Chapter 66 - Laparotomy in patients with human immunodeficiency virus infection

Summary

Early detection and advances in the medical treatment of patients infected with the human immunodeficiency virus (HIV) has moved the care for many patients from acute to chronic care over the last decade. Accordingly, as in any other immunosuppressed patient, there is no strict contraindication to major abdominal surgery in HIV-positive patients. In general, patients with undetected viral load and CD4 T-cell count greater than 200 mm³ undergo emergent laparotomy for the same indications as any other individual (gastrointestinal perforation, refractory hemorrhage, ischemia, and complete bowel obstruction). CD4 count less than 200 mm³ is a predictor for postoperative sepsis and, therefore, additional judgment should be exercised before performing laparotomy because several opportunistic medical infections can mimic peritonitis and potentially can prompt unwarranted exploration. These infections most commonly include mycobacterium avium complex (MAC), cytomegalovirus (CMV), and microsporidia. HIV-positive patients who are immunocompromised are also at increased risk for more uncommon malignancies (non-Hodgkin's lymphoma and Kaposi's sarcoma). HIV-positive patients experience frequent diarrhea (30–60%). Therefore, infectious etiologies for patients with abdominal pain and diarrhea must be investigated to rule them out as causes of acute abdominal pain. Organomegaly may also be a cause of pain in these patients.

One retrospective study has shown that 8% of patients presenting to the emergency room with acute abdominal pain and HIV required abdominal surgery. In the same study, acute abdominal pain in patients with advanced HIV was found to be secondary to opportunistic infections in 10% of the patients. The most common cause of emergency laparotomy in AIDS patients is perforated viscous from CMV. In the absence of a working diagnosis, diagnostic laparoscopy can be considered as an initial means of abdominal exploration to avoid a large laparotomy incision. Common acute abdominal conditions such as appendicitis and cholecystitis should be treated accordingly. In patients with a negative laparotomy result, culture and biopsy of mesenteric lymph nodes is indicated in order to help determine rare infectious etiologies for the development of acute pain.