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HIV and pancreatitis

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Related Terms
  • Acquired immune deficiency syndrome, acquired immunodeficiency syndrome, AIDS, antiretroviral therapy, antiretrovirals, ART, fusion inhibitor, gallbladder, gallstones, HAART, highly active antiretroviral therapy, HIV, human immunodeficiency virus, immune, immune defense system, immune system, immunocompromised, immunodeficiency, infection, inflammation, pancreas, pancreatic enzyme, protease inhibitor, viral infection, virus, weakened immune system, white blood cells.

Background
  • Patients infected with the human immunodeficiency virus (HIV) have an increased risk of developing pancreatitis, a severe inflammation of the pancreas. Pancreatitis occurs when the digestive enzymes in the organ become active too soon. Instead of becoming active in the intestines, they become active inside the pancreas, where they can cause organ damage.
  • The pancreas is located behind the stomach. It produces enzymes that are released into the small intestine to break down protein in food. The pancreas also produces insulin, a hormone that helps regulate the amount of sugar in the blood.
  • HIV patients may develop pancreatitis as a result of heavy alcohol consumption, gallstones that block a tube in the pancreas called the pancreatic duct, infections (such as mycobacterium avium complex), or medications, such as pentamidine (Pentam®)
  • Although HIV patients are more likely to develop pancreatitis than HIV-negative patients, it is still considered a rare condition. For instance, researchers from one study found that less than one percent of 976 HIV patients who were receiving anti-HIV drugs (antiretrovirals) developed the condition.
  • Treatment for pancreatitis depends on the underlying cause. Once the cause is treated, most patients experience a full recovery. However, if the condition is left untreated, scarring may occur in the organ. Once the organ becomes scarred, the condition cannot be reversed and the patient requires long-term treatment to manage the symptoms.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
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  3. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed May 14, 2009.
  4. San Francisco AIDS Foundation. . Accessed May 14, 2009.
  5. Sekimoto M, Takada T, Kawarada Y, et al. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J Hepatobiliary Pancreat Surg. 2006;13(1):10-24. .
  6. The Body: The Complete HIV/AIDS Resource. . Accessed May 14, 2009.
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  8. Young B, Weidle PJ, Baker RK, et al. Short-term safety and tolerability of didanosine combined with high- versus low-dose tenofovir disproxil fumarate in ambulatory HIV-1-infected persons. AIDS Patient Care STDS. 2006 Apr;20(4):238-44. .

Causes
  • Alcohol: Alcohol is the leading cause of pancreatitis in both HIV-positive and HIV-negative patients. Individuals who drink heavily for many years have an increased risk of developing pancreatitis. It is not clear exactly how alcohol affects the pancreas. However, researchers have found that alcohol causes digestive enzymes to be released sooner than normal. Alcohol also increases the permeability of the small ducts (tubes). As a result, the pancreatic digestive enzymes are able to cause damage to healthy tissue inside the pancreas. In addition, heavy drinking has been shown to cause protein plugs, which may develop into gallstones.
  • Gallstones: Gallstones are another common cause of pancreatitis. Gallstones develop when tiny particles in bile harden and become a stone-like mass. Sometimes the gallstones move from the gallbladder to a small tube called the common bile duct. This common bile duct connects to another tube called the pancreatic duct. If the stone blocks the pancreatic duct, it causes the pancreas to become inflamed. If left untreated, enzymes may leak from the pancreas and damage healthy tissues.
  • HIV: Some researchers believe that HIV can cause pancreatitis if the virus infects pancreatic cells. Although HIV primarily infects immune cells, researchers suggest that the virus may also infect pancreatic cells in some patients. However, further research is needed to determine whether HIV itself can cause pancreatitis.
  • Infections: HIV infects and destroys immune cells, making the patient vulnerable to infections. Some infections that are commonly associated with HIV may damage the pancreas and lead to pancreatitis. For instance, mycobacterium avium complex (MAC), toxoplasmosis, and a cancer called Kaposi's sarcoma have been shown to cause pancreatitis in HIV patients.
  • Medications: Some medications, including antibiotics like pentamidine (Pentam®) and the anti-HIV drug didanosine (Videx®), have been shown to cause pancreatitis. Also, studies have shown that some drugs, including the antiretroviral tenofovir (Viread®) and the anti-cancer drug hydroxyurea (Droxia®, Hydrea®), may increase the amount of didanosine in the blood, which further increases the risk of pancreatitis.

Symptoms
  • Acute: Acute symptoms of pancreatitis appear suddenly and may lasts for several hours or even days. Common symptoms include nausea, rapid pulse, fever, vomiting, and severe abdominal pain and swelling. The abdomen may be tender when touched. Drinking alcohol causes the symptoms to worsen.
  • Chronic: If the underlying cause of pancreatitis is not treated, the condition may become chronic (long-term). Common symptoms of chronic pancreatitis include nausea, vomiting, fever, and unintentional weight loss. Chronic pancreatitis may lead to temporary diabetes, malnutrition, and severe pain.

