Radiographic Manifestations of Gastrointestinal Disease in AIDS: Differential Diagnosis by Anatomical Site

Esophagus and Stomach

Many AIDS patients experience severe dysphagia or odynophagia, which may be due to a variety of etiologies. Air contrast examination of the esophagus and stomach is important to evaluate focal lesions and the condition of the intervening mucosa. Esophageal disease may be caused by HIV, resulting in multiple discrete, large shallow ulcers. Esophageal herpes simplex virus (HSV) infection produces numerous discrete ulcers which may be surrounded by edema and which are separated by normal mucosa, producing a cobblestone appearance on barium swallow (Fig. 8.49). The rectum and anus may also be involved. Cytomegalovirus is another common cause of esophageal ulceration, characteristically producing large somewhat diamond-shaped ulcers (Fig. 8.50). In the stomach, thickening of mucosal folds and antral stenosis are characteristic findings.

Many of the AIDS patients who complain of dysphagia/odynophagia will have thrush (candidiasis). For example, candidiasis was noted in 21%-40% of AIDS patients in the Democratic Republic of the Congo and in Burundi 31% had this complication. Oral thrush is often found in patients with esophageal candidiasis. A barium swallow early in the course of involvement will show small round plaque-like exophytic lesions on the mucosal surface of the esophagus. In more severe cases, the interstices between plaques, mucosal ulcerations and pseudomembranes produce a "shaggy" appearance (Fig. 8.51). Kaposi's sarcoma may involve the esophagus, stomach, small bowel, or large bowel, originating as flat submucosal lesions but enlarging into polypoid masses often demonstrating central umbilication (target lesion). These lesions may be accompanied by enlarged lymph nodes, which may enhance on contrast injection.

Fig. 8.49. The barium air contrast study of the esophagus of an AIDS patient with herpes simplex esophagitis. There are multiple ulcers separated by areas of normal mucosa.

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Fig. 8.50 A, B. Cytomegalovirus. (A) A barium swallow shows a large and deep ulcer, which is characteristic of cytomegalic involvement of the esophagus. (B) In the stomach gastritis is often characterized by thickened folds and stenosis of the antral region (arrows).

Fig. 8.51. The barium swallow of a patient with AIDS and candidiasis shows a "shaggy" appearance of the esophagus because barium is trapped in the interstices between plaque-like lesions.

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