ULCERATIVE DISEASE OF THE ANORECTUM IN THE HIV+ PATIENT

Ulcerative processes are the most disabling of anal diseases in HIV+ p atients. The spectrum ranges from ''benign'' fissures to invasive ulce rative processes. It is important to recognize their salient features in order to effectuate proper management. Since 1989, 74 HIV+ patients with ulcerative anal disease were evaluated. Of 33 patients with beni gn fissures, 1 3 had sphincterotomy, with symptomatic relief in 12 and healing in 11. Ten had improvement with standard conservative treatme nt, and 10 did not return for re-evaluation. Of 41 patients with ''idi opathic'' anal ulcers, 34 underwent operative evaluation, biopsy, vira l culture, and debridement. Thirty had significant pain relief, and 17 showed variable evidence of healing. Four patients with intractable p ain had injection of Depo-Medrol(R) (The Upjohn Co., Kalamazoo, MI) in to the bed of the ulcer with significant pain relief. One patient was diverted. We propose that anal ulcerative disease be classified as ben ign lesions and therefore treated as if the patient were HIV negative. In those patients with HIV-associated anal ulcers, evaluation under a nesthesia, biopsy, culture, and debridement should be performed and th erapy directed against any neoplastic or viral agents found. Those pat ients with no identifiable agents may be helped with aggressive debrid ement or intralesional steroid therapy. This approach allows safe and effective treatment in most patients.