Problems of the Digestive System

The digestive system includes the mouth; the tube through which food passes after being swallowed, called the esophagus; the stomach; the small intestine, where food is broken down and absorbed; the large in­testine or colon, where unabsorbed material is stored for elimination; and the anus.

HIV infection can affect any part of the digestive system, and does so commonly in the later stages. The symptoms are often a clue to which part of the digestive system is being affected. Painful or difficult swal­lowing is usually a symptom of problems with the esophagus. Pain in the abdomen, nausea, and vomiting are usually symptoms of problems with the stomach. Diarrhea, pain, and malnutrition from the failure to absorb nutrients are all symptoms of problems with the small intestine. And pain, diarrhea, or constipation are symptoms of problems with the colon.

Many of the problems in the digestive system also interfere with nu­trition. Anything that interferes with nutrition is especially important to someone with HIV infection, because HIV infection itself causes weight loss and nutritional deficiencies. Severe malnutrition also seems to fur­ther weaken the immune system. Anyone with HIV infection and such problems with the digestive system should be under the care of a physi­cian.

Loss of Appetite

Loss of appetite has several possible causes. One cause is usually the drugs taken for HIV, or HIV itself, which somehow causes an altered sense of taste: food just doesn’t seem to taste good. Other causes are depression, complications, or infections of the mouth. Loss of appetite can substantially reduce the quality of life and, when severe, can cause weight loss and malnutrition.

Treatment depends on the exact cause. When the cause is the drugs taken for HIV, changing the regimen might be necessary. Tell your health care provider. Some drugs—AZT, ddI, and all the PIs—are particularly suspect. Taking AZT with food often helps you tolerate the drug better, but ddI needs to be taken on an empty stomach. Some PIs are better tol­erated than others. Ritonavir, however, is a real problem and in fact is used not in full doses but in small doses to boost another PI; and even then, “baby dose ritonavir” can be a problem. When the cause is HIV and an altered sense of taste, the best treatment is to learn your prefer­ences and eat accordingly. A person with an altered sense of taste often has a particular problem with protein-rich foods, particularly with red meat. The solution in that case is to find other sources of protein: poul­try, fish, eggs, and cheese are all excellent sources of protein. So are dried beans and rice. A person with an altered sense of taste also seems to have the best appetite in the morning: try to eat large, nutritious breakfasts. If you have a preference for foods at different temperatures, indulge your preference. Try eating foods that smell good: the senses of smell and taste are closely connected. Try adding herbs, bacon, garlic, olives, cheese—anything that livens up the flavor of the food and doesn’t dis­agree with you.

Some HIV-related complications of the mouth (thrush, herpes, aph­thous ulcers, and Kaposi’s sarcoma), discussed in the preceding section, cause pain with eating. When eating hurts, people often lose their ap­petites. In this case, avoid foods that cause pain. Stay away from salt and seasoned salts; from hot spices like pepper, chili pepper, and paprika; and from acidic foods like vinegar, citrus fruits and juices, tomatoes, pineap­ple, and pickles. Try food at moderate or cool temperatures. Try foods that are soft and won’t irritate the mouth: mild cheeses, cottage cheese, yogurt, cooked eggs, cream soups, ice cream, puddings, popsicles, ground meats, baked fish, bread, noodles and pastas, and cooked or canned fruits (see also, below, the foods that are least troublesome if you have pain on swallowing).

Another cause of appetite loss is the emotional reaction to having HIV infection. At times, people become anxious or depressed and lose interest in eating. Both anxiety and depression can occur at any stage of this infection. One way to fight this might be to make eating a special event: put on some music, prepare the food so it looks attractive, think of a meal as a break from your worries or a reward for your work, re­lax, take your time with the meal. Eat your favorite foods unless you are on a special diet. If your HIV medication is a problem, tell your health care provider: there are twenty medications to pick from. Keep snacks around: ice cream, cheese, canned fruit, crackers, peanut butter. Small meals are less filling; try several small meals a day. Eating is often a social event, and many people enjoy food best in someone else’s com­pany.

