">",
" Heidi M Connolly, MD",
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href=\"UTD.htm?0/3/48/contributors\">",
" Deputy Editor",
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0/3/48/contributors\">",
" Melanie S Kim, MD",
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" Literature review current through:",
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" Oct 2013.",
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" This topic last updated:",
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" Dec 18, 2012.",
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" <p class=\"headingAnchor\" id=\"H173193567\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" &nbsp;&mdash;&nbsp;Atrioventricular (AV) canal defects are a group of
congenital cardiac defects involving, to varying extent, the AV septum and AV
valves (ie, mitral and tricuspid valves). They are also referred to as AV septal
defects, endocardial cushion defects, or persistent AV ostium.",
" </p>",
" <p>",
" The management and outcome of patients with AV canal defects will be reviewed
here. The anatomy, pathophysiology, clinical features, and diagnosis of AV canal
defects are discussed separately. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of atrioventricular
(AV) canal defects\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H173193592\">",
" <span class=\"h1\">",
" VARIOUS FORMS OF AV CANAL DEFECTS",
" </span>",
" &nbsp;&mdash;&nbsp;Failure of the superior and inferior endocardial cushions
to fuse correctly during cardiac development results in a broad range of
atrioventricular (AV) septal and valve defects as follows (",
" <a class=\"graphic graphic_figure graphicRef86338 \" href=\"UTD.htm?
39/23/40312\">",
" figure 1",
" </a>",
" and",
" <a class=\"graphic graphic_figure graphicRef86346 \" href=\"UTD.htm?
25/5/25686\">",
" figure 2",
" </a>",
" ):",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Complete AV canal defect is a result of complete failure of fusion between
endocardial cushions. It is characterized by a primum atrial septal defect (ASD)
that is contiguous with a ventricular septal defect (VSD) and a common AV valve.",
" </li>",
" <li>",
" Partial AV canal defect is due to incomplete fusion of the endocardial
cushions and consists of a primum ASD and a common valvular annulus with two
separate valve orifices. Due to abnormal fusion of the left tubercle of the
superior and inferior cushions, the anterior leaflet of the mitral valve is cleft,
which is often associated with mitral valve regurgitation.",
" </li>",
" <li>",
" Transitional AV canal defect is anatomically a subtype of complete AV canal
defect, as it consists of a large primum defect, cleft mitral valve, and inlet
ventricular septal defect. However, dense chordal attachments to the ventricular
septum result in small shunting at the ventricular level and delineate distinct
left and right AV valve orifices, resulting in a defect that is similar to the
physiology of a partial AV canal defect.",
" </li>",
" <li>",
" Intermediate AV canal defect is a rare subtype of complete AV canal defect,
in which a bridging tongue of tissue divides a common AV valve into two distinct
orifices. This defect is physiologically similar to a complete AV canal defect and
usually has both a large primum atrial and large inlet ventricular septal defects.
Due to natural division of the common AV valve into left and right AV valve
components by the tongue of tissue, surgical division is not required.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H173193611\">",
" <span class=\"h1\">",
" OVERVIEW OF MANAGEMENT",
" </span>",
" &nbsp;&mdash;&nbsp;The management approach for atrioventricular (AV) canal
defects is based on the type of defect, determining whether there are other
associated anatomic and hemodynamic abnormalities (eg, relative ventricular size,
AV valve regurgitation, and right or left ventricular outflow obstruction), and
whether or not other cardiac conditions are present (eg, patent ductus
arteriosus).",
" </p>",
" <p>",
" In general, surgical correction is recommended because of the significant
morbidity and mortality associated with the uncorrected defect.",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Complete AV canal defect &ndash; Patients with complete AV canal defects,
including those with the intermediate type, generally develop heart failure by one
year of age. In addition, uncorrected patients will develop elevated pulmonary
vascular resistance due to unrestricted pulmonary blood flow, and subsequent
pulmonary arterial hypertension (PAH) resulting in systemic cyanosis due to right
to left intracardiac shunting (ie, Eisenmenger&rsquo;s syndrome). As a result, in
these patients, surgical intervention is recommended by six months of age. (See",
" <a class=\"local\" href=\"#H8314440\">",
" 'Complete AV canal defect'",
" </a>",
" below and",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link&amp;anchor=H1062508#H1062508\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of
atrioventricular (AV) canal defects\", section on 'Complete AV canal defect'",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link&amp;anchor=H6370705#H6370705\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of
atrioventricular (AV) canal defects\", section on 'Complete AV canal defect'",
" </a>",
" .)",
" </li>",
" <li>",
" Partial and transitional AV canal defect &ndash; Even though many patients
with partial and transitional AV canal defects are asymptomatic until adulthood,
surgical repair is recommended because the primum atrial septal defect will not
spontaneously close and these patients are at-risk for atrial fibrillation and
heart failure later in life. Patients with significant mitral regurgitation are
more likely to present earlier with signs of mitral regurgitation, features of
atrial fibrillation, or symptoms of heart failure. (See",
" <a class=\"local\" href=\"#H8314476\">",
" 'Partial and transitional atrioventricular canal defect'",
" </a>",
" below and",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link&amp;anchor=H8312866#H8312866\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of
atrioventricular (AV) canal defects\", section on 'Partial and transitional AV
canal defect presentation'",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314440\">",
" <span class=\"h1\">",
" COMPLETE AV CANAL DEFECT",
" </span>",
" &nbsp;&mdash;&nbsp;Management of complete atrioventricular (AV) canal defects
encompasses initial medical management for heart failure, and either primary
complete repair or palliative intervention.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314448\">",
" <span class=\"h2\">",
" Initial medical management",
" </span>",
" &nbsp;&mdash;&nbsp;Infants who have complete AV canal defect usually present
with symptoms of heart failure at about six weeks of age and generally require
medical management before surgical repair. The goal of medical management is to
improve cardiac function, thereby optimizing the patient&rsquo;s condition before
surgery.",
" </p>",
" <p>",
" Medical management includes the following:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Diuretic therapy reduces preload by promoting natriuresis, thereby relieving
volume overload and pulmonary congestion. Diuretic agents include loop (eg,",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?5/26/5544?
source=see_link\">",
" furosemide",
" </a>",
" ) and thiazide diuretics.",
" </li>",
" <li>",
" Ionotropic agents (eg,",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?26/24/27017?
source=see_link\">",
" digoxin",
" </a>",
" ) improve myocardial contractility.",
" </li>",
" <li>",
" Angiotensin blockade reduces afterload, thereby decreasing left-to-right
shunting and mitral regurgitation. In children, angiotensin converting enzyme (ACE)
inhibitors are the preferred agents as there are no published data on the use of
angiotensin receptor blockers in pediatric heart failure.",
" </li>",
" <li>",
" Promoting adequate nutrition, especially in patients with poor feeding and
failure to thrive. In these patients, caloric supplementation is often needed and
may require the use of nasogastric tube feeding or, rarely, gastric tube insertion
before surgical repair.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H173193842\">",
" <span class=\"h2\">",
" Surgical interventions",
" </span>",
" &nbsp;&mdash;&nbsp;Primary complete repair is the preferred surgical approach,
with overall low morbidity and mortality. However, in some cases with unbalanced
lesions (ie, one of the ventricles is hypoplastic), a two-ventricle repair is not
feasible. In those individuals, surgical palliation is performed using
interventions developed for other single ventricular cardiac conditions, such as
hypoplastic left heart syndrome (HLHS). (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/27/41401?
source=see_link&amp;anchor=H18895239#H18895239\">",
" \"Hypoplastic left heart syndrome\", section on 'Surgical management'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314462\">",
" <span class=\"h3\">",
" Primary complete repair",
" </span>",
" &nbsp;&mdash;&nbsp;Primary repair in infancy has an operative mortality of
less than 3 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/1-3\">",
" 1-3",
" </a>",
" ].",
" <strong>",
" </strong>",
" The objectives of surgical repair are to close atrial and ventricular defects,
and to form two separate and competent AV valves.",
" </p>",
" <p class=\"headingAnchor\" id=\"H173193872\">",
" <span class=\"h4\">",
" Surgical timing",
" </span>",
" &nbsp;&mdash;&nbsp;Elective surgical repair is recommended prior to six months
of age in order to avoid the development of pulmonary vascular disease (PVD).
Earlier repair should be considered in infants with heart failure who are
unresponsive to medical management, symptomatic infants with significant AV valve
regurgitation, or those with aortic coarctation. However, surgeons generally
consider that optimal valve construction is more easily performed in patients who
are older than six weeks [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/4\">",
" 4",
" </a>",
" ].",
" <strong>",
" </strong>",
" </p>",
" <p>",
" In patients with Down syndrome, heart failure symptoms may not develop,
probably due to persistent elevation of pulmonary vascular resistance from birth.
Nevertheless, elective repair is recommended prior to six months of age regardless
of whether symptoms are present or not because of concerns of developing PVD. Long-
term outcome is similar in patients with Down syndrome repaired during infancy
compared with patients without Down syndrome [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/5\">",
" 5",
" </a>",
" ].",
" </p>",
" <p>",
" Adults with unrepaired complete AV canal defects are rarely encountered and
generally have irreversible pulmonary vascular disease with associated right-to-
left shunting. Patients are not candidates for reparative surgery once PVD is
severe.",
" </p>",
" <p class=\"headingAnchor\" id=\"H173193932\">",
" <span class=\"h4\">",
" Surgical procedures",
" </span>",
" &nbsp;&mdash;&nbsp;Since the first described successful surgical repair of AV
canal defect in 1955 [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/6\">",
" 6",
" </a>",
" ], the surgical correction of complete AV canal defects has undergone a number
of modifications. In 2012, closure of the septal defect for complete AV canal
defect is performed by one of the following approaches [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/7\">",
" 7",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" One-patch repair &ndash; In the single patch technique, prosthetic patch
material is placed to close the ventricular and atrial communications. The common
AV valve is divided and re-attached to the patch (",
" <a class=\"graphic graphic_figure graphicRef86337 \" href=\"UTD.htm?
32/17/33045\">",
" figure 3",
" </a>",
" ).",
" </li>",
" <li>",
" Two-patch repair &ndash; In the two-patch technique, prosthetic patch
material is used to close the ventricular septal defect, and the common AV valve is
sutured to the top of the patch. The atrial component is closed with a pericardial
patch that is sutured to the common AV valve and ventricular patch.",
" </li>",
" <li>",
" Modified (simplified) single patch repair &ndash; In the modified single-
patch technique, the common AV valve is directly sutured to the crest of the
ventricular septum. Pericardium is used to close the atrial component and is
sutured to the crest of the ventricular septum, separating the common AV valve into
right and left components [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/8\">",
" 8",
" </a>",
" ]. This newer technique simplified the one-patch repair and resulted in
significantly shorter cardiopulmonary bypass and aortic cross-clamp time [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/3,9\">",
" 3,9",
" </a>",
" ].",
" </li>",
" </ul>",
" </p>",
" <p>",
" There are limited observational data that compare these three techniques, and
the most optimal approach for primary complete repair remains uncertain.",
" </p>",
" <p>",
" A multicenter observational study published results after repair of complete
AV canal defect in 120 children (median age 3.7 months) from June 2004 and 2006 [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/9\">",
" 9",
" </a>",
" ]. In this cohort, two-patch, one-patch, and the modified single patch repair
was used in 72, 18, and 10 percent of cases, respectively. The following findings
were noted:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Patients who underwent the modified single patch repair were younger (mean
age 2.6 months) compared with those corrected by either the single- or double-patch
repair (mean age 4.4 and 3.8 months).",
" </li>",
" <li>",
" The overall in-hospital mortality was 2.5 percent, and six-month mortality
was 4 percent.",
" </li>",
" <li>",
" The incidence of residual ventricular septal defect (VSD) or left AV valve
regurgitation was not affected by the age at operation, presence of Down syndrome,
or type of repair.",
" <strong>",
" </strong>",
" </li>",
" <li>",
" There was a lower rate of additional annuloplasty modifications in patients
who underwent the modified single-patch repair compared with either the single- or
double-patch repairs (0, 14, and 30 percent, respectively).",
" </li>",
" <li>",
" Return to bypass for surgical revision during the initial operation occurred
more frequently in patients repaired with the modified single technique, but this
may also be reflective of the younger age of this group of patients.",
" </li>",
" </ul>",
" </p>",
" <p>",
" In a single-center case series of 55 infants who underwent primary complete
repair between 2000 and 2006, modified single patch repair was used in 26 patients
(mean age 4.4 months) and the double-patch repair in 29 patients (5.5 months) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/3\">",
" 3",
" </a>",
" ]. The following findings were noted:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" There was one death in the modified single patch group and no deaths in the
double-patch group.",
" </li>",
" <li>",
" The mean cross-clamp time and cardiopulmonary bypass times were shorter in
the modified single-patch group (97 versus 123 minutes).",
" </li>",
" <li>",
" There were no differences between the two groups regarding postoperative
length of stay and the degree of postoperative AV valve insufficiency assessed by
echocardiography.",
" </li>",
" <li>",
" Reoperation for mitral valve was performed in one patient in the modified
single-patch group, and three patients in the double-patch group. No patient from
either group required reoperation for left ventricular outflow tract (LVOT)
obstruction.",
" </li>",
" </ul>",
" </p>",
" <p>",
" A review article compared the outcome of selected case series that used the
three different techniques [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/7\">",
" 7",
" </a>",
" ]. In this report, modified single-patch repair was used in four reports with
200 patients, two-patch repair in six reports with 889 patients, and classical one-
patch repair in 350 patients. Of note, this was not a systematic review of the
literature, and no statistical analysis was presented to determine if the observed
outcome differences reached statistical significance.",
" </p>",
" <p>",
" The following observations were noted:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Operative mortality was low with an incidence of 2, 3.5, and 4.8 percent for
modified single-patch, two-patch, and classical single-patch repairs, respectively.
Late mortality was also low for two- and one-patch repairs (2.1 and 4 percent), but
there were no data on late mortality for the modified single-patch repair.",
" </li>",
" <li>",
" Mitral valve reoperation appears to be lower in the group who underwent
modified single-patch repair (2 percent) compared with two- and one-patch repair
(7.2 and 9.7 percent). However, no statistical analysis was performed.",
" </li>",
" <li>",
" The rate of heart block was also low with an incidence of 0.5, 2, and 2.3
percent for modified single-patch, two-patch, and classical single-patch repairs.",
" </li>",
" </ul>",
" </p>",
" <p>",
" Two additional outcome measures were not addressed in the above review:
reoperation for LVOT obstruction and the relative size of the VSD.",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" LVOT obstruction &mdash; In a case series of 116 patients who predominantly
underwent a two-patch repair, the rate of LVOT obstruction requiring reoperation
was 4 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/10\">",
" 10",
" </a>",
" ]. In comparison, in a case series of 128 patients who underwent modified
single-patch repair, no patients required reoperation for LVOT obstruction [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/11\">",
" 11",
" </a>",
" ].",
" </li>",
" <li>",
" Size of VSD &mdash; The modified single-patch has been used preferentially
in patients with a comparatively smaller VSD [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/7,9\">",
" 7,9",
" </a>",
" ]. Thus, the utility of this technique remains unclear in patients with a
large VSD, and in these patients, it is unclear whether the outcome of this
procedure is comparable or better than the other two procedures.",
" </li>",
" </ul>",
" </p>",
" <p>",
" Because of the paucity of data, most experts in the field suggest the major
current determinants of a successful outcome are surgeon preference and familiarity
with a specific technique, and institutional experience rather than the technique
itself [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/9\">",
" 9",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H266402567\">",
" <span class=\"h4\">",
" Cleft AV valve",
" </span>",
" &nbsp;&mdash;&nbsp;With any of the three techniques, closure of the cleft in
the mitral component of the valve is controversial. Some investigators believe that
the cleft in the left AV valve is a true commissure and should be left open so that
the repaired valve functions as a three-leaflet valve [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/12\">",
" 12",
" </a>",
" ].",
" <strong>",
" </strong>",
" Other investigators state that the cleft should be closed because significant
residual left AV valve regurgitation through the cleft is a frequent reason for
reoperation.",
" </p>",
" <p>",
" Support for this latter view was based on results from a retrospective single
center study of all patients who underwent repair of complete AV canal defects from
1984 to 1997, which showed overall outcomes including that freedom from reoperation
for left AV was more favorable in patients who underwent left AV valve cleft repair
(n = 96) compared with patients in whom the cleft was left open (n = 63) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/13\">",
" 13",
" </a>",
" ].",
" <strong>",
" </strong>",
" The authors concluded, and we agree, that the AV valve cleft should be
surgically addressed whenever the morphology of the left AV valve allows for
closure without producing stenosis.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314469\">",
" <span class=\"h3\">",
" Single ventricle palliation",
" </span>",
" &nbsp;&mdash;&nbsp;The term &ldquo;unbalanced AV canal defect&rdquo; has been
used when there is significant right or left ventricular hypoplasia associated with
an unequally positioned common AV valve either over the right or over the left
ventricle. The management of unbalanced AV canal defect remains difficult. In
general, two-ventricle repair is better tolerated in patients with right
ventricular hypoplasia than in patients with left ventricular. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link&amp;anchor=H450999452#H450999452\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of atrioventricular
(AV) canal defects\", section on 'Balanced/unbalanced classification'",
" </a>",
" .)",
" </p>",
" <p>",
" Echocardiography is used to measure the relative sizes of the ventricles in
patients with an unbalanced AV canal defect and to determine whether or not a
complete primary repair is feasible. The AV valve index can be used to help predict
the success of two-ventricle repair. It is derived by the ratio of the area of the
AV valve apportioned to the left ventricle over the combined area of the AV valve
measured in the subcostal left anterior oblique view. Two-ventricle repair is
typically successful when the AV valve index is between 0.4 and 0.6 [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/14,15\">",
" 14,15",
" </a>",
" ].",
" </p>",
" <p>",
" When a two-ventricle repair is not possible, palliative intervention (modified
Fontan approach) is performed based on techniques developed in patients with single
ventricular cardiac defects. The success of this approach is dependent on the
competency of the AV valve and the protection of the pulmonary vascular bed.",
" </p>",
" <p>",
" Surgical repair typically consists of three staged palliative procedures.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/27/41401?
