Oral and upper gastrointestinal Crohn's disease.

Crohn's disease is a heterogeneous, inflammatory condition that can affect any location of the gastrointestinal tract. Proximal gastrointestinal involvement occurs in 0.5-16% of patients, and it is usually diagnosed after recognition of intestinal disease. Symptoms are often mild and nonspecific; however, upper gastrointestinal disease predicts a more severe Crohn's phenotype with a greater frequency of complications such as obstruction and perforation. Gastroscopy and biopsy is the most sensitive diagnostic investigation. There is a paucity of data examining the treatment of this condition. Management principles are similar to those for intestinal disease, commencing with topical therapy where appropriate, progressing to systemic therapy such as glucocorticoids, 5-aminosalicylic acid, immunomodulators, and biologics. Acid suppression therapy has symptomatic but no anti-inflammatory benefit for gastroduodenal and esophageal involvement. Surgical intervention with bypass, strictureplasty, or less frequently, endoscopic balloon dilation may be required for complications or failed medical therapy.

Impact of post-haemorrhoidectomy pain relief checklists on pain outcomes: a randomized controlled trial.

BACKGROUND: Haemorrhoidectomy is associated with significant post-operative pain which is primarily managed pharmacologically. Whether a non-pharmacological adjunct such as a checklist can improve pain outcomes after an open haemorrhoidectomy has yet to be studied. The purpose of this study was to determine if a patient-completed checklist of prescribed post-haemorrhoidectomy pain medications would improve pain management after surgery. METHODS: We conducted a dual-centre randomized controlled trial of patients undergoing a Milligan-Morgan haemorrhoidectomy for symptomatic third or fourth degree haemorrhoids. Thirty-five patients were randomized into either a control group which received post-operative pain medication plus a visual analogue scale (VAS) form, or an intervention group which received a post-operative medication checklist in addition to the items the control group received. Both groups recorded their pain levels on the VAS forms at 10.00, 14.00 and 20.00 hours each day for 14 days post-operatively. RESULTS: Patients in the checklist group reported a significantly greater reduction in mean VAS pain score of 2.51 (95% confidence interval (CI) 1.34-3.68; P < 0.001) between day 1 post-op and day 14 post-op compared to 1.86 (95% CI 0.77-2.95; P = 0.001) for the control group. There was no significant difference between mean pain experienced by patients in either group over each of the 14 days individually or overall (P = 0.07). CONCLUSION: The pain medication checklist lead to a greater reduction in pain between day 1 and 14 after an open haemorrhoidectomy compared to standard care but did not significantly reduce mean pain across any individual days or overall.

How to decide to undertake a randomized, controlled trial of stent or surgery in colorectal obstruction.

BACKGROUND: Colorectal stents have been available as a management option in obstruction for 23 years, yet there is little randomized evidence of their effectiveness. This study investigated current surgeon-related barriers to conducting a randomized, controlled trial (RCT) of colorectal stent insertion for obstruction in patients with colorectal cancer. METHODS: A binational survey of current members of the Colorectal Surgical Society of Australia and New Zealand was conducted by a mailed questionnaire assessing perceived barriers to adoption of colonic stents and willingness to participate in future multicentre randomized controlled trials, and surgeons' treatment preferences in 16 hypothetical clinical scenarios. RESULTS: Of 148 eligible surgeons, 96 (65%) responded. Colonic stenting was available to 98% of respondents. In the clinical setting of colorectal obstruction, only 29% (95% CI, 20-39%) of surgeons expressed a willingness to participate in a RCT involving colonic stents in the curative setting. More than 70% of surgeons preferred the use of stents in unfit patients for palliation, and preferred surgery in fit patients with curable disease. In the curative setting, most respondents considered colonic stents not cost effective (90%; 95% CI, 82-94%) and believed that their patients would not prefer stents over surgery (80%; 95% CI, 71-87%). CONCLUSION: This study highlights the limitation to conducting a future randomized controlled trial to assess the efficacy of colonic stenting, especially in the curative setting, based on surgeon preference, despite the lack of level I evidence.