Introduction
Human immunodeficiency virus (HIV) infection is becoming a global epidemic. In HIV-infected individuals, anorectal diseases are common and the commonest indications for surgical intervention. However, it has not been clear whether the cause and management of anorectal conditions differ in patients who are HIV negative and those who are HIV positive.
Aim
To compare the presentation of perianal diseases in HIV +ve and HIV –ve patients and to determine the best therapy for perianal diseases in HIV +ve patients
Methods
The study period was from 1999 to 2002. Patients seen at Helen Joseph Hospital during the author’s gastroenterology fellowship period and those from his private practice were recruited. Those who agreed to HIV testing and who were treated by the author were included in the study. The patients were categorized according to HIV status, CDC classification and perianal pathology. Standardized
questionnaires were used for every patient. Patients were reviewed every two weeks after the procedure until fit for discharge.
Results
The sample comprised 241 patients: 100 HIV+ve (63 males and 37 females) and 141 HIV-ve (61 males and 80 females). The mean age of the HIV+ve patients was 34,8y (range 17-62y), and the mean age of the HIV-ve patients was 41y (range 5-82y). Follow-up was from two weeks to two years. The pathology included 62 (25 +ve, 37 -ve) haemorrhoids, 67 (27 +ve, 40 –ve) fistulas, 59 (25 +ve, 34 -ve) abscesses, 46 (11 +ve, 35 -ve) fissures, 24 (22 +ve, 2 -ve) anal ulcers, four (3 +ve, 1 -ve) anal warts, two (both +ve) pilonidal sinuses, three (all -ve) anal cancers and two (1 +ve, 1 -ve) hidradenitis suppurativa. Nine patients with haemorrhoids (4+ve, 5-ve) were treated conservatively, 11 patients with haemorrhoids (6+ve, 5-ve) had rubber band ligation and 42 patients with haemorrhoids (15+ve, 27-ve) had haemorrhoidectomy. Thirteen patients (1+ve, 12-ve; p<0.001) had complex fistulas and 8 patients (7+ve, 1-ve; p=0.006) had multiple fistulas. Ten HIV -ve patients with complex fistulas and seven patients with trans-sphincteric fistulas (3+ve, 4-ve) needed more than six weeks to heal after treatment. Thirty patients with anal fissures had sentinel piles, but there were none in the patients with anal ulcers (p<0.0001). Thirteen HIV +ve patients with anal ulcers had an abnormally weak anal tone, but only one HIV +ve patient with anal fissure
had a weak anal tone (p<0.001). In the patients with anal fissure, 37 (8+ve, 29-ve) had a high anal tone, but none of the patients with anal ulcers had increased anal tone (p<0.0001). Of the 59 patients with perianal suppuration, 23 (8+ve, 15-ve) had primary fistulotomy as well as drainage of the abscess.
Conclusions
Multiple fistulas were more commonly seen in advanced HIV patients, whereas complex fistulas were more commonly seen in HIV negative individuals. Healing after fistula surgery is determined more by the type of fistula than the HIV status or stage.
Anal fistulas associated with perianal suppuration can be treated the same way in both HIV negative and positive patients, without increased complications.
Careful physical examination is essential to differentiate between anal ulcers and fissures. Both conditions are common, and have similar symptoms in HIV positive patients. They can, however, be readily and safely distinguished on clinical examination, since fissures are associated with high anal tone,
and a sentinel pile, while the AIDS ulcer lacks the sentinel pile, and the pressure is low.
Anal malignancies, especially squamous cell carcinoma, have been uncommon in our experience.
With the addition of anti-retroviral therapy and antibiotics, haemorrhoids may be safely treated according to standard principles (rubber band ligation and haemorrhoidectomy, as appropriate).
Our practice has favoured a conservative approach in patients with advanced HIV disease. However, anti-retroviral therapy and antibiotics may improve the safety and outcome after surgical procedures.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/6921 |
| Date | 05 May 2009 |
| Creators | Tun, Myint |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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