Gastrointestinal symptoms among ambulatory HIV patients: appropriate symptom management requires improved symptom recognition

Gastrointestinal (GI) disorders are among the most frequent complaints in patients with HIV disease. Before combination antiretroviral therapy, it was suggested that 50-93% of all patients with HIV disease had marked GI symptoms during the course of their illness [1,2]. Inflammatory changes, direct mucosal invasion of the GI tract by HIV, opportunistic infections and neoplasms are well recognized causative factors [3]. GI manifestations of HIV disease may be debilitating and include anorexia, weight loss, diarrhea, nausea, vomiting, dysphagia and odynophagia, abdominal pain, anorectal disease, GI bleeding, jaundice and hepatomegaly, and GI tumors [4]. Progressive immunosuppression is associated with increasing prevalence of GI symptoms [5,6] and thus the evaluation of specific GI complaints must be based on an assessment of the degree of immunosuppression. However, antiretroviral therapy may change the nature of HIV disease and can lead to improvement in gastrointestinal symptoms for patients with advanced immunosuppression [5,6]. Appropriate symptom management requires improved symptom recognition and should be an essential component of patient care at all stages of any disease worldwide [7]. However, limited data exist regarding the incidence of various GI manifestations in HIV-infected patients in certain areas of the world including the Caribbean. The paper by Thompson et al in this issue of Annals of Gastroenterology [8] investigated the prevalence of common GI symptoms in the ambulatory Jamaican HIV infected population compared to those seen in a healthy population of blood donors not known to have HIV. This study revealed that in HIV-infected patients the presence of symptoms was directly related to CD4 count similarly to previous studies [9] and that GI symptoms were common in ambulatory HIV-infected patients and controls. Heartburn, belching and nausea were more common in the control patients whereas early satiety was the only symptom significantly more common in the HIV-infected patients. However, pain on swallowing, and vomiting were significantly more common in patients with CD4 <350 cells/μL than in controls. The authors conclude that the relatively low incidence of significant GI symptoms in HIV-infected patients may reflect the changing manifestations of HIV infection due to the success of antiretroviral therapy. However, although the incidence of certain GI symptoms such as dysphagia and weight loss in the Jamaican population was similar to the incidence of GI symptoms reported in previous studies [10], it was surprising that 35% of control patients had weight loss. Indeed, this present study has several limitations. Firstly, the weight loss as reported in this study was subjective and thus the estimated incidence may be inaccurate. Similarly, the subjective reporting of other GI symptoms such as belching and nausea may also explain why these symptoms were more common in the control patients. Secondly, the used questionnaire did not seek to determine if weight loss was intentional. Thirdly, the number of patients and controls was relatively small. Finally, the sample of HIV-infected patients represented only the ambulatory patients and was not entirely representative of the general population of HIV-infected patients. It would also be of interest to look at the possible association of specific antiretrovirals with the incidence of GI symptoms, similarly to previous studies [5,10]. In conclusion, improved symptom recognition of GI symptoms in HIV patients should be an essential component of patient care worldwide and an astute clinical acumen is often required to avoid subjective interpretation of certain GI symptoms.