Anal diseases at Patient with AIDS
These are usually sexually transmitted, although anoreceptive intercourse is probably not necessary for the development of anal canal warts. The treatment of these warts requires local scissor excision or destruction by some other local method, for example diathermy or laser. Less extensive wart infection can be controlled by application of podophyllin. The wart virus (human papilloma virus) is able to incorporate in the human genome and some types promote cancer development. In the presence of reduced immune surveillance, this can result in early neoplastic change within the anal epithelium which is termed anal intraepithelial neoplasia (AIN). The risk of progression of this intraepithelial neoplasia to invasive anal malignancy is small, although a precise figure is unknown. The finding of AIN in HIV disease is probably of little clinical significance since progression to invasive malignancy is unlikely within the prognosis of the HIV disease. The objective of anal wart treatment in these patients should be to control the local discomfort or leakage associated with the warts. AIN may also occur in the absence of warts (Fig. 9.4), although these patients are probably infected with human papilloma virus.
The usual varieties of anal fistula can develop in HIV-positive patients. The combination of local anal trauma resulting from anoreceptive sex with reduced immunity probably results in an increased risk of perianal sepsis. Perineal healing is reduced in patients with advanced HIV disease associated with a low CD4+ lymphocyte count. In those patients who do not have a CD4+ count of less than 100, conventional management of perianal sepsis is appropriate.
For patients with severe reduction in CD4+ count who are likely to have AIDS, a more conservative approach to control sepsis, for example, with the use of a seton, is probably more appropriate. It was initially believed that perianal sepsis was more complex in the HIV than in the non-HIV patient population. However, subsequent experience does not suggest that HIV-positive patients are more likely to have difficult or complicated high fistulas
Ulcers may occur in any part of the anal canal or lower rectum, and are usually associated with AIDS. In some cases they can be shown to be due to herpes simplex virus infection, but in other cases no organism has been demonstrated, although infection remains the most likely cause. Treatment for herpes simplex virus with acyclovir should be tried first. Occasionally, excision of the ulcerated area with a gentle anal stretch can be helpful. In some cases it is not possible to achieve healing of the ulcer.
The probability of an HIV-positive patient with anal symptoms having anal neoplasia is much higher than in the nonHIV population. The commonest anal neoplasms are squamous carcinoma of the anal canal , Kaposi’s sarcoma involving the anal canal, and perirectal or perianal non-Hodgkin’s lymphoma. Lymphoma can produce a tense painful swelling in the ischiorectal fossa which is easily mistaken for perianal sepsis. Thus needle aspiration is helpful before incision and drainage of suspected ischiorectal abscesses in the HIV-positive patient since this may avoid a breach in the skin overlying the lymphoma with subsequent risk of ulceration. The majority of patients with anal neoplasia has advanced HIV disease.
Homosexuals who undergo repeated anorectal intercourse weaken the internal anal sphincter. The association of a weakened internal anal sphincter with some degree of infective proctitis can produce minor faecal incontinence.
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