source=see_link&amp;anchor=H18895239#H18895239\">",
" \"Hypoplastic left heart syndrome\", section on 'Surgical management'",
" </a>",
" .)",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Stage 1 establishes a controlled source of pulmonary blood flow and provides
blood flow from the &ldquo;single ventricle&rdquo;, which can either be a dominant
right or left ventricle, to the systemic circulation. In some cases, pulmonary
artery banding is sufficient, but in others, banding of the pulmonary artery to
lower pulmonary artery pressure may lead to worsening of AV valve regurgitation",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" subsequent distortion of the central pulmonary arteries. In these patients,
an alternative approach directly shunts pulmonary blood flow from a systemic artery
to pulmonary artery through a component of a divided main pulmonary artery.",
" </li>",
" <li>",
" Stage 2 is performed when the patients begin to outgrow their original
shunt. In general, a bidirectional Glenn shunt or a hemi-Fontan procedure is
performed that results in direct drainage of blood from the superior vena cava into
the pulmonary artery. This leads to improved systemic oxygenation and a decreased
volume load on the heart.",
" </li>",
" <li>",
" Stage 3 is performed after further growth. This stage entails a modified
Fontan procedure that separates the venous and arterial circulations. This
separation is obtained by baffling the blood return from the inferior vena cava
directly to the pulmonary artery, usually with an extracardiac conduit.",
" </li>",
" </ul>",
" </p>",
" <p>",
" Similar to HLHS, mortality is high in patients with unbalanced lesions who are
not amenable to two-ventricular repair. The three-stage palliative approach reduces
early mortality, but the long-term outcome remains uncertain. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/27/41401?
source=see_link&amp;anchor=H70091449#H70091449\">",
" \"Hypoplastic left heart syndrome\", section on 'Outcome'",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/27/41401?
source=see_link&amp;anchor=H70091736#H70091736\">",
" \"Hypoplastic left heart syndrome\", section on 'Choice of management'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314476\">",
" <span class=\"h1\">",
" PARTIAL AND TRANSITIONAL ATRIOVENTRICULAR CANAL DEFECT",
" </span>",
" &nbsp;&mdash;&nbsp;Children with partial and transitional atrioventricular
(AV) canal defects are largely asymptomatic. However, with increasing age, patients
are at risk for developing symptoms of right heart volume overload, especially with
exertion, as the defect is associated with a moderate to large left-to-right shunt
that is unlikely to resolve spontaneously. Patients with left AV valve
regurgitation are more likely to develop symptoms of left ventricular volume
overload and heart failure (eg, growth failure and dyspnea) at an earlier age.",
" </p>",
" <p>",
" Elective surgical repair is recommended to lessen the incidence of morbidity
later in life including heart failure and atrial fibrillation [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/16\">",
" 16",
" </a>",
" ].",
" <strong>",
" </strong>",
" The goal of surgical repair is to close the interatrial communication, and
restore and preserve left AV valve competence. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link&amp;anchor=H8312866#H8312866\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of atrioventricular
(AV) canal defects\", section on 'Partial and transitional AV canal defect
presentation'",
" </a>",
" and",
" <a class=\"local\" href=\"#H173193611\">",
" 'Overview of management'",
" </a>",
" above.)",
" </p>",
" <p>",
" Because of low morbidity and nearly absent mortality, surgical repair for
partial and transitional AV canal defect is usually performed when the patient is
18 to 24 months of age or, in older patients, whenever the diagnosis is made. This
was illustrated in a retrospective multicenter study of 87 patients who underwent
repair of a partial or transitional defect in seven centers in North America [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/17\">",
" 17",
" </a>",
" ]. The median age at surgery was 1.8 years; 20 percent of patients had growth
failure and a third of patients had moderate or severe left AV valve regurgitation.
These last two findings are indicative of a more symptomatic and severely affected
cohort. At mean follow-up, there was one death (perioperative fatality of a four-
day-old infant who also underwent arch reconstruction), three patients with mild
left ventricular dysfunction, and one with a residual atrial septal defect.
Improved weight gain was observed with an increase in the median z-score of 0.4
units. Left AV valve regurgitation was the most common residual defect, occurring
more frequently in children repaired after four years of age. These results suggest
that surgical repair before preschool age may be advantageous in preventing left AV
valve regurgitation.",
" </p>",
" <p>",
" Surgical repair of partial and transitional AV canal defects involves patch
closure of the ostium primum defect and mitral valvuloplasty to eliminate or to
minimize mitral regurgitation. For moderate or severe mitral regurgitation,
surgeons suture the mitral valve cleft closed and perform a mitral annuloplasty
when associated annular dilatation is present. Surgical closure of the cleft in the
presence of mild or no mitral regurgitation is controversial. For transitional AV
canal defects, the ventricular septal defect may be closed primarily or with a
patch depending on its size.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314483\">",
" <span class=\"h1\">",
" OUTCOME",
" </span>",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308524\">",
" <span class=\"h2\">",
" Postoperative complications",
" </span>",
" &nbsp;&mdash;&nbsp;Postoperative complications include pulmonary hypertension,
arrhythmias, and residual left atrioventricular (AV) valve regurgitation.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314490\">",
" <span class=\"h3\">",
" Pulmonary hypertension",
" </span>",
" &nbsp;&mdash;&nbsp;The incidence of postoperative pulmonary hypertension
increases with age at operation. In particular, patients with Down syndrome have
higher pulmonary vascular resistance than children without Down syndrome [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/18\">",
" 18",
" </a>",
" ]. It is important to rule out secondary causes of pulmonary hypertension such
as severe left AV valve regurgitation or stenosis, or residual ventricular septal
defect. Postoperative pulmonary hypertension can be treated with sedation,
paralysis, oxygen, fluids, and inhaled nitric oxide [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/19,20\">",
" 19,20",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314497\">",
" <span class=\"h3\">",
" Arrhythmias",
" </span>",
" &nbsp;&mdash;&nbsp;Postoperative arrhythmias include sinus node dysfunction,
junctional ectopic tachycardia, and complete heart block. Reports from large series
show that the incidence of postoperative heart block varies from 0 to 4 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/21-23\">",
" 21-23",
" </a>",
" ].",
" <strong>",
" </strong>",
" Heart block in patients with an AV canal defect and heterotaxy syndrome (rare
condition in which the usual position of the heart and other organs are reversed as
mirror images of the normal location [ie, situs inversus]) may be progressive,
regardless of surgical intervention. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?32/24/33161?
source=see_link&amp;anchor=H24#H24\">",
" \"Bradycardia in children\", section on 'AV Heart block'",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?32/24/33161?
source=see_link&amp;anchor=H21#H21\">",
" \"Bradycardia in children\", section on 'Sinus node dysfunction'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314504\">",
" <span class=\"h3\">",
" AV valve complications",
" </span>",
" &nbsp;&mdash;&nbsp;AV valve complications typically involve the left AV valve
and include left AV valve regurgitation and stenosis. These often require
reoperation. However, the increasing use of intraoperative transesophageal
echocardiography during the primary repair allows for additional surgery during the
initial repair that may reduce the risk of postoperative AV valve incompetence.",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308370\">",
" <span class=\"h4\">",
" AV valve regurgitation",
" </span>",
" &nbsp;&mdash;&nbsp;Following initial surgical correction of partial and
complete AV canal defect, post surgical AV valve regurgitation is a common
complication (",
" <a class=\"graphic graphic_movie graphicRef86877 \" href=\"UTD.htm?
27/59/28599\">",
" movie 1",
" </a>",
" ) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/7,9,17\">",
" 7,9,17",
" </a>",
" ]. In the previously noted multicenter case series of patients with partial or
transitional defects, about one-third of patients had moderate to severe
postoperative left AV valve regurgitation [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/17\">",
" 17",
" </a>",
" ]. Patients who had preoperative AV regurgitation were also more likely to
have postoperative valve incompetence requiring surgical reoperation. It remains
uncertain if there are other risk factors that predict subsequent AV valve
regurgitation. For example, earlier case reports suggest that younger patients were
more likely to have postoperative regurgitation, but as surgical techniques evolve,
later case series indicate that patients who undergo repair after four years of age
were more likely to have moderate or severe left AV valve regurgitation compared
with younger patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/17,24-26\">",
" 17,24-26",
" </a>",
" ]. Reoperation for persistent AV valve regurgitation including an attempt for
valve repair should be performed by a surgeon with experience in congenital cardiac
surgery.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314511\">",
" <span class=\"h4\">",
" AV valve stenosis",
" </span>",
" &nbsp;&mdash;&nbsp;Reoperation for mitral stenosis after AV canal defect
repair is much less common compared with mitral regurgitation [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/27-29\">",
" 27-29",
" </a>",
" ].",
" <strong>",
" </strong>",
" Reoperation for mitral stenosis may be necessary if the valve orifice is
hypoplastic or restrictive due to parachute valve morphology. Assessment of valve
morphology prior to surgical repair and avoiding aggressive cleft closure in cases
with small left mural leaflet decreases the incidence of postoperative mitral
stenosis. Reoperation for AV valve stenosis or inflow obstruction should be
performed by a surgeon with experience in congenital cardiac surgery. The operation
will usually require valve replacement. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/34/11818?
source=see_link&amp;anchor=H779748176#H779748176\">",
" \"Clinical manifestations, pathophysiology, and diagnosis of atrioventricular
(AV) canal defects\", section on 'AV valve abnormalities'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308471\">",
" <span class=\"h4\">",
" Transesophageal echocardiography",
" </span>",
" &nbsp;&mdash;&nbsp;Transesophageal echocardiogram in the operating room
immediately before and after initial repair can evaluate AV valve function,
especially detecting and assessing the degree of left AV valve regurgitation or
stenosis. In some cases with significant AV pathology, further surgery on the AV
valve may be performed before leaving the operating room. However, immediate
postoperative findings by transesophageal echocardiography may not accurately
correlate with later echocardiographic findings and long-term results, likely due
to changes in ventricular volume and systemic vascular resistance related to
anesthesia and cardiopulmonary bypass. These hemodynamic changes can directly
affect the degree of mitral regurgitation; therefore, the severity of regurgitation
seen in the operating room may not directly correspond to the severity of
regurgitation seen under different hemodynamic conditions [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/30,31\">",
" 30,31",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H8314519\">",
" <span class=\"h2\">",
" Long-term outcome",
" </span>",
" &nbsp;&mdash;&nbsp;In the current era, the mortality rate for treatment of AV
canal defect is about 3 percent with minimal long-term morbidity [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/7,9,17\">",
" 7,9,17",
" </a>",
" ]. Ten-year survival rates are 80 to 90 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/32\">",
" 32",
" </a>",
" ]. Long-term follow-up remains necessary after AV canal defect repair, mainly
to monitor for mitral regurgitation, atrial arrhythmias, left ventricular outflow
tract obstruction, and ventricular function [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/33,34\">",
" 33,34",
" </a>",
" ]. Follow-up should be performed by a cardiologist with special training in
the care of patients with congenital cardiac disorders. Worsening mitral
regurgitation is the leading reason for reoperation, necessary in 5 to 10 percent
of cases [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/33\">",
" 33",
" </a>",
" ].",
" <strong>",
" </strong>",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308591\">",
" <span class=\"h1\">",
" FOLLOW-UP CARE",
" </span>",
" &nbsp;&mdash;&nbsp;Longitudinal follow-up care, typically annually, is
required in all patients with atrioventricular (AV) canal defects in conjunction
with a cardiologist with expertise in congenital heart disease. Clinicians need to
know the associated complications following surgical repair and in unoperated
patients. As noted above, complications following surgical repair include AV valve
regurgitation, arrhythmias, left ventricular outflow obstruction, and heart failure
(particularly in uncorrected individuals).",
" </p>",
" <p>",
" Follow-up care consists of routine visits that include a history, physical
examination, and cardiac testing (electrocardiography and echocardiography) that
are focused on identifying patients with ventricular dysfunction (eg, heart failure
or outflow obstruction), arrhythmia, and worsening mitral regurgitation (MR).",
" </p>",
" <p class=\"headingAnchor\" id=\"H241555\">",
" <span class=\"h2\">",
" History",
" </span>",
" &nbsp;&mdash;&nbsp;The history focuses on the cardiac status of the patient.
The following findings are suggestive of cardiac dysfunction:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Increasing exercise intolerance suggestive of worsening heart failure",
" </li>",
" <li>",
" Episodes of palpitations or syncope suggestive of an underlying arrhythmia",
" </li>",
" <li>",
" Dyspnea that may suggest worsening MR or, in the case of unoperated
patients, worsening of pulmonary hypertension",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H241563\">",
" <span class=\"h2\">",
" Physical examination",
" </span>",
" &nbsp;&mdash;&nbsp;The physical examination includes:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Vital signs, particularly the pulse, to determine any irregularity that
suggests an underlying arrhythmia",
" </li>",
" <li>",
" Cardiac auscultation to detect any gallop or murmur due to residual shunt,
MR, mitral stenosis, or subaortic stenosis",
" </li>",
" <li>",
" Examination for signs of heart failure including pulmonary congestion,
peripheral edema, and hepatomegaly",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H241571\">",
" <span class=\"h2\">",
" Tests",
" </span>",
" &nbsp;&mdash;&nbsp;The following tests are routinely performed:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Electrocardiography is performed yearly to detect and diagnose arrhythmias.
Holter or event recorder monitoring may be periodically useful tests and are
particularly helpful in patients with a history suggestive of arrhythmia.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Routine echocardiography is initially performed annually or if there any
concerning clinical findings. It is used to evaluate ventricular function, residual
shunts, AV valve",
" <span class=\"nowrap\">",
" regurgitation/stenosis,",
" </span>",
" and subaortic stenosis.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308696\">",
" <span class=\"h2\">",
" Activity",
" </span>",
" &nbsp;&mdash;&nbsp;After recovering from surgery, normal daily activities
should be allowed. Most patients remain asymptomatic with a normal functional
status. The 36",
" ^{",
" th",
"}",
" Bethesda conference provides exercise and athletic participation guidelines
for patients with congenital heart disease. Patients who have no residual defects,
normal ventricular function, and have no evidence of atrial or ventricular
tachyarrhythmias may participate in all competitive sports without restrictions.
Patients who have arrhythmias or residual cardiac lesions are addressed on an
individual basis [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/35\">",
" 35",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308738\">",
" <span class=\"h2\">",
" Endocarditis prophylaxis",
" </span>",
" &nbsp;&mdash;&nbsp;Prophylactic antibiotics for endocarditis are recommended
for all patients for six months after a complete repair, and beyond that for
patients who have repairs that include the use of prosthetic material, a prior
episode of endocarditis, and those with a residual intracardiac shunt. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?0/36/585?
source=see_link\">",
" \"Antimicrobial prophylaxis for bacterial endocarditis\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H115923629\">",
" <span class=\"h2\">",
" Pregnancy",
" </span>",
" &nbsp;&mdash;&nbsp;A comprehensive cardiovascular evaluation by a congenital
cardiac specialist is recommended prior to pregnancy in a patient with repaired AV
canal defect to confirm there are no cardiovascular features that would be best
treated before a pregnancy, or to suggest a pregnancy would be high risk and not
advised. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/21/35159?
source=see_link&amp;anchor=H9#H9\">",
" \"Pregnancy in women with congenital heart disease: Specific lesions\",
section on 'Atrioventricular septal defect'",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?13/52/14154?
source=see_link&amp;anchor=H568452#H568452\">",
" \"Ventricular septal defect in adults\", section on 'Pregnancy with AVSD'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308786\">",
" <span class=\"h2\">",
" Neurodevelopmental outcome",
" </span>",
" &nbsp;&mdash;&nbsp;Children with AV canal defects are at-risk for
developmental impairment and should undergo appropriate surveillance, screening,",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" referral as recommended in a 2012 scientific statement from the American Heart
Association (AHA) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/48/abstract/36\">",
" 36",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/49/26394?
source=see_link\">",
" \"Developmental-behavioral surveillance and screening in primary care\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H901308817\">",
" <span class=\"h1\">",
" SUMMARY AND RECOMMENDATIONS",
" </span>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Atrioventricular (AV) canal defects are a group of congenital cardiac
defects involving the AV septum and AV valves (ie, mitral and tricuspid valves).
Failure of the superior and inferior endocardial cushions to fuse correctly during
cardiac embryology results in complete (both atrial and ventricular septal defects)
and partial (only atrial septal defect) anatomic forms (",
" <a class=\"graphic graphic_figure graphicRef86346 \" href=\"UTD.htm?
25/5/25686\">",
" figure 2",
" </a>",
" ). (See",
" <a class=\"local\" href=\"#H173193592\">",
" 'Various forms of AV canal defects'",
" </a>",
" above.)",
" </li>",
" <li>",
" Surgical correction for an AV canal defect is generally performed because of
the significant morbidity and mortality associated with the uncorrected lesion. The
management approach is based on the type of AV canal defect, determining whether
there are other associated anatomic and hemodynamic abnormalities (eg, relative
ventricular size, AV valve regurgitation, and right or left ventricular outflow
obstruction), and whether or not other cardiac conditions (eg, patent ductus
arteriosus) are present. (See",
" <a class=\"local\" href=\"#H173193611\">",
" 'Overview of management'",
" </a>",
" above.)",
" </li>",
" <li>",
" Management of complete AV canal defects encompasses initial medical
management for heart failure, and either primary complete repair or palliative
intervention.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <ul class=\"hyphen-block\">",
" <li>",
" The goal of medical management is to improve cardiac function in patients
with heart failure, thereby optimizing the patient&rsquo;s condition before
surgery. Therapeutic interventions include diuretic therapy, ionotropic support,
angiotensin blockade, and the provision of adequate nutrition. (See",
" <a class=\"local\" href=\"#H8314448\">",
" 'Initial medical management'",
" </a>",
" above.)",
" </li>",
" <li>",
" In patients with a balanced complete AV canal defect (two ventricles are
similar in size), we recommend primary surgical repair (",
" <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
" Grade 1B",
" </a>",
" ). We recommend that repair occur before six months of age (",
" <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
" Grade 1B",
" </a>",
" ). Surgical intervention during early infancy is associated with a low
mortality rate and avoids the development of pulmonary vascular disease. (See",
" <a class=\"local\" href=\"#H8314462\">",
" 'Primary complete repair'",
" </a>",
" above.)",
" </li>",
" <li>",
" In some cases with unbalanced lesions (ie, one of the ventricles is
hypoplastic), a two-ventricle repair is not feasible. In those individuals, we
suggest surgical palliation be performed using interventions developed for single
ventricular cardiac conditions, such as hypoplastic left heart syndrome (HLHS) or
tricuspid atresia (",
" <a class=\"grade\" href=\"._grade_5?title=Grade 2B\">",
" Grade 2B",
" </a>",
" ). (See",
" <a class=\"local\" href=\"#H8314469\">",
" 'Single ventricle palliation'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Patients with partial and transitional AV valve defects are generally
asymptomatic during childhood but are likely to develop symptoms of right heart
overload as adults. Patients with significant left AV valve regurgitation are at-
risk for left heart failure and atrial fibrillations. As a result, we recommend
surgical correction be performed in patients with partial and transitional AV canal
defects (",
" <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
" Grade 1B",
" </a>",
" ). Surgical correction is associated with low morbility and mortality, and
decreases the risk of morbidity associated with uncorrected lesions. (See",
" <a class=\"local\" href=\"#H8314476\">",
" 'Partial and transitional atrioventricular canal defect'",
" </a>",
" above.)",
" </li>",
" <li>",
" The overall mortality rate for surgical repair of AV canal defects is about
3 percent, and the 10-year survival rate approaches 90 percent. (See",
" <a class=\"local\" href=\"#H8314519\">",
" 'Long-term outcome'",
" </a>",
" above.)",
" </li>",
" <li>",
" Morbidity associated with surgical repair includes postoperative pulmonary
hypertension and arrhythmias, and AV valve complications including regurgitation
and, less commonly, stenosis. Patients with preoperative AV regurgitation are
likely to have postoperative regurgitation, which often requires reoperation.
