Book Review

AIDS — Politics, Policies, and Patients

Anorectal Disease in AIDS

N Engl J Med 1993; 328:451-452February 11, 1993

Article

Anorectal Disease in AIDS
Edited by T.G. Allen-Mersh and L. Gottesman. 174 pp., illustrated. London, Edward Arnold, 1992. $65. (Distributed in the U.S. by Williams and Wilkins, Baltimore.) ISBN: 0-340-54643-3

Anorectal diseases are among the most frustrating problems encountered in patients with AIDS, particularly homosexual men who practice anoreceptive intercourse. This book brings together chapters by clinicians and clinical scientists from the United Kingdom and the United States to provide guidance for doctors who increasingly will be encountering anorectal diseases in patients with AIDS. For the most part the book accomplishes its goals. It is directed primarily to colorectal surgeons, though physicians caring for homosexuals, patients with AIDS, or patients in whom AIDS may develop (almost anyone) will benefit from this collection of fine reviews. The first chapter is an excellent brief review of the physiology of AIDS; it is focused only partially on anorectal disorders and will certainly be helpful for those who do not specialize in AIDS medicine. In it, physicians are cautioned to pay careful attention to their patients' associated problems, including malnutrition. The next two chapters provide important insights into the practice of anoreceptive intercourse and its relation to the development of anorectal diseases and the acquisition of HIV. The section on the anorectal examination probably offers little to the colorectal surgeon but a good deal more to the medical generalist.

Other chapters cover specific types of disease, including proctitis, ulcers, warts, and neoplasms. All are well done. Most important, they emphasize proper serologic, culture, and biopsy techniques, which are crucial for proper diagnosis and appropriate therapy. There are a few inconsistencies concerning some of these techniques among the chapters, however. What should be stressed, I believe, is that the physician must be prepared for dealing with patients who have AIDS by having ready access to proper transport and culture mediums and by understanding what the clinical laboratory has available and how to use these tools for patient care.

Management of each type of anorectal disorder is covered. The chapter on neoplasia is somewhat overly detailed with respect to staging and chemotherapy (details only an oncologist might find helpful), but not quite complete. Nonetheless, it gives important prognostic information and emphasizes the complexity of treating neoplasia in AIDS. Anorectal sepsis is particularly well presented; this chapter provides surgeons with helpful pointers on dealing with a problem that is not uncommon but extremely complex when associated with AIDS.

Two chapters are devoted largely to methods of protecting medical personnel, particularly surgeons, and patients. They are somewhat redundant, though one is well supplied with instructive and witty photographs. These sections underscore differences in practice between the United States and the United Kingdom. Physicians in the United Kingdom still base their use of precautions on the presumed risk that an individual patient harbors HIV, citing economic considerations, whereas few physicians in the United States would argue against the need for universal precautions.

In general, the editors have done a good job. There are a few glaring typographic errors, some redundancy, and rare inconsistencies, but the book provides in one place much well-researched information and carefully compiled clinical experience about conditions with regard to which our approach and expectations are still evolving. It is particularly noteworthy that humane care giving is never overlooked here. This book will be valuable to surgeons and gastroenterologists and should be in hospital libraries. Given the explosion of information about AIDS, I can envision an updated second edition in short order.

Murray N. Ehrinpreis, M.D.
Wayne State University School of Medicine, Detroit, MI 48201