Still another cause of loss of appetite is fatigue: people are simply too tired to eat. Fatigue can also interfere with their ability to prepare a meal if they live alone. If you eat less because you are tired, be careful to eat meals especially high in calories and proteins, so that even if you eat less, you get the same level of nutrition. Try milkshakes, dried fruits, peanut butter, ice cream, cheese, sour cream, hot chocolate, custard, cream soups, scrambled eggs or an omelet with cream cheese, noodles with cheese and cream. Preparing main courses that are high in protein and calories and then freezing them also saves energy: spaghetti sauce, chili, pot roasts, beef or chicken or lamb stews, and soups all taste good made in large amounts, frozen, and reheated; they freeze well. High- protein main courses are also sold prepared and frozen in grocery stores. In either case, frozen food can be reheated on the stove or in a microwave oven. Keep ready-to-eat and nutritious snacks on hand. Many commu­nities also have organizations that will prepare or deliver meals.

In general, the treatment for appetite loss depends on the situation.

When appetite loss is temporary, try to get in as many calories as possible without regard to the nutritional value: you simply are not go­ing to become malnourished in a few days. Try fortifying foods with oil, butter, mayonnaise, a little dried milk, grated cheese, cream. Try mak­ing shakes out of combinations of different foods: milk, ice cream, in­stant breakfast, buttermilk, bananas or strawberries or peaches or apri­cots or pears, fruit juice, yogurt, honey, cocoa, chocolate syrup, peach or pear or apricot nectars, ginger ale, brown sugar.

Most important is drinking enough fluids: healthy people can sur­vive over one hundred days without food, but no one can survive more than a few days without fluid. Drink fluids that are high in calories and protein—milk, shakes—instead of diet drinks, coffee, or tea. Routinely stir some dried milk into your milk.

If people with HIV infection eat poorly for weeks or months, a physician should be consulted. In some cases, the physician may pre­scribe an appetite stimulant such as Megace.

Painful Swallowing

Some people find eating unpleasant and good nutrition difficult because they have pain when they swallow. Sometimes the pain is in the back of the mouth; usually it is in the chest and is a result of esophagitis, an in­flammation of the esophagus. The most common cause is infection with Candida albicans, the fungus responsible for thrush.

The probability of Candida albicans is often so great that physi­cians treat for Candida without testing for it. The treatment is usually fluconazole (Diflucan), taken by mouth. People usually respond well within five days. If Candida comes back after treatment is stopped, you may need to take fluconazole until your CD4 count comes back. If the person with esophagitis does not respond at all to this treatment and the cause is therefore obscure, an endoscopy—a special procedure in which a specialist (gastroenterologist) puts a tube into the esophagus and takes a sample of tissue—is often advised. If the cause is a viral in­fection, like CMV or herpes simplex, esophagitis can be treated with antiviral drugs. All these complications occur only when the CD4 count is low, below 200 and usually below 100. If the cause is aphthous ul­cers, the ulcers in the esophagus, like those in the mouth, often respond to corticosteroids.

Anyone with painful swallowing should see a physician. Despite painful swallowing, it is important to maintain nutrition. Eat foods that are soft or liquid: milkshakes, milk, oatmeal, puddings made with milk or cream, custard, jello, ice cream, cottage cheese, cooked and pureed bland vegetables, popsicles, ground meats, baked fish, melons, bananas, scrambled eggs, omelets, French toast, cream soups, noodles, mashed potatoes.

Nausea and Vomiting

Nausea and vomiting have a number of causes, the most common being the drugs taken for complications of HIV infection. Drugs whose side ef­fects include nausea and vomiting are amphotericin B, atazanavir (Rey- ataz), atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), trimethoprim-sulfamethoxazole (Bac­trim, Septra), dapsone, ddI (Videx), doxycycline, dronabinol (Marinol), ethambutol (Myambutol), fluconazole (Diflucan), fosamprenavir, hy­droxyurea (Hydrea), indinavir (Crixivan), inferferon (Roferon, Intron), itraconazole (Sporanox), ketoconazole (Nizoral), lopinavir (Kaletra), metronidazole (Flagyl), oxandrolone (Oxandrin), paromycin (Humatin), pyrazinamide, pyrimethamine (Daraprim), ritonavir (Norvir), saquina­vir (Invirase), 3TC (Epivir), zidovudine (AZT, Retrovir).