(See",
" <a class=\"local\" href=\"#H901308524\">",
" 'Postoperative complications'",
" </a>",
" above.)",
" </li>",
" <li>",
" Longitudinal follow-up care is required in all patients with AV canal
defects in conjunction with a cardiologist with expertise in congenital heart
disease. Clinicians need to know the complications following surgical repair and in
unoperated patients. Follow-up care consists of routine visits that include
history, physical examination, and cardiac testing (electrocardiography and
echocardiography) that are focused on identifying patients with ventricular
dysfunction, arrhythmia, and worsening AV valve regurgitation. (See",
" <a class=\"local\" href=\"#H901308591\">",
" 'Follow-up care'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
" <ol id=\"reference\">",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/1\">",
" Hanley FL, Fenton KN, Jonas RA, et al. Surgical repair of complete
atrioventricular canal defects in infancy. Twenty-year trends. J Thorac Cardiovasc
Surg 1993; 106:387.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/2\">",
" Crawford FA Jr, Stroud MR. Surgical repair of complete atrioventricular
septal defect. Ann Thorac Surg 2001; 72:1621.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/3\">",
" Backer CL, Stewart RD, Bailliard F, et al. Complete atrioventricular canal:
comparison of modified single-patch technique with two-patch technique. Ann Thorac
Surg 2007; 84:2038.",
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" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/4\">",
" Singh RR, Warren PS, Reece TB, et al. Early repair of complete
atrioventricular septal defect is safe and effective. Ann Thorac Surg 2006;
82:1598.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/5\">",
" Masuda M, Kado H, Tanoue Y, et al. Does Down syndrome affect the long-term
results of complete atrioventricular septal defect when the defect is repaired
during the first year of life? Eur J Cardiothorac Surg 2005; 27:405.",
" </a>",
" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/6\">",
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" Backer CL, Mavroudis C, Alboliras ET, Zales VR. Repair of complete
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" Ashraf MH, Amin Z, Sharma R, Subramanian S. Atrioventricular canal defect:
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" Baslaim G, Basioni A. Repair of complete atrioventricular septal defects:
results with maintenance of the coronary sinus on the right atrial side. J Card
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" Murashita T, Kubota T, Oba J, et al. Left atrioventricular valve
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" Stulak JM, Burkhart HM, Dearani JA, et al. Reoperations after initial repair
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" Permut LC, Mehta V. Late results and reoperation after repair of complete
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" Lee HR, Montenegro LM, Nicolson SC, et al. Usefulness of intraoperative
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" Stulak JM, Burkhart HM, Dearani JA, et al. Reoperations after repair of
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Thorac Surg 2010; 89:1352.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/33\">",
" Alsoufi B, Al-Halees Z, Khouqeer F, et al. Results of left atrioventricular
valve reoperations following previous repair of atrioventricular septal defects. J
Card Surg 2010; 25:74.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/34\">",
" Rhodes J, Warner KG, Fulton DR, et al. Fate of mitral regurgitation
following repair of atrioventricular septal defect. Am J Cardiol 1997; 80:1194.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/35\">",
" Maron BJ, Zipes DP. Introduction: eligibility recommendations for
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/48/abstract/36\">",
" Marino BS, Lipkin PH, Newburger JW, et al. Neurodevelopmental outcomes in
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statement from the American Heart Association. Circulation 2012; 126:1143.",
" </a>",
" </li>",
" </ol>",
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var script_f0_3_48=[""].join("\n");
var outline_f0_3_48=[" <div id=\"toggleOutline\">",
" <a href=\"#\" title=\"Collapse Topic Outline\">",
" <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
" </a>",
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" <div id=\"innerOutline\">",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <div id=\"outline\">",
" <ul>",
" <li>",
" <a class=\"sr_button\" href=\"#H901308817\" id=\"summRecButton\">",
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" SUMMARY &amp; RECOMMENDATIONS",
" </span>",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H173193567\">",
" INTRODUCTION",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H173193592\">",
" VARIOUS FORMS OF AV CANAL DEFECTS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H173193611\">",
" OVERVIEW OF MANAGEMENT",
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" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H8314440\">",
" COMPLETE AV CANAL DEFECT",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H8314448\">",
" Initial medical management",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H173193842\">",
" Surgical interventions",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H8314462\">",
" - Primary complete repair",
" </a>",
" </li>",
" <li class=\"bulletItem2\">",
" <a class=\"outlineLink\" href=\"#H173193872\">",
" Surgical timing",
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" Surgical procedures",
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" Cleft AV valve",
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" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H8314469\">",
" - Single ventricle palliation",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H8314476\">",
" PARTIAL AND TRANSITIONAL ATRIOVENTRICULAR CANAL DEFECT",
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" <a class=\"outlineLink\" href=\"#H8314483\">",
" OUTCOME",
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" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H901308524\">",
" Postoperative complications",
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" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H8314490\">",
" - Pulmonary hypertension",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H8314497\">",
" - Arrhythmias",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H8314504\">",
" - AV valve complications",
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" <a class=\"outlineLink\" href=\"#H901308370\">",
" AV valve regurgitation",
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" AV valve stenosis",
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" Transesophageal echocardiography",
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" Long-term outcome",
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" FOLLOW-UP CARE",
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" <a class=\"outlineLink\" href=\"#H241555\">",
" History",
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" <a class=\"outlineLink\" href=\"#H241563\">",
" Physical examination",
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" <a class=\"outlineLink\" href=\"#H241571\">",
" Tests",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H901308696\">",
" Activity",
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" </li>",
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" Endocarditis prophylaxis",
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" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H115923629\">",
" Pregnancy",
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" </li>",
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" <a class=\"outlineLink\" href=\"#H901308786\">",
" Neurodevelopmental outcome",
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" SUMMARY AND RECOMMENDATIONS",
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" <li class=\"plainItem\">",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" <div class=\"openRelatedGraphics\" id=\"PEDS/86278\" rel=\"outline_link\">",
" GRAPHICS",
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" FIGURES",
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" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_figure\" href=\"UTD.htm?39/23/40312\"
title=\"figure 1\">",
" Embryology of AV canal defects",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_figure\" href=\"UTD.htm?25/5/25686\"
title=\"figure 2\">",
" Different forms of AV canal defects",
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" </li>",
" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_figure\" href=\"UTD.htm?32/17/33045\"
title=\"figure 3\">",
" One-patch repair for complete AV canal defect",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <div class=\"openRelatedGraphics\" id=\"PEDS/86278|MOV\">",
" <a href=\"#\" title=\"MOVIES\">",
" MOVIES",
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" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_movie\" href=\"UTD.htm?27/59/28599\" title=\"movie
1\">",
" Echo AV valve regurgitation postsurgery of AV canal defect",
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" <h1>",
" RELATED TOPICS",
" </h1>",
" <div id=\"relatedTopics\">",
" <ul>",
" <li class=\"plainItem\">",
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source=related_link\">",
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var title_f0_3_49="Management of dyslipidemia and cardiovascular risk in the HIV-
infected patient";
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" Management of dyslipidemia and cardiovascular risk in the HIV-infected
patient",
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" Author",
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0/3/49/contributors\">",
" Judith S Currier, MD",
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0/3/49/contributors\">",
" John G Bartlett, MD",
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href=\"UTD.htm?0/3/49/contributors\">",
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0/3/49/contributors\">",
" Allyson Bloom, MD",
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" </div>",
" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H1\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" &nbsp;&mdash;&nbsp;Dyslipidemia is common in HIV-infected patients who are
receiving antiretroviral therapy (ART) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/1\">",
" 1",
" </a>",
" ]. It may be seen as an isolated finding or as part of the HIV-associated
lipodystrophy syndrome of fat redistribution, insulin resistance, and
hyperlipidemia. Although the implications of dyslipidemia in this patient
population are not fully understood, an increasing amount of data suggest that
lipid abnormalities are associated with cardiovascular morbidity and mortality.
These epidemiologic observations have prompted increased awareness of the need for
risk assessment and modification for cardiovascular disease as an integral part of
routine HIV care.",
" </p>",
" <p>",
" Approximately one-half of all patients with a coronary heart disease (CHD)
event have no established risk factors other than age and gender. Due to this
observation, concepts of optimal blood pressure, blood glucose, and lipid values
have been revised downward in the past 20 years. Whether HIV infection is itself a
risk factor for CHD is unclear. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?38/59/39866?
source=see_link\">",
" \"Overview of the risk equivalents and established risk factors for
cardiovascular disease\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/1/26650?
source=see_link\">",
" \"Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients\"",
" </a>",
" .)",
" </p>",
" <p>",
" The evaluation and management of hyperlipidemia in HIV-infected patients is
discussed below. The epidemiology, morbidity, and mortality associated with
hyperlipidemia in HIV-infected patients and issues related to HIV-associated
lipodystrophy are discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/1/26650?
source=see_link\">",
" \"Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/43/26298?
source=see_link\">",
" \"Epidemiology, clinical manifestations, and diagnosis of HIV-associated
lipodystrophy\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?43/36/44617?
source=see_link\">",
" \"Treatment of HIV-associated lipodystrophy\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H2\">",
" <span class=\"h1\">",
" ASSESSING CARDIOVASCULAR RISK FACTORS",
" </span>",
" &nbsp;&mdash;&nbsp;Mounting data suggests that HIV infection and exposure to
antiretroviral medications lead to early development of risk factors traditionally
associated with cardiovascular disease. It is of paramount importance that
clinicians identify and initiate preventative interventions since most patients
eventually do require treatment of these risk factors.",
" </p>",
" <p>",
" Clinicians should assess a patient's individual risk factors as part of the
initial medical visit as they would for any other patient. This includes not only
laboratory assessment for the presence of diabetes and dyslipidemia, but also a
thorough history to assess smoking habits, diet, and level of exercise activity.
The patient should be interviewed regarding any family history of coronary artery
disease, hypertension, or diabetes. Baseline measurements of blood pressure, waist
circumference and body mass index should be performed. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/43/26298?
source=see_link\">",
" \"Epidemiology, clinical manifestations, and diagnosis of HIV-associated
lipodystrophy\"",
" </a>",
" .)",
" </p>",
" <p>",
" These risk factors can used to predict an individual's risk for the
development of CHD using established multivariate risk models, such as the
Framingham risk score [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2,3\">",
" 2,3",
" </a>",
" ]&nbsp;(",
" <a class=\"graphic graphic_table graphicRef64978 graphicRef76742 \"
href=\"UTD.htm?30/1/30751\">",
" table 1A-B",
" </a>",
" ). However, the pathophysiological mechanisms that may confer increased risk
in HIV-infected patients may not be accounted for in standard risk assessment
methods (eg, hypercoagulability) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/4\">",
" 4",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?38/8/39048?
source=see_link\">",
" \"Estimation of cardiovascular risk in an individual patient without known
cardiovascular disease\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H3\">",
" <span class=\"h1\">",
" SCREENING FOR DYSLIPIDEMIA",
" </span>",
" &nbsp;&mdash;&nbsp;HIV-infected patients should undergo screening for
dyslipidemia prior to initiating ART and within three to six months after starting
a new regimen [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2,5\">",
" 2,5",
" </a>",
" ]. The approach to screening is no different than screening an HIV-
seronegative patient and includes an overnight fasting lipid profile for
triglycerides, high density lipoprotein (HDL) cholesterol, and total cholesterol.
Low density lipoprotein (LDL) cholesterol (in",
" <span class=\"nowrap\">",
" mg/dL)",
" </span>",
" is then calculated using Friedewald's equation [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/5\">",
" 5",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" LDL cholesterol = total cholesterol (TC)- HDL cholesterol -",
" <span class=\"nowrap\">",
" triglycerides/5",
" </span>",
" </li>",
" </ul>",
" </p>",
" <p>",
" When the triglyceride level is greater than 400",
" <span class=\"nowrap\">",
" mg/dL,",
" </span>",
" the calculated LDL fraction is unreliable and a direct measurement of LDL
should be obtained [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/5\">",
" 5",
" </a>",
" ]. Other exacerbating factors should also be considered such as alcohol use,
hypothyroidism, hypogonadism, or use of drugs known to interfere with glucose or
lipid metabolism (eg, growth hormone) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/6\">",
" 6",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?32/29/33241?
source=see_link\">",
" \"Screening guidelines for dyslipidemia\"",
" </a>",
" .)",
" </p>",
" <p>",
" The World Health Organization (WHO) does not recommend routine lipid
monitoring during first-line ART regimens in resource-limited settings [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/7\">",
" 7",
" </a>",
" ]. One study from Uganda of 987 treatment-naive patients taking an NNRTI-
containing regimen supported the safety of this approach; over a period of 24
months of follow-up, increases in HDL-c were substantial and proportionally greater
than increases in total cholesterol or triglycerides [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/8\">",
" 8",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H4\">",
" <span class=\"h1\">",
" RISK STRATIFICATION AND TARGET GOALS",
" </span>",
" &nbsp;&mdash;&nbsp;Definitions for dyslipidemia, as defined by the National
Cholesterol Education Program (NCEP) guidelines, include TC &ge;200",
" <span class=\"nowrap\">",
" mg/dL,",
" </span>",
" LDL cholesterol &ge;130",
" <span class=\"nowrap\">",
" mg/dL,",
" </span>",
" triglycerides &ge;150 mg",
" <span class=\"nowrap\">",
" /dL,",
" </span>",
" HDL cholesterol &lt;40",
" <span class=\"nowrap\">",
" mg/dL,",
" </span>",
" and",
" <span class=\"nowrap\">",
" TC/HDL",
" </span>",
" ratio &ge;6.5 (",
" <a class=\"graphic graphic_table graphicRef53863 \" href=\"UTD.htm?
15/15/15612\">",
" table 2",
" </a>",
" ). These guidelines suggest that the intensity of risk reduction therapy
should be tailored to the patient's risk of having a cardiovascular event [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/9\">",
" 9",
" </a>",
" ]. The factors that are examined in the assessment of risk include age,
smoking, elevated total cholesterol, low HDL, family history of premature CHD,
hypertension, and in women, menopausal status.",
" </p>",
" <p>",
" Cardiovascular risk assessment is an essential requirement for the judicious
use of cholesterol-lowering therapies in primary prevention of CHD. The highest-
risk patients (eg, with known CHD or CHD equivalent, such as diabetes) are treated
most aggressively [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. Target goals for the general patient population are discussed in detail
elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?38/8/39048?
source=see_link\">",
" \"Estimation of cardiovascular risk in an individual patient without known
cardiovascular disease\"",
" </a>",
" .)",
" </p>",
" <p>",
" Guidelines from the Infectious Diseases Society of America and the HIV
Medicine Association suggest that HIV-infected adults should undergo evaluation and
treatment on the basis of the NCEP guidelines for dyslipidemia, with particular
attention to potential drug interactions [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. However, one study showed that 40 percent of the HIV-infected patients who
had abnormal LDL levels did not have appropriate clinical management by their
providers over 12 months of follow-up [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/10\">",
" 10",
" </a>",
" ]. This observation may have been related to lack of awareness of treatment
guidelines.",
" </p>",
" <p>",
" Initial therapy with a statin is recommended for elevated low-density
lipoprotein cholesterol levels. The level at which a medication intervention is
initiated depends on the number of cardiac risk factors that are present. The early
initiation of a fibrate, in addition to nonpharmacologic therapy, is recommended
when triglyceride concentrations exceed 500",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" to reduce the risk of pancreatitis [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. If moderate elevations of triglycerides are present (eg, 200-500",
" <span class=\"nowrap\">",
" mg/dL),",
" </span>",
" pharmacologic treatment, in addition to diet and exercise, should be initiated
if two or more cardiovascular risk factors are present [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/11\">",
" 11",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?14/32/14856?
source=see_link\">",
" \"Treatment of lipids (including hypercholesterolemia) in primary
prevention\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?38/8/39048?
source=see_link\">",
" \"Estimation of cardiovascular risk in an individual patient without known
cardiovascular disease\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/47/35578?
source=see_link\">",
" \"Approach to the patient with hypertriglyceridemia\"",
" </a>",
" .)",
" </p>",
" <p>",
" The NCEP guidelines have also identified the metabolic syndrome as a secondary
target for intervention [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. Since many of the features of this syndrome overlap with HIV associated
lipodystrophy, these guidelines have direct implications for the majority of HIV-
infected patients. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/43/26298?
source=see_link\">",
" \"Epidemiology, clinical manifestations, and diagnosis of HIV-associated
lipodystrophy\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H5\">",
" <span class=\"h1\">",
" MINIMIZING THE RISK OF CARDIOVASCULAR DISEASE",
" </span>",
" &nbsp;&mdash;&nbsp;The optimal approach to risk reduction is not precisely
defined, but it is widely accepted that the same risk reduction techniques that are
used in HIV-seronegative individuals should apply [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/5\">",
" 5",
" </a>",
" ]. These strategies include",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/7/24698?source=see_link\">",
" aspirin",
" </a>",
" use, if appropriate, lipid therapy, blood pressure control, and attention to
diabetes [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/6\">",
" 6",
" </a>",
" ]. Counseling about lifestyle interventions should address potentially
modifiable risk factors, such as smoking, obesity, excessive alcohol use, diet, and
lack of physical activity. (See",
" <a class=\"local\" href=\"#H2\">",
" 'Assessing cardiovascular risk factors'",
" </a>",
" above and",
" <a class=\"medical medical_review\" href=\"UTD.htm?5/28/5576?
