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Background: Diarrhea is a frequent gastrointestinal symptom in patients with acquired immunodeficiency syndrome (AIDS) and is a major source of morbidity and mortality. A stepwise diagnostic approach is often recommended to search for treatable causes. However, whether the stepwise diagnostic approach is adequate for planning treatment and whether specific treatment for infectious etiologies will affect the survival of patients with AIDS remain unknown. Methods: From March 1996 to September 1997, endoscopy was performed in AIDS patients with diarrhea, the etiology of which was not identified by noninvasive methods. Specific treatment was given according to the identified etiologies and symptomatic treatment was given for those without definite diagnosis. The clinical symptoms, signs, and duration of follow-up were recorded and survival patterns were analyzed. Results: Etiologic diagnoses were made in 26 of 40 patients (65%) who underwent endoscopic studies. Amebic colitis and cytomegalovirus colitis were the 2 leading causes of prolonged diarrhea in patients with AIDS. Thirty-five patients (87.5%) recovered after treatment. The difference in survival time after diarrhea between patients whose symptoms resolved after treatment and those who continued to have diarrhea was statistically significant (p < 0.001). Conclusions: Endoscopic studies were helpful for the diagnosis of prolonged diarrhea in AIDS patients who had negative stool studies and did not respond to 2 weeks of empiric treatment. Specific treatment according to the results of endoscopy may improve survival in these patients. (Gastrointest Endosc 2000;51:427-32.)

Background: Little is known about lower gastrointestinal (GI) hemorrhage in the human immunodeficiency virus (HIV)–infected population. Our aim was to determine the underlying causes, the clinical outcome, and the risk factors for recurrent bleeding and mortality in HIV-infected patients with acute LGIH. Methods: We reviewed the medical records of consecutive HIV-infected patients with acute lower GI hemorrhage who were evaluated with endoscopy from January 1992 through January 1997 at Bellevue Hospital Center. Results: During the 5-year study period, 312 patients with acute lower GI hemorrhage underwent colonoscopy (n = 233) or flexible sigmoidoscopy (n = 79). Cytomegalovirus colitis (25.3%), lymphoma (12.2%), and idiopathic colitis (12.2%) were the most common causes identified. Within 30 days of presentation, recurrent bleeding occurred in 17.6% of patients. Independent predictors of recurrent bleeding included the presence of at least one comorbid illness, a hemoglobin level of less than 8 gm/dL, a platelet count of less than 100,000/mm 3 , and major stigmata of hemorrhage. The 30-day mortality from lower GI hemorrhage was 14.4%, and the presence of comorbid disease, recurrence of bleeding, and surgical intervention were found to be the only independent predictors of mortality in this patient population. Conclusions: Acute lower GI hemorrhage in HIV-infected patients is most commonly caused by cytomegalovirus colitis and is associated with a high short-term morbidity and mortality. (Gastrointest Endosc 1999;49:748-53.)

Background: Cytomegalovirus colitis is an important complication of the acquired immunodeficiency syndrome (AIDS), although the clinical and colonoscopic manifestations of this disease have not been systematically characterized. Methods: Patients with AIDS and cytomegalovirus colitis were prospectively identified at two medical centers. The diagnosis of cytomegalovirus disease was based on established endoscopic and histologic criteria. At the time of sigmoidoscopic and/or colonoscopic examination, clinical features were recorded; the location, size, and appearance of all endoscopic abnormalities were documented; and multiple biopsies of any lesions were performed. Results: Fifty-six patients were studied. The majority of the patients were homosexual men with severe immunodeficiency (median CD4 lymphocyte count 15/mm 3 , range 1 to 294/mm 3 ). Chronic diarrhea and abdominal pain were the most frequent clinical manifestations, seen in 45 (80%) and 28 (50%) patients, respectively. Five patients (9%) presented with lower gastrointestinal hemorrhage, three of whom had no antecedent history of diarrhea. The colonoscopic abnormalities could be categorized into three main groups: colitis associated with ulcer (39%), ulceration alone (38%), or colitis alone (20%). Subepithelial hemorrhage was a prominent endoscopic manifestation of disease. Of the 31 patients undergoing colonoscopy to the cecum, in four (13%) endoscopic evidence of disease was limited to the colon proximal to the splenic flexure. Conclusions: Cytomegalovirus colitis in AIDS appears to have variable but stereotypical clinical and colonoscopic manifestations. Distal colitis associated with ulceration is the most common colonoscopic pattern. (Gastrointest Endosc 1998;48:39-43.)

Although gastrointestinal cytomegalovirus (CMV) disease most frequently occurs in adults with immune deficiency, such as the acquired immunodeficiency syndrome (AIDS), organ transplantation, cancer chemotherapy, and steroid therapy, it can occur in persons with normal immune function.1-3 Many manifestations of gastrointestinal CMV infection, including ulcerative lesions, perforation, hemorrhagic proctocolitis, inflammatory pseudotumor, lesions mimicking neoplasia, appendicitis, toxic megacolon, pseudomembrane formation, and pneumonitis intestinalis, have been observed.1-3 We describe a patient who developed a perianal fistula that was presumed to be due to CMV infection. To our knowledge, this is the first reported case of CMV colitis complicated by perianal fistula formation. CASE REPORT

OBJECTIVES Diarrhea in AIDS patients is one of the most important and disabling symptom, and often decreases their quality of life. Cytomegalovirus colitis is among the principal causes of this sympton, and colonoscopy is the gold standard examination to diagnose it. The objetive of this study is to define the main endoscopic findings in AIDS patients with CMV colitis. PATIENTS AND METHODS On two hundred forty five colonoscopies perfomed in AIDS patients, over a ten year period, sixty two examinationts in fifty one patients diagnosed cytomegalovirus colitis. Full length colonocopy with ileum intubation and multiple biopsies of all segments examined were always attempted. All diagnoses were confirmed by histologic and inmunohistochemical studies. RESULTS Total colonoscopy was possible in 97,5% of these examinations, and ileum intubation was achieved in 87,2% of them. A heterogeneous ulcerative pattern was present in 82% of these cases and in 50% of then only the proximal segments were affected. The cytomegalovirus was also found in one patient with normal mucosa on total endoscopic examination. In 10% of these exams another infectious agent was observed. CONCLUSION We may conclude that full length colonoscopy with ileum intubation and multiple biopsies of all segments, even if they are endoscopically normal, has always to be attempted in all cases of AIDS patients with diarrhea.