The probability that a drug is responsible depends on the drug, the dose, and the length of time you’ve been taking it. If you’ve been taking a drug for over a month, it would be unusual for it to abruptly cause nausea and vomiting, unless the dose was increased. The treatment de­pends on the severity of the symptoms, the necessity of the drug, and the possibility of an alternative dosing regimen.

Usually the nausea and vomiting are dose-related, meaning that re­ducing the dose of the drug will reduce the nausea and vomiting. Or the drug can be taken at times that will not interfere with meals. Or, for many conditions, alternative drugs can be prescribed. Consultation with a physician will usually reveal which drug is likely to be the cause, which is expendable, which can be safely reduced in dose, and which can be safely substituted.

Some of the complicating infections—particularly infections that af­fect the head or the digestive system—can also cause nausea and vom­iting. People who have nausea and vomiting, who are taking no med­ication, and who have additional symptoms such as fever or diarrhea should see their physicians.

In general, the person who has nausea or vomiting should eat small, frequent meals, and eat slowly. Avoid greasy, high-fat, and spicy foods. When symptoms are not severe, follow a soft and bland diet that is low in fat: rice, noodles, pasta, clear soups, jello, clear fruit juice, ginger ale, crackers, pretzels, tea, dry toast, oatmeal, boiled eggs. For breakfast, eat crackers, dry cereal, or dry toast. Cold meals that have little odor are of­ten easier to eat than hot meals. When symptoms are severe, it is im­portant to replace the liquids and electrolytes lost: try saltines, pretzels, clear fruit juices, ginger ale or colas, caffeine-free Gatorade, clear soups. All liquids should be clear—that is, they should not be thick liquids like vegetable juices, citrus juices, some other fruit juices, or milk. Drink them between meals rather than during meals.

Many drugs reduce nausea and vomiting. Some can be taken by sup­pository in the event that nothing is retained when taken by mouth. Such drugs should be timed to meals; take them as directed, but try taking the drug after eating meals. Some useful drugs do not require a prescrip­tion; these include Dramamine and Pepto-Bismol. Other drugs require a prescription: antihistamines (such as Phenergan or Vistaril) or pheno­thiazines (such as Compazine), which are drugs that also reduce anxi­ety. Most of these drugs cause drowsiness.

Diarrhea

Diarrhea is a relatively common complication of HIV infection. It can be acute, meaning that it begins suddenly and lasts for a short time, or it can be chronic, meaning that it persists for several weeks or months. Diarrhea has a number of causes. Many people have diarrhea simply as a result of anxiety. Some people have recurrent bouts of stomach pain and diarrhea, called irritable bowel syndrome, that go on for years with­out any identifiable cause and without complications or progression. Some people have diarrhea because of HIV itself. Some people have di­arrhea because they do not have the enzyme called lactase that is neces­sary to digest a milk sugar called lactose. Some people with HIV infec­tion who were once able to tolerate lactose become unable to tolerate it. In lactose intolerance, the diarrhea occurs after people eat food con­taining lactose, including milk, ice cream, cheese, instant coffee, choco­late, cream, cocoa, and cream fillings. Yogurt, however, is tolerated by some people who are otherwise lactose intolerant, and is worth trying because it is a good source of protein and calcium. Other symptoms of lactose intolerance are cramping and gas.