source=see_link\">",
" \"Overview of primary prevention of coronary heart disease and stroke\"",
" </a>",
" .)",
" </p>",
" <p>",
" When lifestyle modifications are not sufficient, lipid lowering medications
may be required. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?14/32/14856?
source=see_link\">",
" \"Treatment of lipids (including hypercholesterolemia) in primary
prevention\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?32/29/33241?
source=see_link\">",
" \"Screening guidelines for dyslipidemia\"",
" </a>",
" .)",
" </p>",
" <p>",
" Despite the growing importance of cardiovascular morbidity in HIV-infected
patients, strategies to minimize cardiovascular disease are often not optimally
implemented. As an example, in a study of 397 HIV-infected individuals who were
established patients of an HIV clinic and met criteria for",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/7/24698?source=see_link\">",
" aspirin",
" </a>",
" for primary prevention of cardiovascular disease based on their Framingham
risk scores, only 66 (17 percent) were prescribed the medication [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/12\">",
" 12",
" </a>",
" ]. This finding highlights the importance of improving awareness of
cardiovascular disease risk reduction interventions in the primary care of HIV-
infected patients.",
" </p>",
" <p>",
" Interventions that have been studied specifically in HIV-infected patients are
discussed below.",
" </p>",
" <p class=\"headingAnchor\" id=\"H6\">",
" <span class=\"h2\">",
" Exercise and diet modification",
" </span>",
" &nbsp;&mdash;&nbsp;Exercise and weight reduction should be given emphasis in
any preventive cardiovascular programs for HIV-infected patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/13\">",
" 13",
" </a>",
" ]. One study compared the dietary intake of 362 HIV-infected patients and 164
HIV-seronegative individuals [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/14\">",
" 14",
" </a>",
" ]. Compared to the HIV uninfected participants, a significantly greater number
of HIV-seropositive patients had a dietary history above the US recommended
allowances for total fat, saturated fat, and cholesterol intake. The investigators
felt that the increased intake of saturated fat and cholesterol contributed to the
elevated triglycerides that were also noted in this patient population. These data
suggest that HIV-infected individuals may benefit from extensive dietary
counseling.",
" </p>",
" <p>",
" The benefit of intensive dietary guidance is further supported by the results
of a trial of 83 HIV-infected patients newly initiating antiretroviral therapy, in
which all subjects received individually tailored nutritional counseling and then
were randomly assigned to quarterly nutritional guidance or no further counseling
[",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/15\">",
" 15",
" </a>",
" ]. An equivalent majority of patients in both groups were started on a regimen
of",
" <a class=\"drug drug_general\" href=\"UTD.htm?23/28/24008?source=see_link\">",
" zidovudine",
" </a>",
" ,",
" <a class=\"drug drug_general\" href=\"UTD.htm?5/15/5366?source=see_link\">",
" emtricitabine",
" </a>",
" , and",
" <a class=\"drug drug_general\" href=\"UTD.htm?28/42/29353?source=see_link\">",
" efavirenz",
" </a>",
" . The study reported the following findings at 12 months:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Patients in the intervention group had lower intake of total calories, total
cholesterol, and percentage of calories from fat and had higher intake of
carbohydrate and fiber compared with their own baseline and to the control group.",
" </li>",
" <li>",
" The intervention group had a decrease in triglycerides and no change in
total cholesterol, LDL-c, and body mass index compared with baseline. In contrast,
the control group experienced increases in total cholesterol, triglycerides, and
LDL-c, as well as body mass index compared with baseline. Compared with the control
group, the intervention group had lower levels of total cholesterol, triglycerides,
and LDL-c and lower body mass index.",
" </li>",
" <li>",
" There were fewer patients with total cholesterol &gt;200, triglycerides
&gt;150, and LCL-c &gt;130 in the intervention group than in the control group (7,
16, and 2 versus 39, 51, and 18 percent).",
" </li>",
" </ul>",
" </p>",
" <p>",
" Other small case series and studies also demonstrate an improvement in
dyslipidemia as well as improvements in waist circumference, systolic blood
pressure, and hemoglobin A1C levels with dietary or exercise interventions [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/16-18\">",
" 16-18",
" </a>",
" ].",
" </p>",
" <p>",
" While some patients substantially improve their dyslipidemia from dietary
interventions and exercise, many patients require the addition of a lipid-lowering
agent to reach their target cholesterol goals [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/19\">",
" 19",
" </a>",
" ]. (See",
" <a class=\"local\" href=\"#H10\">",
" 'Lipid-lowering agents'",
" </a>",
" below.)",
" </p>",
" <p class=\"headingAnchor\" id=\"H7\">",
" <span class=\"h2\">",
" Smoking cessation",
" </span>",
" &nbsp;&mdash;&nbsp;In the United States, smoking accounts for nearly one in
five deaths [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/20\">",
" 20",
" </a>",
" ]. A higher prevalence of smoking has been demonstrated among HIV-infected
patients than in HIV-seronegative controls [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/4,21\">",
" 4,21",
" </a>",
" ]. Despite this, there are few studies evaluating smoking cessation in those
infected with HIV.",
" </p>",
" <p>",
" The efficacy of two smoking cessation approaches was evaluated in 95
economically disadvantaged HIV-seropositive patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/22\">",
" 22",
" </a>",
" ]. All study participants received nicotine patches for 10 weeks, self-help
pamphlets, and initial counseling by their physician. Forty-eight study patients
were randomly assigned to receive an additional intervention of eight counseling
phone calls over the initial two month cessation period. Three months after
completion of treatment, individuals who received the counseling intervention were
significantly more likely to be abstinent than the control group (mean 30.4 days
versus 18.5 days). A behavioral approach to smoking cessation is discussed
elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?12/38/12904?
source=see_link\">",
" \"Smoking cessation counseling strategies in primary care\"",
" </a>",
" .)",
" </p>",
" <p>",
" Pharmacologic interventions may be of benefit to individuals who want to stop
smoking. Clinicians should be aware that",
" <a class=\"drug drug_general\" href=\"UTD.htm?25/29/26073?source=see_link\">",
" bupropion",
" </a>",
" is metabolized by the cytochrome P450 enzyme system and may cause interactions
with antiretroviral drugs. Other commonly employed smoking cessation agents are not
metabolized by this system and theoretically should not interact with a patient's
antiretroviral regimen. A thorough discussion of smoking cessation is discussed
elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/11/34997?
source=see_link\">",
" \"Patterns of tobacco use\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?23/3/23609?
source=see_link\">",
" \"Overview of smoking cessation management in adults\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H8\">",
" <span class=\"h2\">",
" Role of antiretroviral therapy",
" </span>",
" &nbsp;&mdash;&nbsp;Some HIV treatment guidelines recommend the initiation of
antiretroviral therapy (ART) in all HIV-infected patients regardless of CD4 cell
count, in part because of the risk of non-AIDS-associated complications, including
cardiovascular morbidity, with uncontrolled HIV infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/23\">",
" 23",
" </a>",
" ]. Other guidelines specify that ART should be offered regardless of CD4 cell
count to HIV-infected patients at high risk of a cardiovascular event [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/24\">",
" 24",
" </a>",
" ]. In a multivariate analysis involving 487 HIV-infected patients and 69,870
HIV-seronegative patients, elevated C-reactive protein (CRP) and HIV infection were
independently associated with risk of developing an acute myocardial infarction [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/25\">",
" 25",
" </a>",
" ]. Although some studies have shown that ART reduces the level of biomarkers,
like CRP, they remain elevated compared with HIV seronegative individuals [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/25-27\">",
" 25-27",
" </a>",
" ]. To date there are no data from randomized clinical trials to demonstrate
that earlier ART will in fact lower the incidence of CVD, however, studies are in
progress to address this question.",
" </p>",
" <p class=\"headingAnchor\" id=\"H30236040\">",
" <span class=\"h3\">",
" Treatment-naive patients",
" </span>",
" &nbsp;&mdash;&nbsp;When initiating ART in the patient with cardiovascular risk
factors, consideration should be given to initiating medications with more
favorable lipid profiles. For example,",
" <a class=\"drug drug_general\" href=\"UTD.htm?0/31/506?source=see_link\">",
" atazanavir",
" </a>",
" [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/28\">",
" 28",
" </a>",
" ] or",
" <a class=\"drug drug_general\" href=\"UTD.htm?35/39/36473?source=see_link\">",
" darunavir",
" </a>",
" may be preferred to other protease inhibitors in the treatment-naive
patient.",
" </p>",
" <p>",
" Some data from the D:A:D and SMART trials suggest an association between",
" <a class=\"drug drug_general\" href=\"UTD.htm?30/63/31734?source=see_link\">",
" abacavir",
" </a>",
" use and risk of myocardial infarction. In treatment-naive patients with
significant cardiovascular risk factors and no evidence of drug resistance or renal
disease,",
" <a class=\"drug drug_general\" href=\"UTD.htm?1/52/1863?source=see_link\">",
" tenofovir-emtricitabine",
" </a>",
" may be a preferred nucleoside analog backbone until further data are
available. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/1/26650?
source=see_link\">",
" \"Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?3/18/3370?
source=see_link\">",
" \"Considerations prior to initiating antiretroviral therapy\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H30236047\">",
" <span class=\"h3\">",
" Treatment-experienced patients",
" </span>",
" &nbsp;&mdash;&nbsp;Several studies have evaluated whether certain switch
strategies may be beneficial in lowering lipids:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Several randomized studies suggest that switching from a lopinavir-
containing regimen to an",
" <a class=\"drug drug_general\" href=\"UTD.htm?0/31/506?source=see_link\">",
" atazanavir",
" </a>",
" -containing regimen has a beneficial effect on lipid profiles while
maintaining virologic suppression [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/29-31\">",
" 29-31",
" </a>",
" ]; however, one study, which also evaluated endothelial function (as
measured by brachial artery flow mediated dilation) did not show any improvement
after switching to atazanavir [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/31\">",
" 31",
" </a>",
" ].",
" </li>",
" <li>",
" Two randomized controlled trials have evaluated the impact of a switch from
a boosted PI to a",
" <a class=\"drug drug_general\" href=\"UTD.htm?10/27/10678?
source=see_link\">",
" raltegravir",
" </a>",
" -based regimen [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/32,33\">",
" 32,33",
" </a>",
" ]. This approach has been associated with a favorable impact on lipids;
however, some patients who were switched to raltegravir experienced virologic
breakthrough. These data are discussed in detail elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?7/34/7720?
source=see_link\">",
" \"Clinical trials of HIV antiretroviral therapy: Integrase inhibitors\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p>",
" A detailed discussion of the various antiretroviral medications and their
effects on lipids is discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/1/26650?
source=see_link\">",
" \"Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H9\">",
" <span class=\"h2\">",
" Cocaine use",
" </span>",
" &nbsp;&mdash;&nbsp;Cocaine use has been linked to coronary calcification [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/34\">",
" 34",
" </a>",
" ]. In a study of 165 African American HIV-infected patients, significant
coronary stenosis (&ge;50 percent) was detected in 15 percent of participants [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/35\">",
" 35",
" </a>",
" ]. Those patients with long-term cocaine use (greater than 15 years) had the
highest prevalence of significant stenosis (42 percent).",
" </p>",
" <p class=\"headingAnchor\" id=\"H10\">",
" <span class=\"h1\">",
" LIPID-LOWERING AGENTS",
" </span>",
" &nbsp;&mdash;&nbsp;Often changes in lifestyle or antiretroviral medications
are not sufficient to improve lipid profiles in HIV-infected patients and lipid-
lowering agents are required. This principle was well illustrated in a small study
of 130 HIV-seropositive patients on protease inhibitor (PI) therapy who were
randomly assigned to either lipid-reducing medications (",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/27/25016?source=see_link\">",
" pravastatin",
" </a>",
" or",
" <a class=\"drug drug_general\" href=\"UTD.htm?12/40/12933?source=see_link\">",
" bezafibrate",
" </a>",
" ) or a \"switch strategy\" (substitution of protease inhibitor with an non-
nucleoside reverse transcriptase inhibitors) [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/36\">",
" 36",
" </a>",
" ]. Patients in the trial were followed for one year. The study demonstrated
the following results:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Patients in the switch therapy arm experienced a significant decline in
triglycerides, particularly in those who received",
" <a class=\"drug drug_general\" href=\"UTD.htm?18/12/18633?
source=see_link\">",
" nevirapine",
" </a>",
" (a reduction of 25 and 9 percent with nevirapine and",
" <a class=\"drug drug_general\" href=\"UTD.htm?28/42/29353?
source=see_link\">",
" efavirenz",
" </a>",
" , respectively).",
" </li>",
" <li>",
" However, patients treated with a lipid-lowering agent demonstrated a
significantly greater reduction in triglycerides (41 percent decline with",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/27/25016?
source=see_link\">",
" pravastatin",
" </a>",
" ; 47 percent with",
" <a class=\"drug drug_general\" href=\"UTD.htm?12/40/12933?
source=see_link\">",
" bezafibrate",
" </a>",
" ).",
" </li>",
" </ul>",
" </p>",
" <p>",
" These data suggest that there is a modest benefit of a \"switch strategy\".
However, in the patient with significant dyslipidemia, lipid-lowering agents are
often necessary to attain treatment goals. The choice of agent will depend on the
lipid profile of the patient and potential drug interactions as discussed below. As
a general guideline, patients with an elevated serum LDL cholesterol or
triglycerides in the 200-500",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" range should be initiated on a statin. Patients with serum triglycerides
greater than 500",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" usually require a fibrate derivative.",
" </p>",
" <p class=\"headingAnchor\" id=\"H11\">",
" <span class=\"h2\">",
" Statins",
" </span>",
" &nbsp;&mdash;&nbsp;After failing to achieve a desired lipid profile with
lifestyle and antiretroviral modifications, HMG CoA-reductase inhibitors (statins)
are the first drug of choice to reduce elevated LDL cholesterol. Statins also
decrease triglyceride levels, may increase HDL cholesterol, and have a beneficial
effect on endothelial function.",
" </p>",
" <p>",
" The mechanism of action and adverse events associated with statins are
discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?31/35/32314?
source=see_link\">",
" \"Statins: Actions, side effects, and administration\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H12\">",
" <span class=\"h3\">",
" Use with protease inhibitors",
" </span>",
" &nbsp;&mdash;&nbsp;The choice of statin depends on whether or not a patient is
taking a protease inhibitor (PI). All statins are metabolized to some degree by
cytochrome P450 3A4 (CYP3A4) and all protease inhibitors down regulate the activity
of CYP3A4. Coadministration of a statin and a protease inhibitor may lead to an
increased serum concentration of the statin and the potential for severe adverse
reactions, including rhabdomyolysis. For this reason, coadministration of statins
that are highly metabolized by CYP3A4, such as",
" <a class=\"drug drug_general\" href=\"UTD.htm?41/20/42312?source=see_link\">",
" lovastatin",
" </a>",
" or",
" <a class=\"drug drug_general\" href=\"UTD.htm?17/36/17993?source=see_link\">",
" simvastatin",
" </a>",
" , is",
" <strong>",
" contraindicated",
" </strong>",
" &nbsp;[",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ].",
" </p>",
" <p>",
" Since",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?source=see_link\">",
" atorvastatin",
" </a>",
" is only partially metabolized by the CYP3A4 system, it may be used cautiously
with protease inhibitors. A low dose (10 mg) is suggested for initial therapy along
with close monitoring for dose-related adverse effects, including myositis and
hepatitis [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. Atorvastatin is also preferred when the patient has underlying renal
insufficiency since dose reduction is not required. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?31/35/32314?
source=see_link\">",
" \"Statins: Actions, side effects, and administration\"",
" </a>",
" .)",
" </p>",
" <p>",
" The use of other statins is limited by scant data on drug interactions or
decreased efficacy:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Although",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/27/25016?
source=see_link\">",
" pravastatin",
" </a>",
" is not metabolized by CYP3A4, in studies in HIV-seronegative patients, it is
not as efficacious at LDL-c reduction as",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?
source=see_link\">",
" atorvastatin",
" </a>",
" or",
" <a class=\"drug drug_general\" href=\"UTD.htm?10/11/10424?
source=see_link\">",
" rosuvastatin",
" </a>",
" . (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?31/35/32314?
source=see_link\">",
" \"Statins: Actions, side effects, and administration\"",
" </a>",
" .)",
" </li>",
" <li>",
" Although",
" <a class=\"drug drug_general\" href=\"UTD.htm?10/11/10424?
source=see_link\">",
" rosuvastatin",
" </a>",
" is not metabolized by CYP3A4 and is known to produce a robust decrease in
LDL cholesterol, there are limited clinical data regarding its use in HIV-infected
patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/37\">",
" 37",
" </a>",
" ]. In one small study, a 1.5 to 2.0-fold increase in rosuvastatin serum
levels was demonstrated when coadministered to HIV-infected patients who were
taking",
" <span class=\"nowrap\">",
" lopinavir/",
" <a class=\"drug drug_general\" href=\"UTD.htm?11/58/12202?
source=see_link\">",
" ritonavir",
" </a>",
" </span>",
" [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/38\">",
" 38",
" </a>",
" ]. In 2007, AstraZeneca issued a statement that the use of rosuvastatin
should be limited to 10 mg daily in patients using",
" <span class=\"nowrap\">",
" lopinavir/ritonavir,",
" </span>",
" citing a fivefold increase in rosuvastatin steady-state Cmax levels when
coadministered to healthy volunteers with",
" <a class=\"drug drug_general\" href=\"UTD.htm?19/57/20378?
source=see_link\">",
" lopinavir-ritonavir",
" </a>",
" . A subsequent study comparing rosuvastatin (10 mg daily) to",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/27/25016?