Diagnosis
  • Blood tests: A blood test may be performed to determine whether the digestive enzymes from the pancreas are present in the blood. Patients with pancreatitis will test positive for these enzymes. This is because the enzymes in the pancreas leak outside of the organ and into the bloodstream.
  • Imaging studies: Imaging studies, such as an abdominal X-ray or computerized tomography (CT) scan, may be performed to determine whether the pancreas is larger than normal. Both of these tests, which are performed at the hospital, produce images of the internal organs. Patients with pancreatitis will have an inflamed pancreas.
  • Endoscopic retrograde cholangiopancreatography (ERCP): An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at the hospital to evaluate the damage of the pancreas. During the procedure, a thin, flexible tube with a camera is inserted through the mouth into the small intestine. The tube then hooks into the bile duct, allowing the healthcare provider to see the pancreas. During the test, a small tissue sample may be removed and analyzed in a laboratory for infections or cancer. Because this procedure may damage the pancreas if not performed by a qualified physician, it is only conducted if all other tests are nondiagnostic. There is also a slight risk of infection.

Treatment
  • General: Acute pancreatitis usually improves after about one week of treatment. Patients with acute pancreatitis typically experience a full recovery. There is no cure for chronic pancreatitis. However, alcohol avoidance and pain medications can effectively relieve symptoms of the condition.
  • Alcohol avoidance: If the cause of chronic pancreatitis is alcohol, patients should minimize or eliminate alcohol consumption. If the patient is an alcoholic, rehabilitation may be recommended. Rehabilitation programs are tailored to specific individuals. Treatment may include group therapy, motivational interviewing, family therapy, and/or one-on-one counseling. The duration of rehabilitation treatment usually lasts several months. However, treatment varies among individuals. Support groups, like Alcoholics Anonymous (AA), may help individuals stay sober once they have completed a rehabilitation program.
  • Altering medications: If a medication is suspected to be causing acute pancreatitis, a healthcare provider may recommend an alternative dose or medication. Patients should not stop taking medications or take different dosages without first consulting their healthcare providers.
  • Analgesics: Oral pain relievers like meperidine (Demerol® Hydrochloride) have been used to treat pain caused by pancreatitis. Oral anti-inflammatories like naproxen (Naprosyn®, Synflex®) or high doses of aspirin may also help reduce pain. Because the pain may be difficult to manage, patients should remain in close contact with their healthcare providers to monitor the effectiveness of treatments.
  • Antimicrobials: Antimicrobials are used to treat infections that cause pancreatitis. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections. The exact type of medication and length of treatment depends on the type and severity of the infection, as well as the patient's overall health.
  • Dietary changes: Some patients with chronic pancreatitis may benefit from dietary changes. Healthcare providers may recommend smaller meals that are low in fats. This type of diet reduces the amount of digestive enzymes needed to break down the food. As a result, symptoms of pancreatitis may be reduced.
  • Endoscopic sphincterotomy: If a gallstone is causing acute pancreatitis, a surgical procedure called endoscopic sphincterotomy is usually performed. This procedure is used if the gallstone is blocking the bile ducts. During the procedure, which is performed at a hospital, the patient receives general anesthesia and is asleep during the surgery. Then, a thin flexible tube, called an endoscope, is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallbladder.
  • In general, this procedure is considered safe and effective for HIV patients with gallstones that cannot be passed naturally. It is estimated that 5-10% of all patients (HIV-positive and HIV-negative) experience complications from endoscopic sphincterotomy. It is unknown whether this risk is higher among HIV patients. Common complications include inflammation of the pancreas, inflammation of the bile ducts (cholangitis), bleeding, and passage of bacteria into the bloodstream.
  • Non-surgical procedures, such as bile salt tablets and sound wave therapy, are only considered if the patient is unable to undergo surgery or the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
  • Enzyme therapy: Patients with chronic pancreatitis may suffer from poor absorption of nutrients. These patients typically receive enzyme therapy with supplements, such as pancrelipase (Pancrease®, Viokase®). These are man-made versions of the pancreatic enzymes that are leaking out of the organ. These supplements are typically taken before and during meals and snacks.
  • Hospitalization: Most cases of acute pancreatitis require hospitalization for a few days. In order to allow the pancreas time to rest, the patient cannot eat or drink food. Instead, patients will receive fluid and nutrition through an intravenous injection.
  • Insulin injections: Because the pancreatic enzymes may damage the cells that produce insulin, insulin injections may be given to patients who are experiencing symptoms of diabetes. However, insulin should be used cautiously because it may lead to low blood sugar levels. Also, since diabetes often causes dehydration, patients may require intravenous fluids. Fluids taken by mouth may increase symptoms because they activate the pancreas.
  • Surgery: In severe cases, patients may undergo a surgical procedure to destroy the nerves near the pancreas. Once the nerves are dead, they can no longer transmit pain signals to the brain and the patient does not feel pain. Surgery is only performed in patients who have severe pain that cannot be managed with other treatments.