Another cause of diarrhea is the drugs commonly used by people with HIV infection. Among anti-HIV drugs, Kaletra and nelfinavir commonly cause a diarrhea that is usually controlled with loperamide (Imodium). Antibiotics often cause what is called nuisance diarrhea: a few loose stools most days, though they can also cause severe diarrhea accompanied by fever and cramps. The antibiotics that most commonly cause severe di­arrhea are clindamycin, ampicillin, amoxicillin, amoxicillin-clavulanate (Augmentin), a group of drugs called cephalosporins, and another group called Auoroquinalones. Drugs that less commonly cause diarrhea are tri- methoprim-sulfamethoxazole, erythromycin, penicillin, and the fluoro- quinalones (ciprofloxacin, levofloxacin, gatifloxacin, and moxifloxacin). Any person who has severe diarrhea or diarrhea with fever while taking such drugs should discontinue the drug immediately and notify the physician. Less serious forms of diarrhea are often dose-related, that is, diarrhea can be reduced simply by reducing the amount of the antibiotic. Or the person can be prescribed another drug. Some drugs taken for HIV cause diarrhea, especially ddI, nelfinavir (Viracept) and lopinavir (Kale- tra). In this case, diarrhea can often be managed by over-the-counter drugs like Imodium or calcium.

Diarrhea in people with HIV infection is also caused by infections of the digestive system, primarily infections of the small bowel and the colon. Infections are especially likely if the diarrhea is accompanied by a fever. Acute diarrhea can be caused by a number of microbes that are either easily treated with antibiotics, or that go away without treatment, or that progress to chronic diarrhea. Acute diarrhea is often due to food poisoning, viral infection, or anxiety, which are occasional problems for everyone, with or without HIV infection.

Infection is another common cause of diarrhea. Infection often causes a brief bout of gastroenteritis—or “food poisoning,” or “travel­ers’ diarrhea.” Most of these cases of diarrhea come and go in a few days with so-called supportive care: bland food, plenty of water, and a drug like Imodium. In general, people with HIV infection get the same bouts of gastroenteritis as anyone else, and with the few exceptions noted be­low, no worse than anyone else. You should obtain medical attention promptly if you have severe diarrhea of such large volumes that you get dehydrated, if the stool has blood in it, or if you have severe abdominal pain. The possibility of an HIV-related complication increases when the CD4 count is below 200.

Perhaps the most common cause of chronic and often severe diar­rhea in people with AIDS is Cryptosporidium, a parasite that is easily detected in a lab test of the stool. Infection occurs when Cryptosporid­ium is ingested, by contact with animals or with infected people, or most commonly by drinking contaminated water.

Anyone can get cryptosporidiosis diarrhea, but people with HIV in­fection seem unusually susceptible. For a person with a CD4 count of less than 50, the diarrhea can be devastating, with ten to twenty watery stools each day for months. Cryptosporidiosis in healthy people and in those with HIV and good CD4 counts will usually stop after one to two weeks. Cryptosporidiosis has no good treatment, except Imodium or even narcotics to control the diarrhea, fluids to maintain hydration, and nutritional support. Some people try paramomycin, a drug for crypto­sporidiosis, but it doesn’t work very well. The real key is the CD4 count: if the count is low, raising it even a small amount will often get the cryp­tosporidia under control.

Other common infectious causes of chronic diarrhea are a tiny par­asite called Microsporidium, a virus called cytomegalovirus, and a bac­terium called Mycobacterium avium complex (MAC). These latter mi­crobes cause a diarrhea that persists for months and occurs only with late-stage AIDS, that is, a CD4 count of less than 50. Cytomegalovirus causes cramps and fever; the only treatment is intravenous ganciclovir or foscarnet, and it doesn’t work well. MAC causes diarrhea and fever; it responds to clarithromycin plus ethambutol, though the response takes a long time. Microsporidiosis is caused by two types of parasites; one responds to albendazole and the other to fumagillin, but the best treatment is to boost the CD4 count. A substantial portion of the peo­ple with HIV infection have a chronic diarrhea for which their physi­cians can establish no clear cause.

Call your physician if the diarrhea is severe, or if it is accompanied by severe pains in the abdomen or by fever, or if it persists. Chronic di­arrhea is more common late in the course of the infection when the CD4 cell count is low, and is often accompanied by severe weight loss and malnutrition, sometimes referred to as “wasting syndrome.”