source=see_link\">",
" pravastatin",
" </a>",
" (40 mg daily) among 88 HIV-infected patients taking a variety of protease
inhibitors found that rosuvastatin was more effective in lowering both LDL-c and
triglyceride levels; rosuvastatin levels were not affected by the particular
protease inhibitor that was coadministered [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/39\">",
" 39",
" </a>",
" ].",
" </li>",
" <li>",
" To date, there is little clinical data concerning the concurrent use of",
" <a class=\"drug drug_general\" href=\"UTD.htm?8/4/8264?source=see_link\">",
" fluvastatin",
" </a>",
" with protease inhibitors [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/40,41\">",
" 40,41",
" </a>",
" ]. Theoretically, fluvastatin may be started at usual doses since it is not
metabolized by the CYP3A4 system.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H13\">",
" <span class=\"h3\">",
" Use of statins with NNRTI-based regimens",
" </span>",
" &nbsp;&mdash;&nbsp;The most commonly used non-nucleoside reverse transcriptase
inhibitors (NNRTIs) include",
" <a class=\"drug drug_general\" href=\"UTD.htm?18/12/18633?source=see_link\">",
" nevirapine",
" </a>",
" and",
" <a class=\"drug drug_general\" href=\"UTD.htm?28/42/29353?source=see_link\">",
" efavirenz",
" </a>",
" . Nevirapine is a selective inducer of CYP3A4; efavirenz is a mixed inducer
and inhibitor of CYP3A4 [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. Data on coadministration of nevirapine and statins are not available.",
" </p>",
" <p>",
" A study in 52 HIV-seronegative adults who were administered",
" <a class=\"drug drug_general\" href=\"UTD.htm?28/42/29353?source=see_link\">",
" efavirenz",
" </a>",
" and three different statins (",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/27/25016?source=see_link\">",
" pravastatin",
" </a>",
" ,",
" <a class=\"drug drug_general\" href=\"UTD.htm?17/36/17993?source=see_link\">",
" simvastatin",
" </a>",
" , and",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?source=see_link\">",
" atorvastatin",
" </a>",
" ) demonstrated that efavirenz leads to significant induction of statin
metabolism [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/42\">",
" 42",
" </a>",
" ]. These observations suggest that coadministration of efavirenz may lead to
decreased efficacy of statin therapy. In contrast, there was no evidence for
alteration of efavirenz metabolism by coadministration of the statins.",
" </p>",
" <p>",
" The marked induction of metabolism with",
" <a class=\"drug drug_general\" href=\"UTD.htm?28/42/29353?source=see_link\">",
" efavirenz",
" </a>",
" noted above suggests that an increased dosing of statins may be needed in
patients who are taking both agents. If such an approach is considered, it must be
also accompanied by increased surveillance for drug toxicity (eg, quarterly
creatine phosphokinase and liver function tests). We suggest starting with the
lowest usual dose of the chosen statin and titrating upward to therapeutic
effect.",
" </p>",
" <p>",
" An even more complex question may be how to dose a statin when",
" <a class=\"drug drug_general\" href=\"UTD.htm?28/42/29353?source=see_link\">",
" efavirenz",
" </a>",
" is combined with a protease inhibitor; no data are available in this subset of
patients. We suggest dosing the statin based on its interaction with the PI that is
being administered and gradually titrating upwards to desired effect and
tolerability. Increased dosing may be required owing to the concomitant use of
efavirenz. Patients must be monitored closely for drug toxicity.",
" </p>",
" <p class=\"headingAnchor\" id=\"H14\">",
" <span class=\"h3\">",
" Hepatotoxicity",
" </span>",
" &nbsp;&mdash;&nbsp;A retrospective study of 80 HIV-infected patients who were
taking statins, including 38 patients with underlying chronic viral hepatitis,
demonstrated that statin therapy did not lead to drug-induced liver injury. In
fact, many patients with abnormal baseline aminotransferase levels had improvement
in these parameters. Although the reason for the decline in liver function tests
was not readily apparent, statins have led to similar declines in patients with
steatohepatitis [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/43\">",
" 43",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H15\">",
" <span class=\"h2\">",
" Fibrates",
" </span>",
" &nbsp;&mdash;&nbsp;The most commonly used fibrates are",
" <a class=\"drug drug_general\" href=\"UTD.htm?17/23/17784?source=see_link\">",
" fenofibrate",
" </a>",
" and",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/42/43686?source=see_link\">",
" gemfibrozil",
" </a>",
" . In contrast to the statins, these agents are metabolized by CYP4a and are
unlikely to have significant drug interactions with antiretroviral medications.",
" </p>",
" <p>",
" These agents are used to treat hypertriglyceridemia when levels are &gt;500",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" and can also be used in conjunction with statins to achieve target both LDL
cholesterol and triglyceride goals [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/44,45\">",
" 44,45",
" </a>",
" ]. When employing the two different classes together, the patient should be
monitored closely for development of myositis.",
" </p>",
" <p>",
" The mechanism of action and adverse events associated with fibrates are
discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?7/39/7800?
source=see_link\">",
" \"Lipid lowering with fibric acid derivatives\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H16\">",
" <span class=\"h2\">",
" Niacin",
" </span>",
" &nbsp;&mdash;&nbsp;Niacin can be used to decrease LDL cholesterol and
triglycerides, as well as increase HDL cholesterol, in HIV-negative individuals.
However, very little data exists evaluating this agent in HIV-seropositive
patients.",
" </p>",
" <p>",
" In one small study, 14 HIV-positive patients on ART were prescribed extended
release (ER) niacin for dyslipidemia [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/46\">",
" 46",
" </a>",
" ]. ER niacin was titrated up as high as 2000 mg per day for 14 weeks resulting
in a 34 percent decline in median triglyceride levels and a 14 percent decline in
median total cholesterol levels. No significant change was noted in LDL cholesterol
or HDL cholesterol. In addition, although none of the patients developed diabetes
during the course of the study, fasting insulin sensitivity was significantly
reduced after treatment with ER niacin. Treatment was well tolerated;
preadministration of",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/7/24698?source=see_link\">",
" aspirin",
" </a>",
" (325 mg 30 minutes before niacin) minimized niacin-associated cutaneous
flushing.",
" </p>",
" <p>",
" In another small study of 33 HIV-infected patients with dyslipidemia, ER
niacin led to declines in total cholesterol and triglycerides; increases in serum
glucose and insulin levels were transient [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/47\">",
" 47",
" </a>",
" ].",
" </p>",
" <p>",
" Although uncommon, niacin can also cause hepatotoxicity. The mechanism of
action and adverse events associated with niacin are discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/14/42217?
source=see_link\">",
" \"Lipid lowering with drugs other than statins and fibrates\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H17\">",
" <span class=\"h2\">",
" Bile-sequestering resins",
" </span>",
" &nbsp;&mdash;&nbsp;Bile-sequestering resins (eg,",
" <a class=\"drug drug_general\" href=\"UTD.htm?35/33/36374?source=see_link\">",
" cholestyramine",
" </a>",
" ) are not recommended due to concerns about possible effects on absorption of
ART.",
" </p>",
" <p class=\"headingAnchor\" id=\"H18\">",
" <span class=\"h2\">",
" Fish oil",
" </span>",
" &nbsp;&mdash;&nbsp;Fish oil contains two medically relevant long-chain
polyunsaturated fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA), collectively known as omega-3 fatty acids. Omega-3 fatty acids are
successfully employed to treat hypertriglyceridemia in HIV-negative individuals [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/48\">",
" 48",
" </a>",
" ]. They are dosed at 4 grams per day either singly or in a divided dose.",
" </p>",
" <p>",
" Fish oils have demonstrated a positive effect on triglyceride levels in HIV-
infected patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/49,50\">",
" 49,50",
" </a>",
" ]. One study randomly assigned 52 HIV-infected patients with
hypertriglyceridemia to receive lifestyle modification counseling with or without
fish oil supplementation for 16 weeks [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/49\">",
" 49",
" </a>",
" ]. After four weeks, mean triglyceride levels significantly declined from 461
to 306",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" in the supplementation group and remained low. Omega-3 fatty acid
supplementation was well tolerated when taken daily with food.",
" </p>",
" <p>",
" Since fish oil has antiplatelet effects, patients concomitantly using drugs
that affect bleeding time should be monitored for adverse effects. Potential side
effects of fish oil are discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?27/51/28474?
source=see_link\">",
" \"Lipid lowering with diet or dietary supplements\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H19\">",
" <span class=\"h2\">",
" Ezetimibe",
" </span>",
" &nbsp;&mdash;&nbsp;",
" <a class=\"drug drug_general\" href=\"UTD.htm?4/42/4773?source=see_link\">",
" Ezetimibe",
" </a>",
" reduces the absorption of cholesterol from the gastrointestinal tract and is
indicated as an adjunctive therapy to diet",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" statins for the reduction of LDL cholesterol in patients with primary
hypercholesterolemia. Clinical trials evaluating individuals not infected with HIV
have shown ezetimibe to reduce LDL cholesterol by 20 percent when used alone. The
addition of a statin resulted in close to a 50 percent reduction [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/51\">",
" 51",
" </a>",
" ]. However, recent trials of combination therapy with ezetimibe and statin
therapy in HIV-uninfected adults failed to demonstrate a beneficial effect on
carotid intima media thickness [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/52\">",
" 52",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/14/42217?
source=see_link\">",
" \"Lipid lowering with drugs other than statins and fibrates\"",
" </a>",
" .)",
" </p>",
" <p>",
" Statins can be problematic in HIV-infected patients due to drug interactions;
however,",
" <a class=\"drug drug_general\" href=\"UTD.htm?4/42/4773?source=see_link\">",
" ezetimibe",
" </a>",
" does not have any P450 interactions, which decreases the risk of potential
drug interactions with other antiretroviral agents.",
" </p>",
" <p>",
" There are limited data on the use of",
" <a class=\"drug drug_general\" href=\"UTD.htm?4/42/4773?source=see_link\">",
" ezetimibe",
" </a>",
" in HIV-infected patients:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" The safety and efficacy of",
" <a class=\"drug drug_general\" href=\"UTD.htm?4/42/4773?source=see_link\">",
" ezetimibe",
" </a>",
" was evaluated in randomized, double-blind cross over trial in 48 HIV-
infected individuals with LDL cholesterol &ge; 75",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/53\">",
" 53",
" </a>",
" ]. All patients were using ART and none were receiving lipid lowering agents
on study admission. Individuals were randomized to ezetimibe 10 mg daily or placebo
for a six week period, followed by a two week wash out period and finally a six
week cross over. During the six weeks of use, ezetimibe was well tolerated and
resulted in a significant decline in LDL cholesterol (median 12 percent decrease
compared to placebo). No changes in HDL cholesterol or TC were observed.",
" </li>",
" <li>",
" In a multicenter, double-blind, placebo-controlled crossover trial, 44
patients were randomly assigned to",
" <a class=\"drug drug_general\" href=\"UTD.htm?4/42/4773?source=see_link\">",
" ezetimibe",
" </a>",
" (10 mg daily) or placebo for 12 weeks followed by 4 weeks of washout and
then 12 weeks with the alternative study assignment [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/54\">",
" 54",
" </a>",
" ]. All patients were already taking a statin for an abnormal lipid profile.
The addition of ezetimibe was associated with significant declines in LDL-c, total
cholesterol, non-HDL-c and apolipoprotein. No significant changes in triglycerides
were seen.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H20\">",
" <span class=\"h1\">",
" CHOICE OF INITIAL DRUG REGIMEN",
" </span>",
" &nbsp;&mdash;&nbsp;As noted in the guidelines from the Infectious Diseases
Society of America and the HIV Medicine Association, when a lipid-lowering drug is
necessary, the choice of agent will depend on the lipid profile [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]&nbsp;(",
" <a class=\"graphic graphic_table graphicRef62891 \" href=\"UTD.htm?
2/44/2764\">",
" table 3",
" </a>",
" ). Generally, statins should be used preferentially in most situations. We
recommend",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?source=see_link\">",
" atorvastatin",
" </a>",
" (10 mg daily starting dose) due to its efficacy (compared with other classes
of lipid lowering drugs) and lower risk of drug interactions with protease
inhibitors (compared with other statins).",
" <a class=\"drug drug_general\" href=\"UTD.htm?24/27/25016?source=see_link\">",
" Pravastatin",
" </a>",
" (20 daily starting dose) is an acceptable alternative due to its lack of
metabolism through the CYP3A4 system; however, it is not as efficacious as
atorvastatin in reducing LDL cholesterol. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?31/35/32314?
source=see_link\">",
" \"Statins: Actions, side effects, and administration\"",
" </a>",
" .)",
" </p>",
" <p>",
" One exception to this approach is in the patient with a triglyceride level of
&gt;500",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. We recommend",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/42/43686?source=see_link\">",
" gemfibrozil",
" </a>",
" (600 mg twice daily given 30 minutes before morning and evening meals) due to
its efficacy and established role in reducing cardiovascular risk in patients with
hypertriglyceridemia. Another alternative is",
" <a class=\"drug drug_general\" href=\"UTD.htm?17/23/17784?source=see_link\">",
" fenofibrate",
" </a>",
" 54 to 160 mg daily. Fish oil and niacin may also be considered.",
" </p>",
" <p>",
" Once an intervention is selected, a fasting lipid profile should be repeated
within the next three to four months to assess the therapeutic response.",
" </p>",
" <p class=\"headingAnchor\" id=\"H21\">",
" <span class=\"h1\">",
" COMBINATION THERAPY",
" </span>",
" &nbsp;&mdash;&nbsp;In those patients who do not reach their target cholesterol
goals on their initial therapy, combination therapy with a statin and fibrate
derivative can be considered. The potential benefit and safety of combination
therapy in HIV-infected patients was noted in one study of",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?source=see_link\">",
" atorvastatin",
" </a>",
" and",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/42/43686?source=see_link\">",
" gemfibrozil",
" </a>",
" [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/55\">",
" 55",
" </a>",
" ]. However, combination therapy should be approached with caution due to the
risk of myopathy [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/49/abstract/2\">",
" 2",
" </a>",
" ]. This may be of particular concern in patients who are also taking
antiretroviral agents with the potential for inducing myopathy, such as",
" <a class=\"drug drug_general\" href=\"UTD.htm?23/28/24008?source=see_link\">",
" zidovudine",
" </a>",
" .",
" </p>",
" <p>",
" Statin therapy may also be combined with niacin for persistently elevated LDL
cholesterol with monitoring of liver function tests and random glucose
concentrations.",
" </p>",
" <p>",
" For patients who do not reach their target triglyceride level goals, the
addition of a fish oil supplement or niacin can be considered. If the patient is
considered at risk of pancreatitis due to severe elevations of triglycerides,
attention should also be paid to any other modifiable risk factors for pancreatitis
(eg, alcohol use or concomitant",
" <a class=\"drug drug_general\" href=\"UTD.htm?14/38/14952?source=see_link\">",
" didanosine",
" </a>",
" or",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/45/43734?source=see_link\">",
" stavudine",
" </a>",
" use).",
" </p>",
" <p class=\"headingAnchor\" id=\"H22\">",
" <span class=\"h1\">",
" SUMMARY AND RECOMMENDATIONS",
" </span>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Dyslipidemia is common in HIV-infected patients who are receiving
antiretroviral therapy. It may be seen as an isolated finding or in the presence
fat redistribution and insulin resistance. &nbsp;(See",
" <a class=\"local\" href=\"#H1\">",
" 'Introduction'",
" </a>",
" above.)",
" </li>",
" <li>",
" We suggest that HIV-infected adults be evaluated and treated for
dyslipidemia in a similar fashion as in any HIV-seronegative patient with
comprehensive attention to underlying cardiac risk factors (",
" <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
" Grade 2C",
" </a>",
" ). (See",
" <a class=\"local\" href=\"#H2\">",
" 'Assessing cardiovascular risk factors'",
" </a>",
" above.)",
" </li>",
" <li>",
" Cardiac risk factor assessment should be considered when designing an
initial ART regimen in the patient with cardiac risk factors. (See",
" <a class=\"local\" href=\"#H8\">",
" 'Role of antiretroviral therapy'",
" </a>",
" above.)",
" </li>",
" <li>",
" Definitions for dyslipidemia, as defined by the National Cholesterol
Education Program (NCEP) guidelines should be utilized to guide management of HIV-
infected patients, pending further data. (See",
" <a class=\"local\" href=\"#H4\">",
" 'Risk stratification and target goals'",
" </a>",
" above.)",
" </li>",
" <li>",
" Lifestyle and dietary modifications and should be addressed in every
patient. Smokers should be advised regarding the benefits of smoking cessation.