Integrative therapies
  • Good scientific evidence:
  • Probiotics: Supplementing with Lactobacillus plantarum 299 may help prevent pancreatic infection (sepsis), reduce the number of operations needed, and reduce the length of hospital stay in acute pancreatitis. Additional research is needed to make a conclusion.
  • Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
  • Unclear or conflicting scientific evidence:
  • Chlorophyll: Chlorophyll is a chemoprotein commonly known for its contribution to the green pigmentation in plants; it is related to protoheme, the red pigment of blood. It can be obtained from green leafy vegetables (broccoli, Brussels sprouts, cabbage, lettuce, and spinach), algae (Chlorella and Spirulina), wheat grass, and numerous herbs (alfalfa, damiana, nettle, and parsley). Based on early study, it has been suggested that chlorophyll-a may reduce the mortality rate in chronic pancreatitis. Additional study is needed in this area.
  • Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes, or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.
  • Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. For many years, danshen has been used as a traditional Chinese medicine (TCM) remedy to treat acute pancreatitis. However, little scientific research is currently available regarding the use of danshen in humans.
  • Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or hypotensives including ACE inhibitors such as captopril, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure, and following cerebal ischemia. Avoid if pregnant or breastfeeding.
  • Grape seed: Limited available human study suggests that grape seed may reduce abdominal pain in chronic pancreatitis. Further research is needed.
  • Reports exist of people with allergy to grapes or other grape compounds, including anaphylaxis. Individuals allergic to grapes should not take grape seed and related products. Use cautiously if taking anticoagulants. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Grape seed may interfere with the way the body processes certain drugs that use the liver's cytochrome P450 enzyme system. Avoid if pregnant or breastfeeding.
  • Selenium: There is currently inconclusive evidence regarding the use of selenium in pancreatitis. Additional study is needed in this area.
  • Avoid if allergic or sensitive to products containing selenium. Avoid with a history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
  • Traditional or theoretical uses lacking sufficient evidence:
  • Acupuncture: Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called "chi," circulates. These pathways contain specific "points" that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. Electroacupuncture, which involves needles that send electrical currents into the skin, has been suggested as a possible treatment for pancreatitis. However, there is currently insufficient available evidence on the safety and efficacy of this treatment in humans. Further research is needed before a firm conclusion can be made.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures.
  • Chiropractic: Chiropractic care focuses on how the relationship between musculoskeletal structure (mainly the spine) and bodily function (mainly nervous system) affects health. Chiropractic therapy has been suggested as a beneficial treatment for patients with pancreatitis. However, a firm conclusion cannot be reached until further research is conducted.
  • Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data. Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers.
  • Lycopene: Lycopene is found in tomatoes and it is present in human serum, liver, adrenal glands, lungs, prostate, colon, and skin. It remains unclear whether lycopene is a safe and effective treatment for patients with chronic pancreatitis. Further research is warranted.
  • Avoid if allergic to tomatoes or to lycopene. Due to a lack of conclusive data, avoid if pregnant or breastfeeding.
  • Physical therapy: The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injury. Physical therapists use a variety of methods, including exercises, stretches, traction, electrical stimulation, and massage. Traditionally, physical therapy has been used to treat pancreatitis. However, further research in humans is necessary to determine whether this treatment is safe and effective in humans.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used during pregnancy, and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Prevention
  • Avoid or minimize alcohol consumption because it may lead to pancreatitis.
  • Patients should eat a reduced fat diet. High amounts of fat increase the risk of developing gallstones and gallstones may cause pancreatitis.
  • Patients should receive highly active antiretroviral therapy (HAART) to help prevent infections that may cause pancreatitis. HAART is a combination of anti-HIV drugs (antiretrovirals) that suppresses HIV and boosts the body's immune system.
  • In order to prevent complications of pancreatitis, patients should take medications exactly as prescribed.

Complications
  • Diabetes: Pancreatitis may lead to temporary diabetes. This condition occurs when the digestive enzymes damage the cells that produce insulin. Common symptoms include increased thirst, frequent urination, increased hunger, weight loss, blurred vision, and fatigue. Once the underlying cause of pancreatitis is treated, the diabetes will resolve.
  • Malnutrition: Chronic pancreatitis may lead to poor absorption of nutrients. Some patients may experience no symptoms, while others may experience fatigue, dizziness, weight loss, and decreased immune response. Some patients may experience oily stools caused by poor absorption of fats.
  • Pain: Chronic pancreatitis may be extremely painful if not managed properly. Without treatment, pain may prevent patients from performing normal daily activities. Patients should take their medications exactly as prescribed to minimize pain. Patients should consult their healthcare providers if their medications are not effectively reducing pain.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.