The first consideration is to see if diarrhea is being caused by drugs. If drugs are not the cause, the first test to diagnose other causes of se­vere or chronic diarrhea should be an analysis of the stool for infectious microbes. If no microbes are found, and if the symptoms are severe, it is often recommended that the digestive system be examined directly with an instrument called an endoscope. An endoscope is a long tube that can be passed through the mouth to look at the top part of the gas­trointestinal tract—the esophagus, the stomach, and the small intestine —or passed through the rectum to look at the colon. The physician who performs the test is a gastroenterologist, a specialist in digestive dis­eases. Endoscopy permits not only a direct view of the wall of the in­testine, but also removal of a small piece of tissue (a biopsy) of any area that appears abnormal. The tissue can then be examined under the mi­croscope to identify the nature of the problem. A number of X-ray pro­cedures also allow a look at the intestine. The person should be fore­warned that these types of specialized tests tend to be unpleasant and expensive.

The treatment of diarrhea depends largely on the severity and cause. When drugs are responsible, a physician will reduce the dose or—if the drug is not critical or if a substitute is easily available—will discontinue the drug. Regardless of the cause, it is important, first, to drink enough fluids and, second, to eat enough food. The usual recommendation is to eat small, frequent meals and to drink fluids between meals. Avoid in­soluble fiber: seeds, brans, nuts, whole wheat bread, the skins of fruits and vegetables. Avoid anything that causes gas: carbonated drinks, beans, cabbage, spicy foods, gum. Avoid fats, milk, cheese, ice cream. Since caffeine is a bowel stimulant, avoid coffee, tea, colas and some so­das, hot chocolate, and chocolate.

Soluble fiber, like pectin, counters diarrhea: oatmeal, jello, apples, bananas, mangoes, melons, fruit nectars, and cooked and skinned fruits and vegetables are sources of soluble fiber. Try white bread, white rice, noodles, and pastas. Drink plenty of liquids: water, clear fruit juices, clear soups, broth, ginger ale and caffeine-free colas (stir out the bub­bles). Dietitians call such a diet a BRATT diet: bananas, rice, applesauce, tea (caffeine-free), and toast. The BRATT diet, though helpful in con­trolling acute diarrhea, lacks many nutrients and should not be contin­ued for more than a week. In addition, avoid drinking fluids during meals; fluids should be taken between meals. As with nausea and vom­iting, it is important to replace lost electrolytes: try saltines, pretzels, clear fruit juices, Gatorade, ginger ale or caffeine-free colas, potatoes, bananas, clear soups. When diarrhea is unrelated to eating, there may be an advantage to adding foods containing soluble fiber—as listed above—in an effort to add bulk to the diet.

With severe diarrhea, when malnutrition becomes a worry, supple­ment the diet with special high-nutrient fluids such as Ensure, Ensure Plus, Jevity, Peptamen, or Perative. High-nutrient fluids, which can be obtained in grocery stores and pharmacies, provide a rich source of calo­ries and protein. These supplements are commonly recommended for wasting, but some—Ensure Plus and Peptamen—actually cause diar­rhea and should be diluted before using. All of these dietary decisions are best made with the advice of a physician and a dietitian.

Drugs may also be used to reduce diarrhea. Some treatments that re­duce diarrhea are available without prescription: Donnagel, Kaopectate, Lactinex, Pepto-Bismol, loperamide (Imodium), oat bran, psyllium, cal­cium, SP-303, and the like. All of these seem to work some of the time, and most cost less than $10 a month. If the diarrhea is caused by a mi­crobe, your physician will prescribe drugs to eradicate the microbe, if it can be treated; the specific treatment will depend on the microbe found. As noted, however, many microbes do not respond to antibiotics, and sometimes no microbial cause is found. In these cases, diarrhea is often treated with prescription drugs—including diphenoxylate (Lomotil), tincture of opium, and paregoric—that quiet the motion of the muscles of the intestines. Diarrhea due to nelfinavir (Viracept) or lopinavir (Kale- tra) is so common that it is expected. Most cases are not severe enough to require discontinuing the drug, and reducing the dose is unacceptable.

Most cases can be controlled by over-the-counter drugs, like those listed above.