(See",
" <a class=\"local\" href=\"#H5\">",
" 'Minimizing the risk of cardiovascular disease'",
" </a>",
" above.)",
" </li>",
" <li>",
" The antiretroviral regimen should be scrutinized to determine if drug
modification may be potentially helpful to minimize lipid abnormalities. For
patients with dyslipidemia who have an undetectable viral load (and no prior
history of virologic failure or drug resistance) while on a regimen based on",
" <span class=\"nowrap\">",
" lopinavir/",
" <a class=\"drug drug_general\" href=\"UTD.htm?11/58/12202?
source=see_link\">",
" ritonavir",
" </a>",
" </span>",
" or other protease inhibitors associated with lipid abnormalities, we suggest
a switch to either a boosted",
" <a class=\"drug drug_general\" href=\"UTD.htm?0/31/506?source=see_link\">",
" atazanavir",
" </a>",
" - or",
" <a class=\"drug drug_general\" href=\"UTD.htm?10/27/10678?
source=see_link\">",
" raltegravir",
" </a>",
" -based regimen (",
" <a class=\"grade\" href=\"._grade_5?title=Grade 2B\">",
" Grade 2B",
" </a>",
" ). Alternatively, a protease inhibitor can be switched to a non-nucleoside
reverse transcriptase inhibitor, such as",
" <a class=\"drug drug_general\" href=\"UTD.htm?18/12/18633?
source=see_link\">",
" nevirapine",
" </a>",
" or possibly",
" <a class=\"drug drug_general\" href=\"UTD.htm?15/27/15798?
source=see_link\">",
" rilpivirine",
" </a>",
" . The prior treatment history should be examined to evaluate for potential
underlying drug resistance that may increase the risk of virological failure with a
switch in antiretroviral regimen. (See",
" <a class=\"local\" href=\"#H8\">",
" 'Role of antiretroviral therapy'",
" </a>",
" above and",
" <a class=\"medical medical_review\" href=\"UTD.htm?26/1/26650?
source=see_link\">",
" \"Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients\"",
" </a>",
" .)",
" </li>",
" <li>",
" In some patients, these conservative measures are not enough to attain
desirable lipid levels. Statin therapy is preferred for patients with elevated LDL
cholesterol. In patients with moderately elevated triglycerides (200 to 500",
" <span class=\"nowrap\">",
" mg/dL),",
" </span>",
" the administration of a statin should be considered when two or more cardiac
risk factors are present. When a statin is desired, we suggest",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?
source=see_link\">",
" atorvastatin",
" </a>",
" (10 mg daily) to decrease the risk of drug interactions (",
" <a class=\"grade\" href=\"._grade_5?title=Grade 2B\">",
" Grade 2B",
" </a>",
" ). (See",
" <a class=\"local\" href=\"#H11\">",
" 'Statins'",
" </a>",
" above.)",
" </li>",
" <li>",
" Fibrate therapy (",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/42/43686?
source=see_link\">",
" gemfibrozil",
" </a>",
" or",
" <a class=\"drug drug_general\" href=\"UTD.htm?17/23/17784?
source=see_link\">",
" fenofibrate",
" </a>",
" ) is preferred as first line therapy in patients with severe
hypertriglyceridemia (&gt; 500",
" <span class=\"nowrap\">",
" mg/dL).",
" </span>",
" (See",
" <a class=\"local\" href=\"#H15\">",
" 'Fibrates'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/36\">",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/37\">",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/39\">",
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" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/40\">",
" Doser N, K&uuml;bli S, Telenti A, et al. Efficacy and safety of fluvastatin
in hyperlipidemic protease inhibitor-treated HIV-infected patients. AIDS 2002;
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" </a>",
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" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/41\">",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/42\">",
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" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/43\">",
" Milazzo L, Menzaghi B, Corvasce S, et al. Safety of statin therapy in
HIV/hepatitis C virus-coinfected patients. J Acquir Immune Defic Syndr 2007;
46:258.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/44\">",
" Aberg JA, Zackin RA, Brobst SW, et al. A randomized trial of the efficacy
and safety of fenofibrate versus pravastatin in HIV-infected subjects with lipid
abnormalities: AIDS Clinical Trials Group Study 5087. AIDS Res Hum Retroviruses
2005; 21:757.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/45\">",
" Visnegarwala F, Maldonado M, Sajja P, et al. Lipid lowering effects of
statins and fibrates in the management of HIV dyslipidemias associated with
antiretroviral therapy in HIV clinical practice. J Infect 2004; 49:283.",
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" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/46\">",
" Gerber MT, Mondy KE, Yarasheski KE, et al. Niacin in HIV-infected
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Infect Dis 2004; 39:419.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/47\">",
" Dub&eacute; MP, Wu JW, Aberg JA, et al. Safety and efficacy of extended-
release niacin for the treatment of dyslipidaemia in patients with HIV infection:
AIDS Clinical Trials Group Study A5148. Antivir Ther 2006; 11:1081.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/48\">",
" Kris-Etherton PM, Harris WS, Appel LJ, American Heart Association. Nutrition
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/49\">",
" Wohl DA, Tien HC, Busby M, et al. Randomized study of the safety and
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" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/50\">",
" Gerber JG, Kitch DW, Fichtenbaum CJ, et al. Fish oil and fenofibrate for the
treatment of hypertriglyceridemia in HIV-infected subjects on antiretroviral
therapy: results of ACTG A5186. J Acquir Immune Defic Syndr 2008; 47:459.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/51\">",
" Toth PP, Davidson MH. Cholesterol absorption blockade with ezetimibe. Curr
Drug Targets Cardiovasc Haematol Disord 2005; 5:455.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/52\">",
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ezetimibe and carotid intima-media thickness. N Engl J Med 2009; 361:2113.",
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" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/53\">",
" Wohl DA, Waters D, Simpson RJ Jr, et al. Ezetimibe alone reduces low-density
lipoprotein cholesterol in HIV-infected patients receiving combination
antiretroviral therapy. Clin Infect Dis 2008; 47:1105.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/54\">",
" Chow D, Chen H, Glesby MJ, et al. Short-term ezetimibe is well tolerated and
effective in combination with statin therapy to treat elevated LDL cholesterol in
HIV-infected patients. AIDS 2009; 23:2133.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/49/abstract/55\">",
" Henry K, Melroe H, Huebesch J, et al. Atorvastatin and gemfibrozil for
protease-inhibitor-related lipid abnormalities. Lancet 1998; 352:1031.",
" </a>",
" </li>",
" </ol>",
" </div>",
" <div id=\"topicVersionRevision\">",
" Topic 3739 Version 9.0",
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" </div>",
" <div class=\"lgnd\">",
" In this Spitz tumor with atypical features, the lesion is dome-shaped and
circumscribed with a symmetric profile.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 594px\">",
" <div class=\"ttl\">",
" Histology of atypical Spitz tumor",
" </div>",
" <div class=\"cntnt\" style=\"width: 574px; height: 430px; background-image:
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" </div>",
" <div class=\"lgnd\">",
" Atypical Spitz tumor. There is a lentiginous melanocytic proliferation with
increased cytological atypia and pleomorphism. The lesion lacks eosinophilic
globules (Kamino bodies).",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 596px\">",
" <div class=\"ttl\">",
" Cytologic features of atypical Spitz tumor",
" </div>",
" <div class=\"cntnt\" style=\"width: 576px; height: 432px; background-image:
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\">",
" </div>",
" <div class=\"lgnd\">",
" Atypical Spitz tumor. There is increased cytologic atypia within the deep
dermal component with irregular nesting pattern.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_3_50=[""].join("\n");
var outline_f0_3_50=null;
var title_f0_3_51="UpToDate Inc.";
var content_f0_3_51=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=UNDERCONSTRUCTION
%2F86988&amp;source=image_view&amp;view=print\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=UNDERCONSTRUCTION
%2F86988&amp;source=image_view&amp;view=print\" onclick=\"\" title=\"Print this
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" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
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" </div>",
"</div>"].join("\n");
var script_f0_3_51=[""].join("\n");
var outline_f0_3_51=null;
var title_f0_3_52="HBV consensus definitions";
var content_f0_3_52=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=GAST
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title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=GAST
%2F81182&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
title=\"Print this page\">",
" Print",
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" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" Email",
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" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Glossary of clinical terms used in HBV infection",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Definitions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" Chronic hepatitis B",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Chronic necroinflammatory disease of the liver caused by persistent
infection with hepatitis B virus. Chronic hepatitis B can be subdivided into HBeAg
positive and HBeAg negative chronic hepatitis B.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" Inactive HBsAg carrier state",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Persistent HBV infection of the liver without significant, ongoing
necroinflammatory disease.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" Resolved hepatitis B",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Previous HBV infection without further virological, biochemical or
histological evidence of active virus infection or disease.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" Acute exacerbation or flare of hepatitis B",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Intermittent elevations of aminotransferase activity to more than 10 times
the upper limit of normal and more than twice the baseline value.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" Reactivation of hepatitis B",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Reappearance of active necroinflammatory disease of the liver in a person
known to have the inactive HBsAg carrier state or resolved hepatitis B.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" HBeAg clearance",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Loss of HBeAg in a person who was previously HBeAg positive.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_single\">",
" HBeAg seroconversion",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Loss of HBeAg and detection of anti-HBe.",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
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var title_f0_3_53="Beta blocker poisoning - Rapid overview";
var content_f0_3_53=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=EM
%2F82572&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
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title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=EM
%2F82572&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
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" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Beta blocker poisoning: Rapid overview",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td>",
" <span style=\"color: #ff0000;\">",
" To obtain emergent consultation with a medical toxicologist, call the
United States Poison Control Network at 1-800-222-1222, or access the World Health
Organization's list of international poison centers (",
" </span>",
" <a
href=\"file://www.who.int/gho/phe/chemical_safety/poisons_centres/en/index.html\"
target=\"_blank\">",
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" <span style=\"color: #ff0000;\">",
" ).",
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" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Clinical and laboratory features",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Prominent features include hypotension and bradycardia",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Electrocardiogram can show PR prolongation or any bradydysrhythmia",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Beta-blockers with membrane-stabilizing activity may cause QRS
prolongation",
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" <tr>",
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" Diagnostic evaluation",
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" <tr>",
" <td>",
" Diagnosis depends on history and clinical presentation",
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" <tr>",
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" Assays for beta-blockers are not routinely available",
" </td>",
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" <td>",
" Toxicologic differential diagnosis for unexplained bradycardia includes
beta blockers, calcium channel blockers, digoxin, and cholinergic agents",
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" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Management",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Stabilize airway, breathing, and circulation",
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" </tr>",
" <tr>",
" <td>",
" Give boluses of isotonic IV fluids: give atropine 1 mg IV (up to 3 doses)
for initial treatment of hypotension and bradycardia",
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" </tr>",
" <tr>",
" <td>",
" <p>",
" For severe poisoning (eg, profound hypotension), give following
treatments simultaneously (dosing given below): IV glucagon, IV calcium salts,
vasopressor, IV high-dose insulin (with glucose), and IV lipid emulsion therapy.",
" </p>",
" For mild symptoms, give treatments in succession, but only if prior
treatment is ineffective.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Gastrointestinal decontamination: single dose activated charcoal; consider
whole bowel irrigation if an extended-release preparation has been ingested",
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" <tr>",
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" Glucagon: give 5 mg IV bolus, if IV fluids and atropine ineffective; may
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" </tr>",
" <tr>",
" <td>",
" Calcium chloride (via central venous access) 10 to 20 mL of 10 percent
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" <strong>",
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" </tr>",
" <tr>",
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" </tr>",
" <tr>",
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" Bolus of 1 unit/kg IV of regular, short-acting insulin, followed by",
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" </tr>",
" <tr>",
" <td class=\"sublist1\">",
" Continuous infusion of 0.5 units/kg per hour IV; titrate infusion upwards
until hypotension corrected or dose reaches 2 units/kg per hour",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Intravenous lipid emulsion (20 percent solution): give 1.5 mL/kg over 2
minutes, followed by 1.5 mL/kg infusion over 60 minutes",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Other potential treatments include: sodium bicarbonate (eg, prolonged
QRS), magnesium (ventricular dysrhythmia), intraaortic balloon pump, temporary
transvenous pacing, and hemodialysis",
" </td>",
" </tr>",
" </tbody>",
" </table>",
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" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
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var title_f0_3_54="Acral lentiginous melanoma";
var content_f0_3_54=[" <div id=\"graphicsToolbar\">",
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" ^{",
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" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
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" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" Acral lentiginous melanoma",
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" </div>",
" <div class=\"lgnd\">",
" An acral lentiginous melanoma shows the asymmetry and color variegation of
typical melanomas. They are distinguished clinically by their location on the
palms, soles, or nails.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of James C Shaw, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_3_54=[""].join("\n");
var outline_f0_3_54=null;
var title_f0_3_55="Sesamoid under 5th mcp lateral";
var content_f0_3_55=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=EM
%2F66231&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=EM
%2F66231&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 511px\">",
" <div class=\"ttl\">",
" Small sesamoid underlying the fifth metatarsophalangeal joint (arrow)",
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" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of Robert L Hatch, MD, MPH.",
" </div>",
" </div>",
" </div>",
" </div>",
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var title_f0_3_56="Morton neuroma";
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" </div>",
" <div class=\"lgnd\">",
" Symptoms of a Morton's neuroma include hyperesthesia of the toes, numbness and
tingling, and aching and burning in the distal forefoot. Pain radiates forward from
the metatarsal heads to the third and fourth toes. It is aggravated by walking on
hard surfaces and wearing tight or high-heeled shoes. Physical examination reveals
tenderness in the plantar aspect of the distal foot over the third and fourth
metatarsals; compressing the forefoot reproduces the symptoms.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_3_56=[""].join("\n");
var outline_f0_3_56=null;
var title_f0_3_57="Core components rehab B";
var content_f0_3_57=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=CARD
%2F73513&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=6\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=CARD
%2F73513&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=6\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Core components of cardiac rehabilitation/secondary prevention programs: Blood
pressure management, lipid management, diabetes management, tobacco cessation,
psychosocial management, physical activity counseling, and exercise training",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Blood pressure management",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Measure seated resting blood pressure on &ge;two visits.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Measure blood pressure in both arms at program entry.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" To rule out orthostatic hypotension, measure lying, seated, and standing
blood pressure at program entry and after adjustments in antihypertensive drug
therapy.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Assess current treatment and compliance.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Assess use of nonprescription drugs that may adversely affect blood
pressure.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Provide and/or monitor drug therapy in concert with primary healthcare
provider as follows:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" If blood pressure is 120 to 139 mmHg systolic or 80 to 89 mmHg
diastolic:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Provide lifestyle modifications, including regular physical
activity/exercise; weight management; moderate sodium restriction and increased
consumption of fresh fruits, vegetables, and low-fat dairy products; alcohol
moderation; and smoking cessation.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Provide drug therapy for patients with chronic kidney disease,
heart failure, or diabetes if blood pressure is &ge;130 / &ge;80 mmHg after
lifestyle modification.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" If blood pressure is &ge;140 mmHg systolic or &ge;90 mmHg diastolic:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Provide lifestyle modification and drug therapy.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Short-term: Continue to assess and modify intervention until normalization
of blood pressure in prehypertensive patients; &lt;140 mmHg systolic and &lt;90
mmHg diastolic in hypertensive patients; &lt;130 mmHg systolic and &lt;80 mmHg
diastolic in hypertensive patients with diabetes, heart failure, or chronic kidney
disease.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Long-term: Maintain blood pressure at goal levels.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Lipid management",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Obtain fasting measures of total cholesterol, high-density lipoprotein,
low-density lipoprotein, and triglycerides. In those patients with abnormal levels,
obtain a detailed history to determine whether diet, drug, and/or other conditions
that may affect lipid levels can be altered.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Assess current treatment and compliance.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Repeat lipid profiles at&nbsp;four to six&nbsp;weeks after hospitalization
and at two months after initiation or change in lipid-lowering medications.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Assess creatine kinase levels and liver function in patients taking lipid-
lowering medications as recommended by NCEP.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Provide nutritional counseling consistent with the Therapeutic Lifestyle
Change diet, such as the recommendation to add plant stanol/sterols and viscous
fiber and the encouragement to consume more omega-3 fatty acids, as well as weight
management counseling, as needed, in all patients. Add or intensify drug treatment
in those with low-density lipoprotein &gt;100 mg/dL; consider adding drug treatment
in those with low-density lipoprotein &gt;70 mg/dL.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Provide interventions directed toward management of triglycerides to
attain non-high-density lipoprotein cholesterol &lt;130 mg/dL. These include
nutritional counseling and weight management, exercise, smoking cessation, alcohol
moderation, and drug therapy as per NCEP and AHA/ACC.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Provide and/or monitor drug treatment in concert with primary healthcare
provider.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Short-term: Continue to assess and modify intervention until low-density
lipoprotein is &lt;100 mg/dL (further reduction to a goal &lt;70 mg/dL is
considered reasonable) and non-high-density lipoprotein cholesterol &lt;130 mg/dL
(further reduction to a goal of &lt;100 mg/dL is considered reasonable).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Long-term: Low-density lipoprotein cholesterol &lt;100 mg/dL (further
reduction to a goal &lt;70 mg/dL is considered reasonable). Non-high-density
lipoprotein cholesterol &lt;130 mg/dL (further reduction to a goal of &lt;100 mg/dL
is considered reasonable).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Diabetes management",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" From medical record review:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Confirm presence or absence of diabetes in all patients.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; If a patient is known to be diabetic, identify history of
complications such as findings related to heart disease; vascular disease; problems
with eyes, kidneys, or feet; or autonomic or peripheral neuropathy.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" From initial patient interview:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Obtain history of signs/symptoms related to above complications
and/or reports of episodes of hypoglycemia or hyperglycemia.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Identify physician managing diabetic condition and prescribed
treatment regimen, including:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist3\">",
" - Medications and extent of compliance.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist3\">",
" - Diet and extent of compliance.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist3\">",
" - Blood sugar monitoring method and extent of compliance.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" Before starting exercise:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Obtain latest fasting plasma glucose (FPG) and glycosylated
hemoglobin (HbA1c).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Consider stratifying patient to high-risk category because of the
greater likelihood of exercise-induced complications.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Educate patient and staff to be alert for signs/symptoms of hypoglycemia
or hyperglycemia and provide appropriate assessment and interventions as per the
American Diabetes Association.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" In those taking insulin or insulin secretogogues:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Avoid exercise at peak insulin times.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Advise that insulin be injected in abdomen, not muscle to be
exercised.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Test blood sugar levels pre- and post-exercise at each session: if
blood sugar value is &lt;100 mg/dL, delay exercise and provide patient 15 g of
carbohydrate; retest in 15 minutes; proceed if blood sugar value is &gt;100 mg/dL;
if blood sugar value is &gt;300 mg/dL, patient may exercise if he or she feels
well, is adequately hydrated, and blood and/or urine ketones are negative;
otherwise, contact patient's physician for further treatment.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Encourage adequate hydration to avoid effects of fluid shifts on
blood sugar levels.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Caution patient that blood sugar may continue to drop for 24 to 48
hours after exercise.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" In those treated with diet, metformin, alpha glucosidase inhibitors,
and/or thiozolidinediones, without insulin or insulin secretogogues, test blood
sugar levels prior to exercise for first 6 to 10 sessions to assess glycemic
control; exercise is generally unlikely to cause hypoglycemia.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" Education recommendations:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Teach and practice self-monitoring skills for use during
unsupervised exercise.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Refer to registered dietitian for medical nutrition therapy.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Consider referral to certified diabetic educator for skill
training, medication instruction, and support groups.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" Short-term:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Communicate with primary physician or endocrinologist about
signs/symptoms and medication adjustments.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Confirm patient's ability to recognize signs/symptoms, self-monitor
blood sugar status, and self-manage activities.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" Long-term:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Attain FPG levels of 90 to 130 mg/dL and HbA1c &lt;7 percent.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Minimize complications and reduce episodes of hypoglycemia or
hyperglycemia at rest and/or with exercise.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Maintain blood pressure at &lt;130 / &lt;80 mmHg.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Tobacco cessation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" Initial encounter:",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Ask the patient about his or her smoking status and use of other
tobacco products. Document status as never smoked, former smoker, current smoker
(includes those who have quit in the last 12 months because of the high probability
of relapse). Specify both amount of smoking (cigarettes per day) and duration of
smoking (number of years). Quantify use and type of other tobacco products.
Question exposure to second-hand smoke at home and at work.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Determine readiness to change by asking every smoker/tobacco user
if he or she is now ready to quit.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Assess for psychosocial factors that may impede success.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Ongoing contact: Update status at each visit during first&nbsp;two
weeks of cessation, periodically thereafter.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" When readiness to change is not expressed, provide a brief motivational
message containing the \"5 Rs\": Relevance, Risks, Rewards, Roadblocks, and
Repetition.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" When readiness to change is confirmed, continue with the \"5 As\": Ask,
Advise, Assess, Assist, and Arrange. Assist the smoker/tobacco user to set a quit
date, and select appropriate treatment strategies (preparation):",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" <em>",
" Minimal (brief)",
" </em>",
" :",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Individual education and counseling by program staff supplemented
by self-teaching materials.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Social support provided by physician, program staff, family and/or
domestic partner; identify other smokers in the house; discuss how to engage them
in the patient's cessation efforts.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Relapse prevention: problem solving, anticipated threats, practice
scenarios.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" <em>",
" Optimal (intense)",
" </em>",
" :",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Longer individual counseling or group involvement.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Pharmacological support (in concert with primary physician):
nicotine replacement therapy, bupropion hydrochloride.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; Supplemental strategies if desired (eg, acupuncture, hypnosis).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" If patient has recently quit, emphasize relapse prevention skills.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Urge avoidance of exposure to second-hand smoke at work and home.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Note: Patients who continue to smoke upon enrollment are subsequently more
likely to drop out of cardiac rehabilitation/secondary prevention programs.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Short-term: Patient will demonstrate readiness to change by initially
expressing decision to quit and selecting a quit date. Subsequently, patient will
quit smoking and all tobacco use and adhere to pharmacological therapy (if
prescribed) while practicing relapse prevention strategies; patient will resume
cessation plan as quickly as possible when temporary relapse occurs.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Long-term: Complete abstinence from smoking and use of all tobacco
products for at least 12 months (maintenance) from quit date. No exposure to
environmental tobacco smoke at work and home.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Psychosocial management",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Identify psychological distress as indicated by clinically significant
levels of depression, anxiety, anger or hostility, social isolation, marital/family
distress, sexual dysfunction/adjustment, and substance abuse (alcohol or other
psychotropic agents), using interview and/or standardized measurement tools.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Identify use of psychotropic medications.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Offer individual and/or small group education and counseling on adjustment
to heart disease, stress management, and health-related lifestyle change. When
possible, include family members, domestic partners, and/or significant others in
such sessions.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Develop supportive rehabilitation environment and community resources to
enhance the patient's and the family's level of social support.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Teach and support self-help strategies.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" In concert with primary healthcare provider, refer patients experiencing
clinically significant psychosocial distress to appropriate mental health
specialists for further evaluation and treatment.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Emotional well-being is indicated by the absence of clinically significant
psychological distress, social isolation, or drug dependency.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient demonstrates responsibility for health-related behavior change,
relaxation, and other stress management skills; ability to obtain effective social
support; compliance with psychotropic medications if prescribed; and reduction or
elimination of alcohol, tobacco, caffeine, or other nonprescription psychoactive
drugs.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Arrange for ongoing management if important psychosocial issues are
present.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Physical activity counseling",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Assess current physical activity level (eg, questionnaire, pedometer) and
determine domestic, occupational, and recreational needs.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Evaluate activities relevant to age, gender, and daily life, such as
driving, sexual activity, sports, gardening, and household tasks.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Assess readiness to change behavior, self-confidence, barriers to
increased physical activity, and social support in making positive changes.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Provide advice, support, and counseling about physical activity needs on
initial evaluation and in follow-up. Target exercise program to meet individual
needs (see Exercise Training section of table). Provide educational materials as
part of counseling efforts. Consider exercise tolerance or simulated work testing
for patients with heavy labor jobs.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Consistently encourage patients to accumulate 30 to 60 minutes per day of
moderate-intensity physical activity on &ge;5 (preferably most) days of the week.
Explore daily schedules to suggest how to incorporate increased activity into usual
routine (eg, parking farther away from entrances, walking &ge;2 flights of stairs,
and walking during lunch break).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Advise low-impact aerobic activity to minimize risk of musculoskeletal
injury. Recommend gradual increases in the volume of physical activity over time.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Caution patients to avoid performing unaccustomed vigorous physical
activity (eg, racquet sports and manual snow removal). Reassess the patient's
ability to perform such activities as exercise training program progresses.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient shows increased participation in domestic, occupational, and
recreational activities.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient shows improved psychosocial well-being, reduction in stress,
facilitation of functional independence, prevention of disability, and enhancement
of opportunities for independent self-care to achieve recommended goals.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient shows improved aerobic fitness and body composition and lessens
coronary risk factors (particularly for the sedentary patient who has adopted a
lifestyle approach to regular physical activity).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Exercise training",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Evaluation",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Symptom-limited exercise testing prior to participation in an exercise-
based cardiac rehabilitation program is strongly recommended. The evaluation may be
repeated as changes in clinical condition warrant. Test parameters should include
assessment of heart rate and rhythm, signs, symptoms, ST-segment changes,
hemodynamics, perceived exertion, and exercise capacity.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" On the basis of patient assessment and the exercise test if performed,
risk stratify the patient to determine the level of supervision and monitoring
required during exercise training. Use risk stratification schema as recommended by
the AHA and the AACVPR.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Interventions",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2_start\">",
" Develop an individualized exercise prescription for aerobic and resistance
training that is based on evaluation findings, risk stratification, comorbidities
(eg, peripheral arterial disease and musculoskeletal conditions), and patient and
program goals. The exercise regimen should be reviewed by the program medical
director or referring physician, modified if necessary, and approved. Exercise
prescription should specify frequency (F), intensity (I), duration (D), modalities
(M), and progression (P).",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; For aerobic exercise: F=3-5 days/wk; I=50-80 percent of exercise
capacity; D=20-60 minutes; and M=walking, treadmill, cycling, rowing, stair
climbing, arm/leg ergometry, and others using continuous or interval training as
appropriate.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist2\">",
" &bull; For resistance exercise: F=2-3 days/wk; I=10-15 repetitions per set
to moderate fatigue; D=1-3 sets of 8-10 different upper and lower body exercises;
and M=calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall
pulleys, or weight machines.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Include warm-up, cool-down, and flexibility exercises in each exercise
session.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Provide progressive updates to the exercise prescription and modify
further if clinical status changes.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Supplement the formal exercise regimen with activity guidelines as
outlined in the Physical Activity Counseling section of this table.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2_left\">",
" Expected outcomes",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient understands safety issues during exercise, including warning
signs/symptoms.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient achieves increased cardiorespiratory fitness and enhanced
flexibility, muscular endurance, and strength.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient achieves reduced symptoms, attenuated physiologic responses to
physical challenges, and improved psychosocial well-being.",
" </td>",
" </tr>",
" <tr>",
" <td class=\"indent1\">",
" Patient achieves reduced global cardiovascular risk and mortality
resulting from an overall program of cardiac rehabilitation/secondary prevention
that includes exercise training.",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Reproduced with permission from: Balady GJ, Williams MA, Ades PA, et al.
Circulation 2007;115:2675. Copyright 2007 Lippincott Williams &amp; Wilkins.",
" </div>",
" </div>",
" </div>",
" </div>",
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" </div>",
" <div class=\"lgnd\">",
" AP and oblique views of the right elbow show a Salter Harris II fracture of
the proximal radial neck.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of Paula Schweich, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
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" Aldesleukin: Corticosteroids may diminish the antineoplastic effect of
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" <div id=\"topicAgreement\">",
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" </div>",
" <div class=\"lgnd\">",
" Erythematous papules and papulovesicles are present on the thigh.
Postinflammatory hyperpigmentation is evident at sites of previous lesions.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Reproduced with permission from: www.visualdx.com. Copyright Logical Images,
Inc.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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\">",
" </div>",
" <div class=\"lgnd\">",
" (Upper panel) Color flow imaging shows the umbilical arteries running around
the cyst (arrows).",
" <br>",
" (Lower panel) Photograph of the newborn infant shows the splayed umbilical
arteries and leaking of urine through the umbilicus.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Reproduced with permission from: Sepulveda W, Bower S, Dhillon HK, Fisk NM.
Prenatal diagnosis of congenital patent urachus and allantoic cyst: the value of
color flow imaging. J Ultrasound Med 1995; 14:47. Copyright &copy; 1995 American
Institute of Ultrasound in Medicine.",
" </div>",
" </br>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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var title_f0_3_63="Evaluation of abdominal pain in the HIV-infected patient";
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" Evaluation of abdominal pain in the HIV-infected patient",
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" <a id=\"authors\">",
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" <a class=\"contributor contributor_credentials contributorType\"
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" Author",
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" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/3/63/contributors\">",
" C Mel Wilcox, MD",
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" Section Editor",
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" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/3/63/contributors\">",
" John G Bartlett, MD",
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href=\"UTD.htm?0/3/63/contributors\">",
" Deputy Editor",
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0/3/63/contributors\">",
" Anna R Thorner, MD",
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" <br/>",
" </div>",
" </div>",
" <div id=\"disclosures\">",
" <a href=\"UTD.htm?0/3/63/contributor-disclosure\" target=\"_blank\">",
" Disclosures",
" </a>",
" </div>",
" <div id=\"reviewProcess\">",
" <span>",
" All topics are updated as new evidence becomes available and our",
" </span>",
" <a href=\"/home/editorial-policy\" target=\"_blank\">",
" peer review process",
" </a>",
" <span>",
" is complete.",
" </span>",
" </div>",
" <div id=\"literatureReviewDate\">",
" <span class=\"emphasis\">",
" Literature review current through:",
" </span>",
" Oct 2013.",
" <span class=\"pipeSpace\">",
" |",
" </span>",
" <span class=\"emphasis\">",
" This topic last updated:",
" </span>",
" Jun 7, 2012.",
" </div>",
" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H1\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" &nbsp;&mdash;&nbsp;The differential diagnosis of abdominal pain in patients
with HIV can be related to opportunistic infections (CMV, MAC) in the setting of
severe immunodeficiency, or may be due to other more common etiologies seen in the
general population (eg, appendicitis, diverticulitis). The widespread adoption of
highly active antiretroviral therapy (HAART) has been associated with a number of
drug-induced side effects, including pancreatitis and the lactic acidosis syndrome,
both of which are associated with abdominal pain [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/1,2\">",
" 1,2",
" </a>",
" ].",
" </p>",
" <p>",
" An overview of the diagnosis of abdominal pain in patients with HIV will be
presented here. Other gastrointestinal and hepatobiliary complications in these
patients are discussed separately. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?4/38/4707?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with odynophagia and dysphagia\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?37/41/38551?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with diarrhea\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?11/25/11670?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with anorectal symptoms\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?20/62/21480?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with hepatobiliary complaints\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H2\">",
" <span class=\"h1\">",
" INCIDENCE",
" </span>",
" &nbsp;&mdash;&nbsp;The incidence of gastrointestinal complaints, including
abdominal pain, is not well established. Severe abdominal pain was observed in
approximately 15 percent of HIV-infected patients and was associated with reduced
survival in the pre-HAART era [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/3\">",
" 3",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H3\">",
" <span class=\"h1\">",
" GENERAL PRINCIPLES",
" </span>",
" &nbsp;&mdash;&nbsp;A few general rules are useful when evaluating
gastrointestinal complaints in patients with AIDS:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Clinical signs and symptoms alone are rarely diagnostic.",
" </li>",
" <li>",
" Specific disorders correlate with the extent of immunocompromise, which can
be estimated from the CD4 count. In general, common bacteria or neoplasia are more
likely in patients with CD4 counts greater than",
" <span class=\"nowrap\">",
" 400/microL,",
" </span>",
" while cytomegalovirus (CMV), fungi, Mycobacterium avium complex (MAC), and
unusual protozoa occur most commonly in patients with CD4 counts less than",
" <span class=\"nowrap\">",
" 100/microL.",
" </span>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?20/52/21320?
source=see_link\">",
" \"Techniques and interpretation of measurement of the CD4 cell count in
HIV-infected patients\"",
" </a>",
" .)",
" </li>",
" <li>",
" Multiple infections can be seen, particularly in patients with advanced
immunosuppression.",
" </li>",
" <li>",
" Clinical investigation of gastrointestinal symptoms should proceed from less
invasive to more invasive testing; the rapidity of the evaluation should be
influenced by the severity and acuity of symptoms.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H4\">",
" <span class=\"h1\">",
" CLINICAL MANIFESTATIONS",
" </span>",
" </p>",
" <p class=\"headingAnchor\" id=\"H5\">",
" <span class=\"h2\">",
" Enteritis",
" </span>",
" &nbsp;&mdash;&nbsp;Small or large bowel enteritis can produce significant
abdominal pain. Potential infectious etiologies include bacterial pathogens
(Salmonella, Shigella, Campylobacter, Yersinia) fungal (Histoplasma) or
mycobacterial diseases (M. tuberculosis, or MAC) or opportunistic infections
(Cryptosporidium, Isospora, Microsporidia) in patients with advanced
immunosuppression. Severe weight loss and diarrhea can also be due to HIV-
associated enteropathy. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?37/41/38551?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with diarrhea\"",
" </a>",
" .)",
" </p>",
" <p>",
" In patients with large bowel involvement, the most common etiologies include
CMV. Clostridium difficile should be considered in any HIV-infected patient who has
recently received antibiotics. Lymphogranuloma venereum has been uncommonly
identified as a cause of colitis. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?20/36/21063?
source=see_link\">",
" \"Lymphogranuloma venereum\"",
" </a>",
" .) In developing countries, tuberculosis is an important cause of abdominal
pain, often involving the ileocecal region, but also involving other luminal
organs, the peritoneum, or mesenteric lymph nodes [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/4,5\">",
" 4,5",
" </a>",
" ].",
" </p>",
" <p>",
" Other diagnostic possibilities include Entamoeba histolytica, Giardia lamblia,
and non-infectious causes, such as lymphoma and Kaposi's sarcoma. In patients with
Kaposi's sarcoma, involvement of the gastrointestinal tract may occur in the
absence of cutaneous disease. The gastrointestinal lesions may be asymptomatic or
cause one or more of the following symptoms: weight loss, abdominal pain,",
" <span class=\"nowrap\">",
" nausea/vomiting,",
" </span>",
" upper or lower GI bleeding, malabsorption, intestinal obstruction, or
diarrhea. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?17/37/18009?
source=see_link\">",
" \"AIDS-related Kaposi sarcoma: Staging and treatment\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H6\">",
" <span class=\"h2\">",
" Gastritis",
" </span>",
" &nbsp;&mdash;&nbsp;Inflammatory disorders of the stomach may present with
substernal",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" epigastric burning pain. Most patients who present with suspected gastritis
are initially treated with a proton pump inhibitor for nonspecific dyspepsia.
(Careful attention should be given to potential drug interactions between proton
pump inhibitors and protease inhibitors that the patient may be taking.)",
" </p>",
" <p>",
" If there is no prompt response, further evaluation for possible mucosal
lesions should be undertaken. H. pylori has been infrequently found in HIV-infected
patients with gastroduodenal ulcers [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/6\">",
" 6",
" </a>",
" ]. If the patient's CD4 count is less than 50 cells, CMV disease should also
be considered.",
" </p>",
" <p>",
" A definitive diagnosis is made by endoscopy with biopsy. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?21/62/22504?
source=see_link&amp;anchor=H11#H11\">",
" \"AIDS-related cytomegalovirus gastrointestinal disease\", section on
'Diagnosis'",
" </a>",
" .)",
" </p>",
" <p>",
" The differential diagnosis of epigastric pain also includes medication-induced
dyspepsia (eg, NSAIDS) or neoplasia. Other important causes of epigastric pain
include pancreatitis as well as biliary tract disease. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?17/37/18009?
source=see_link\">",
" \"AIDS-related Kaposi sarcoma: Staging and treatment\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H7\">",
" <span class=\"h2\">",
" Intestinal perforation",
" </span>",
" &nbsp;&mdash;&nbsp;In the pre-HAART era, intestinal perforation sometimes
resulted from infiltrative diseases, such as CMV infection, in the patient with
advanced AIDS. CMV usually involves the distal small bowel or colon. Lymphoma or
Kaposi's sarcoma may rarely perforate when the tumor is bulky or due to tumor lysis
following chemotherapy or radiation. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?21/62/22504?
source=see_link\">",
" \"AIDS-related cytomegalovirus gastrointestinal disease\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?17/37/18009?
source=see_link\">",
" \"AIDS-related Kaposi sarcoma: Staging and treatment\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H8\">",
" <span class=\"h2\">",
" Obstruction or intussusception",
" </span>",
" &nbsp;&mdash;&nbsp;Intestinal obstruction is most likely to result from an
intestinal neoplasm, while intussusception may be due to a lymphoma or may be
caused by infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/7\">",
" 7",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H9\">",
" <span class=\"h2\">",
" Peritonitis and ascites",
" </span>",
" &nbsp;&mdash;&nbsp;Peritonitis may result from a perforated viscus or from
infectious or nonspecific causes in the absence of bowel perforation. Infections
that have been associated with peritonitis include histoplasmosis, tuberculosis,
MAC, toxoplasmosis, and Cryptococcus. Among patients with ascites, paracentesis is
safe and can uncover bacterial or fungal infection in a significant percentage of
patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/8\">",
" 8",
" </a>",
" ]. High-protein ascites of uncertain etiology may require laparoscopy to
identify the cause [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/9\">",
" 9",
" </a>",
" ]. In one series of eight such patients, non-Hodgkin lymphoma was identified
in three and cryptococcosis in one [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/9\">",
" 9",
" </a>",
" ]. The remaining four had chronic nonspecific peritonitis; exploratory
laparotomy in one and postmortem examination in two of these patients found no
specific cause.",
" </p>",
" <p class=\"headingAnchor\" id=\"H10\">",
" <span class=\"h2\">",
" Pancreatitis",
" </span>",
" &nbsp;&mdash;&nbsp;In the pre-HAART era, acute pancreatitis had been described
in 4.7 percent of hospitalized patients with HIV infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/10\">",
" 10",
" </a>",
" ]. Pancreatic involvement can be part of disseminated infection (CMV,
mycobacteria, cryptococcus) or related to infiltrative diseases such as lymphoma or
Kaposi's sarcoma [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/11,12\">",
" 11,12",
" </a>",
" ]. However, symptomatic pancreatitis is much more commonly associated with
medication use, while gallstone pancreatitis, a frequent cause in non-HIV-infected
subjects, is unusual. Medication-induced hypertriglyceridemia, caused by protease
inhibitors, should also be considered.",
" </p>",
" <p>",
" Case reports of medication-induced pancreatitis have been associated with",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/45/43734?source=see_link\">",
" stavudine",
" </a>",
" ,",
" <a class=\"drug drug_general\" href=\"UTD.htm?21/43/22199?source=see_link\">",
" pentamidine",
" </a>",
" ,",
" <a class=\"drug drug_general\" href=\"UTD.htm?11/58/12202?source=see_link\">",
" ritonavir",
" </a>",
" , and sulfonamides, although the strongest association has been with",
" <a class=\"drug drug_general\" href=\"UTD.htm?14/38/14952?source=see_link\">",
" didanosine",
" </a>",
" &nbsp;[",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/11,13-17\">",
" 11,13-17",
" </a>",
" ]. The association of pancreatitis with use of didanosine was first noted in
the initial dose-ranging clinical trials of this agent where the greatest incidence
was in the highest dosing arm [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/18\">",
" 18",
" </a>",
" ]. This led to current dose recommendations of 400 mg of didanosine daily.
Subsequently, an increased risk of pancreatitis was again noted when didanosine was
dosed with other drugs (",
" <a class=\"drug drug_general\" href=\"UTD.htm?26/25/27033?source=see_link\">",
" ribavirin",
" </a>",
" ,",
" <a class=\"drug drug_general\" href=\"UTD.htm?18/47/19191?source=see_link\">",
" tenofovir",
" </a>",
" ,",
" <a class=\"drug drug_general\" href=\"UTD.htm?16/16/16648?source=see_link\">",
" hydroxyurea",
" </a>",
" ), which led to an increase of intracellular didanosine concentration [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/19-22\">",
" 19-22",
" </a>",
" ]. Ribavirin and hydroxyurea should not be used concomitantly with didanosine;
when tenofovir is used, the dose of didanosine should be reduced to 250 milligrams
daily. Mitochondrial toxicity has been implicated as a potential cause of
medication-induced pancreatitis. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?29/40/30345?
source=see_link&amp;anchor=H14#H14\">",
" \"Mitochondrial toxicity of HIV nucleoside reverse transcriptase
inhibitors\", section on 'Pancreatitis'",
" </a>",
" .)",
" </p>",
" <p>",
" CMV-induced pancreatitis can be difficult to diagnose. Fine-needle aspiration
may uncover the diagnosis, while the findings on endoscopic retrograde
cholangiopancreatography are nonspecific.",
" </p>",
" <p>",
" Pancreatic infiltration by lymphoma [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/11\">",
" 11",
" </a>",
" ] and Kaposi's sarcoma [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/23\">",
" 23",
" </a>",
" ] has also been associated with pancreatitis in AIDS. Clinical findings may
include a mass effect on the adjacent duodenum or exocrine insufficiency if the
pancreatic duct is obstructed.",
" </p>",
" <p>",
" The presentation of pancreatitis in HIV patients is similar to non-HIV
patients, and the prognosis correlates with APACHE II score [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/11\">",
" 11",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?43/29/44504?
source=see_link\">",
" \"Predicting the severity of acute pancreatitis\"",
" </a>",
" .) Hyperamylasemia without clinical signs of pancreatitis may indicate
macroamylasemia, which was observed early in the HIV epidemic [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/24\">",
" 24",
" </a>",
" ]. HAART may be associated with drug-induced hypertriglyceridemia, resulting
in severe pancreatitis.",
" </p>",
" <p class=\"headingAnchor\" id=\"H11\">",
" <span class=\"h2\">",
" Other",
" </span>",
" &nbsp;&mdash;&nbsp;Other less common causes of abdominal pain include
acalculous cholecystitis, AIDS-related cholangiopathy, or abdominal-thoracic
varicella-zoster infection, which can initially present with abdominal pain without
classic skin lesions.",
" </p>",
" <p class=\"headingAnchor\" id=\"H12\">",
" <span class=\"h1\">",
" HISTORY AND PHYSICAL EXAMINATION",
" </span>",
" &nbsp;&mdash;&nbsp;The differential diagnosis of abdominal pain in patients
with AIDS can be narrowed by the history and physical examination, with particular
attention to the quality and location of the pain and the likely organ that is
affected (",
" <a class=\"graphic graphic_table graphicRef67173 \" href=\"UTD.htm?
37/57/38812\">",
" table 1",
" </a>",
" and",
" <a class=\"graphic graphic_table graphicRef65004 \" href=\"UTD.htm?
16/6/16491\">",
" table 2",
" </a>",
" ). As examples, dull pain in the central abdomen with diarrhea, mild nausea,
and vomiting is typically associated with infectious enteritis; in comparison, pain
in the right upper quadrant suggests a hepatobiliary etiology. Perforation with
peritonitis and obstruction are the most serious causes of abdominal pain and need
to be excluded quickly. The following historical clues may help localize the
patient's symptoms to a particular region of the gastrointestinal tract:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Infectious enteritis can be associated with diarrhea and dull, intermittent
abdominal pain or acute pain in the presence of obstruction or perforation. The
portion of the bowel involved (large versus small bowel) will dictate the specific
symptoms and signs. Small bowel involvement can lead to a voluminous secretory
diarrhea. Large bowel involvement can present as bloody diarrhea with tenesmus.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?37/41/38551?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with diarrhea\"",
" </a>",
" .)",
" </li>",
" <li>",
" Abdominal pain with radiation to the back in association with nausea and
vomiting may be presenting symptoms of pancreatitis. A complete list of medications
should be elicited along with any history of chronic pancreatitis, alcohol, or
elevated triglycerides, which can be a complication of antiretroviral therapy.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?20/5/20569?
source=see_link\">",
" \"Clinical manifestations and diagnosis of acute pancreatitis\"",
" </a>",
" .)",
" </li>",
" <li>",
" Patients with a constellation of symptoms, including mild abdominal pain,
nausea, and bloating, may have lactic acidosis related to mitochondrial toxicity of
chronic nucleoside analogue administration. These patients may have hepatomegaly on
examination. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?29/40/30345?
source=see_link\">",
" \"Mitochondrial toxicity of HIV nucleoside reverse transcriptase
inhibitors\"",
" </a>",
" .)",
" </li>",
" <li>",
" HIV-related cholangiopathy is usually seen in the setting of advanced
immunosuppression and can present with right upper quadrant pain and diarrhea.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?20/62/21480?
source=see_link\">",
" \"Evaluation of the HIV-infected patient with hepatobiliary complaints\"",
" </a>",
" .) Associated pathogens include Cryptosporidia, Microsporidia, or CMV.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H13\">",
" <span class=\"h1\">",
" DIAGNOSTIC STUDIES",
" </span>",
" &nbsp;&mdash;&nbsp;Abdominal sonography and computerized tomography (CT)
scanning are useful early in the assessment of abdominal pain, and may detect
disease not suspected clinically [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/25\">",
" 25",
" </a>",
" ]. Examples of frequent unsuspected findings include:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Gallbladder or colonic wall thickening",
" </li>",
" <li>",
" Focal hepatic lesions",
" </li>",
" <li>",
" Biliary stones or ductal dilatation",
" </li>",
" <li>",
" Pancreatic infiltration or edema",
" </li>",
" <li>",
" Abdominal adenopathy or mass lesions",
" </li>",
" <li>",
" Peritoneal thickening",
" </li>",
" <li>",
" Ascites",
" </li>",
" </ul>",
" </p>",
" <p>",
" Diagnostic studies include endoscopy, paracentesis, or endoscopic retrograde
cholangiopancreatography as indicated. Pursuing these findings with more invasive
testing can lead to a specific diagnosis. As an example, one study evaluated 50
patients found to have gastric, duodenal, or colonic wall thickening on CT scan by
endoscopy of the involved segment [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/26,27\">",
" 26,27",
" </a>",
" ]. Fifteen patients in this series were HIV-positive. Endoscopy was abnormal
in 11 of these patients. Cytomegalovirus was identified in four, lymphoma in two,
and MAC infection in one (",
" <a class=\"graphic graphic_picture graphicRef71523 \" href=\"UTD.htm?
40/41/41621\">",
" picture 1",
" </a>",
" ).",
" </p>",
" <p>",
" Paracentesis is a safe procedure in AIDS patients with ascites. In one study
of 24 such patients, paracentesis led to a major diagnosis in 33 percent of
patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/8\">",
" 8",
" </a>",
" ]. These diagnoses included spontaneous bacterial peritonitis, tuberculous or
fungal peritonitis, and lymphoma. High-protein ascites of uncertain etiology has
also been reported; laparoscopy may be necessary to attempt to define a cause [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/9\">",
" 9",
" </a>",
" ].",
" </p>",
" <p>",
" AIDS patients with pancreatitis usually have elevations of serum amylase and
lipase, except those with preexisting chronic pancreatitis. Serum lipase should
always be tested since asymptomatic elevations in serum amylase are common in HIV-
infected patients. Fine needle aspiration can be considered in potential infectious
causes of pancreatitis. In CMV-induced pancreatitis, inclusions can be demonstrated
either in ductal epithelium or acinar cells [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/12\">",
" 12",
" </a>",
" ]; ERCP findings are nonspecific.",
" </p>",
" <p>",
" Helpful diagnostic studies for consideration of lactic acidosis syndrome
include a serum lactate level and imaging to evaluate the liver for evidence of
hepatomegaly with steatosis. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?29/40/30345?
source=see_link\">",
" \"Mitochondrial toxicity of HIV nucleoside reverse transcriptase
inhibitors\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H14\">",
" <span class=\"h1\">",
" TREATMENT",
" </span>",
" &nbsp;&mdash;&nbsp;Treatment of abdominal pain in patients with HIV should be
directed at the underlying cause and the severity of presentation. Indications for
surgical intervention are the same as in patients without HIV. Mesenteric lymph
nodes should be sampled, and tissue specimens should be submitted for bacterial,
viral, and fungal cultures.",
" </p>",
" <p>",
" Early reports of surgical procedures in patients with AIDS demonstrated high
morbidity and mortality, which was in part due to the poor underlying health of
these patients [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/28\">",
" 28",
" </a>",
" ]. However, complications related to surgery today are much less frequent,
especially in those patients treated with HAART and with the increasing usage of
laparoscopy [",
" <a class=\"abstract\" href=\"UTD.htm?0/3/63/abstract/29,30\">",
" 29,30",
" </a>",
" ]. Complications and mortality are much less common in patients with
asymptomatic HIV infection.",
" </p>",
" <p class=\"headingAnchor\" id=\"H38045463\">",
" <span class=\"h1\">",
" SUMMARY AND RECOMMENDATIONS",
" </span>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" The differential diagnosis of abdominal pain in patients with HIV can be
related to opportunistic infections, (such as cytomegalovirus) or may be due to
other more common etiologies seen in the general population (eg, appendicitis,
diverticulitis). (See",
" <a class=\"local\" href=\"#H1\">",
" 'Introduction'",
" </a>",
" above.)",
" </li>",
" <li>",
" Specific disorders correlate with the extent of immunocompromise, which can
be estimated from the CD4 count. In general, common bacteria or neoplasia are more
likely in patients with relatively preserved CD4 counts while cytomegalovirus
(CMV), histoplasmosis, Mycobacterium avium complex (MAC), and unusual protozoa
occur in patients with advanced immunosuppression (CD4 counts less than 100",
" <span class=\"nowrap\">",
" cells/microL).",
" </span>",
" (See",
" <a class=\"local\" href=\"#H3\">",
" 'General principles'",
" </a>",
" above.)",
" </li>",
" <li>",
" The clinical manifestations will depend on the anatomic location of the
infection or tumor. Small bowel involvement may be associated with severe weight
loss or diarrhea while large bowel enteritis can produce significant abdominal
pain. Inflammatory disorders of the stomach may present with substernal",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" epigastric burning pain. Peritonitis may result from a perforated viscus or
from infectious or nonspecific causes in the absence of bowel perforation. (See",
" <a class=\"local\" href=\"#H4\">",
" 'Clinical manifestations'",
" </a>",
" above.)",
" </li>",
" <li>",
" The differential diagnosis of abdominal pain in patients with AIDS can be
narrowed by the history and physical examination, with particular attention to the
quality and location of the pain and the likely organ that is affected. (See",
" <a class=\"local\" href=\"#H12\">",
" 'History and physical examination'",
" </a>",
" above.)",
" </li>",
" <li>",
" Abdominal sonography and computerized tomography (CT) scanning are useful
early in the assessment of abdominal pain. (See",
" <a class=\"local\" href=\"#H13\">",
" 'Diagnostic studies'",
" </a>",
" above.)",
" </li>",
" <li>",
" Treatment of abdominal pain in patients with HIV should be directed at the
underlying cause and the severity of presentation. Indications for surgical
intervention are the same as in patients without HIV. (See",
" <a class=\"local\" href=\"#H14\">",
" 'Treatment'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
" <ol id=\"reference\">",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/3\">",
" Parente F, Cernuschi M, Antinori S, et al. Severe abdominal pain in patients
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" Smit SJ, Du Toit RS. The acute AIDS abdomen--a prospective clinical and
pathological study. S Afr J Surg 2005; 43:88.",
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" Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res 2004;
120:305.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/6\">",
" Varsky CG, Correa MC, Sarmiento N, et al. Prevalence and etiology of
gastroduodenal ulcer in HIV-positive patients: a comparative study of 497
symptomatic subjects evaluated by endoscopy. Am J Gastroenterol 1998; 93:935.",
" </a>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/7\">",
" Wood BJ, Kumar PN, Cooper C, et al. AIDS-associated intussusception in young
adults. J Clin Gastroenterol 1995; 21:158.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/8\">",
" Cappell MS, Shetty V. A multicenter, case-controlled study of the clinical
presentation and etiology of ascites and of the safety and clinical efficacy of
diagnostic abdominal paracentesis in HIV seropositive patients. Am J Gastroenterol
1994; 89:2172.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/9\">",
" Wilcox CM, Forsmark CE, Darragh T, et al. High-protein ascites in patients
with the acquired immunodeficiency syndrome. Gastroenterology 1991; 100:745.",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/10\">",
" Cappell MS, Marks M. Acute pancreatitis in HIV-seropositive patients: a case
control study of 44 patients. Am J Med 1995; 98:243.",
" </a>",
" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/11\">",
" Bonacini M. Pancreatic involvement in human immunodeficiency virus
infection. J Clin Gastroenterol 1991; 13:58.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/12\">",
" Wilcox CM, Forsmark CE, Grendell JH, et al. Cytomegalovirus-associated acute
pancreatic disease in patients with acquired immunodeficiency syndrome. Report of
two patients. Gastroenterology 1990; 99:263.",
" </a>",
" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/13\">",
" Dassopoulos T, Ehrenpreis ED. Acute pancreatitis in human immunodeficiency
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/14\">",
" Pauwels A, Eliaszewicz M, Larrey D, et al. Pentamidine-induced acute
pancreatitis in a patient with AIDS. J Clin Gastroenterol 1990; 12:457.",
" </a>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/15\">",
" Lai HY, Chen JH, Tsai PP, et al. Hepatic steatosis and pancreatitis
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" Perry RC, Cushing HE, Deeg MA, Prince MJ. Ritonavir, triglycerides, and
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" Wilmink T, Frick TW. Drug-induced pancreatitis. Drug Saf 1996; 14:406.",
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" Cooley TP, Kunches LM, Saunders CA, et al. Once-daily administration of
2',3'-dideoxyinosine (ddI) in patients with the acquired immunodeficiency syndrome
or AIDS-related complex. Results of a Phase I trial. N Engl J Med 1990; 322:1340.",
" </a>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/19\">",
" Carrat F, Bani-Sadr F, Pol S, et al. Pegylated interferon alfa-2b vs
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" Kirian MA, Higginson RT, Fulco PP. Acute onset of pancreatitis with
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" Moreno A, Quereda C, Moreno L, et al. High rate of didanosine-related
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/22\">",
" Moore RD, Keruly JC, Chaisson RE. Incidence of pancreatitis in HIV-infected
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" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/23\">",
" Friedman SL, Wright TL, Altman DF. Gastrointestinal Kaposi's sarcoma in
patients with acquired immunodeficiency syndrome. Endoscopic and autopsy findings.
Gastroenterology 1985; 89:102.",
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" </li>",
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" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/24\">",
" Greenberg RE, Bank S, Singer C. Macroamylasaemia in association with the
acquired immunodeficiency syndrome. Postgrad Med J 1987; 63:677.",
" </a>",
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" Jeffrey RB Jr. Gastrointestinal imaging in AIDS--abdominal computed
tomography and ultrasound. Gastroenterol Clin North Am 1988; 17:507.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/26\">",
" Farman J, Lerner ME, Ng C, et al. Cytomegalovirus gastritis: protean
radiologic features. Gastrointest Radiol 1992; 17:202.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/27\">",
" Rockey DC, Halvorsen RA Jr, Higgins JL, Cello JP. Prospective evaluation of
patients with bowel wall thickening. Am J Gastroenterol 1995; 90:99.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/28\">",
" Ferguson CM. Surgical complications of human immunodeficiency virus
infection. Am Surg 1988; 54:4.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/29\">",
" Saltzman DJ, Williams RA, Gelfand DV, Wilson SE. The surgeon and AIDS:
twenty years later. Arch Surg 2005; 140:961.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/3/63/abstract/30\">",
" Sauerland S, Agresta F, Bergamaschi R, et al. Laparoscopy for abdominal
emergencies: evidence-based guidelines of the European Association for Endoscopic
Surgery. Surg Endosc 2006; 20:14.",
" </a>",
" </li>",
" </ol>",
" </div>",
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" INTRODUCTION",
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" INCIDENCE",
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" CLINICAL MANIFESTATIONS",
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" Enteritis",
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" Gastritis",
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" Other",
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" HISTORY AND PHYSICAL EXAMINATION",
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" DIAGNOSTIC STUDIES",
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" REFERENCES",
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" Abdominal pain in AIDS",
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" RELATED TOPICS",
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" <div id=\"relatedTopics\">",
" <ul>",
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" <a class=\"medical medical_review\" href=\"UTD.htm?17/37/18009?
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" Evaluation of the HIV-infected patient with diarrhea",
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" Evaluation of the HIV-infected patient with odynophagia and dysphagia",
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source=related_link\">",
" Predicting the severity of acute pancreatitis",
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" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?20/52/21320?
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" Techniques and interpretation of measurement of the CD4 cell count in HIV-
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" </a>",
" </li>",
" </ul>",
" </div>",
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