Browsing by Author "Kodisinghe, S.K."

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Association between road accidents and minimal hepatic encephalopathy in a cohort of Sri Lankan drivers with cirrhosis
(Sri Lanka Medical Association, 2014) Subasinghe, S.K.C.E.; de Silva, A.P.; Niriella, M.A.; Kodisinghe, S.K.; Nandamuni, Y.; Sameera, R.A.C.; de Silva, H.J.
INTRODUCTION AND OBJECTIVES: Minimal hepatic encephalopathy (MHE) has no recognizable clinical symptoms of hepatic encephaiopathy (HE) but has mild cognitive and psychomotor deficits. Previous studies in Western countries have demonstrated an association between MHE and increased road accidents. Our objective was to investigate this association in a cohort of Sri Lankan drivers with cirrhosis. Study design; Prospective, case controlled study. Study setting; Ongoing study conducted in the Gastroenterology Clinic, University Medical Unit, North Colombo Teaching Hospital, Ragama, from August 2013. METHODS: Patients with cirrhosis of any aetiology, without overt HE, who had been driving any vehicle during the past one month were subjected to 5 standard pencil-paper based psychometric tests to detect MHE. An abnormality in 3 or more tests was considered diagnostic of MHE. Road accidents were recorded among drivers with cirrhosis with MHE. Age and sex matched healthy drivers (controls) who also underwent the 5 psychometric tests. RESULTS: Among 54 drivers with cirrhosis with MHE [males, median age 53 years (range 30-60}], 7 (13%) reported any type of accident compared to 6 (11%) among 54 controls [males; median age 51 years (range 30-60)]. 2 (3.7%) cases and 2 (3.7%) controls reported minor accidents involving another person. There were no major accidents in either group. CONCLUSIONS: Preliminary results of this ongoing study do not indicate an increased frequency of road accidents in a cohort of Sri Lankan drivers with cirrhosis with MHE.
Changing phenotype of IBD in Sri Lanka
(Sri Lanka Medical Association, 2016) Niriella, M.A.; Kodisinghe, S.K.; Dinamithra, N.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; Dassanayake, A.S.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.
INTRODUCTION: Inflammatory bowel disease (IBD) is increasing in Asia Pacific, with recent changes in phenotype reported from some countries. METHOD: Patients with histologically proven IBD [ulcerative colitis(UC), Crohn’s disease(CD), unclassified(U)], diagnosed between January 2006-December 2010 (Group 1) and January 2011-December 2015 (Group 2), who had regular follow up, were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka (two main referral centers). The two groups were compared with regard to phenotype of IBD (subgroups, severity, age at diagnosis, duration of symptoms, extra-intestinal manifestations (EIM) at diagnosis, cigarette smoking, family history, and highest therapy during follow up). RESULTS: 304 patients were included [Group 1: UC-72(74.2%), CD-25(25.8%); Group 2: UC-113(54.6%), CD-90(43.5%), U-4(1.9%)]. There were more females in Group 2 for UC and CD. Median age at diagnosis was similar for UC but higher for CD in Group 2 compared to Group 1.The median duration of symptoms to diagnosis was not different for UC and CD in the two groups. In both groups, left sided colitis (E2) predominated for UC and Ileo-colonic disease (L3) and non-stricturing, non-penetrating (B1) disease predominated for CD. There was no difference in degree of severity, rate of complications, pattern of EIM, smoking history at presentation, family history or highest therapy during follow up for either disease in the two groups (Table 1). CONCLUSIONS: During the 10 years, there seems to be a recent increase in the proportion of CD among IBD patients. However, there were no major changes in disease phenotype for UC or CD.
Changing phenotype, early clinical course and clinical predictors of inflammatory bowel disease in Sri Lanka: a retrospective, tertiary care-based, multi-centre study
(BioMed Central, 2021) Niriella, M.A.; Liyanage, I.K.; Kodisinghe, S.K.; de Silva, A.P.; Jayatissa, A.V.G.A.M.; Navarathne, N.M.M.; Peiris, R.K.; Kalubovila, U.P.; Kumarasena, S.R.; Jayasekara, R.W.; de Silva, H.J.
BACKGROUND: Inflammatory bowel disease (IBD) is increasing in the Asia-Pacific region, with changes in disease phenotype and course. We aimed to assess the changing phenotypes of IBD over ten years, describe the early clinical course (ECC) and identify the clinical predictors (CP) of poor outcomes among a large, multi-centre, cohort of Sri Lankan IBD patients. METHODS: We included patients [diagnosed between June/2003-December/2009-Group-1(G1), January/2010-June/2016-Group-2(G2)] with ulcerative colitis (UC) and Crohn disease (CD) from five national-referral centres. Changing phenotype from G1 to G2, ECC (disease duration < 3-years) and CP of poor outcomes (disease duration ≥ 1-year) was assessed. Poor outcomes were complicated-disease (CompD-stricturing/penetrating-CD, extensive-UC/pancolitis, perforation/bleeding/colectomy/malignancy) and treatment-refractory disease (TRD-frequently-relapsing, steroid-dependent/refractory and biologic use). RESULTS: 375 (UC-227, CD-148) patients were recruited. Both G1/G2 had more UC than CD (77% vs 23%, 54.5 vs 45.5 respectively, p < 0.01). Increase of CD from G1-to-G2 was significant (23-45.4%, p < 0.001). In both groups, left-sided colitis (E2) and ileo-colonic (L3)/non-stricturing, non-penetrating disease behaviour (B1) CD predominated. Extensive-colitis (E3) (36.4% vs 22.7, p < 0.05) and stricturing-CD (B2) (26.1% vs 4.0%, p < 0.01) was commoner in G1. ECC was assessed in 173-patients (UC-94, CD-79). Aggressive disease behaviour and TRD were low among both UC and CD. Immunomodulator use was significantly higher among CD than UC (61.5% vs 29.0% respectively, p < 0.01). Anti-TNF use was low among both groups (UC-3.2%, CD-7.7%). Disease complications among UC [bleeding (2.1%), malignancy-(1.1%), surgery-(2.1%)] and CD [stricture-(3.9%), perforation-(1.3%), malignancy-(1.3%), surgery-(8.9%)] were generally low. CPs were assessed in 271-patients (UC-163, CD-108). Having a family history of IBD (for UC), extraintestinal manifestation (EIM), severe disease at presentation, being in younger age categories and severe disease at presentation, (for both UC and CD) predicted poor outcomes. CONCLUSION: There was an increase in CD over time without change in disease phenotype for both UC and CD. A relatively benign ECC was observed. Family history (UC), EIMs (UC/CD), severe disease at presentation (UC/CD), younger age (CD/UC) CPs of poor outcomes. KEYWORDS: Clinical course; Clinical predictors; Crohn disease; Inflammatory bowel disease; Phenotype; Sri Lanka; Ulcerative colitis.
Changing phenotype, early clinical course and clinical predictors of irritable bowel syndrome in Sri Lanka: a prospective, multi-centre descriptive study
(Sri Lanka Medical Association, 2017) Niriella, M.A.; Kodisinghe, S.K.; Nanayakkara, S.D.; Silva, K.T.M.; Rajapakshe, N.; Luke, D.; de Silva, A.P.; Navarathne, N.M.M.; Dissanayake, V.H.W.; Jayasekara, R.W.; de Silva, H.J.
INTRODUCTION & OBJECTIVES: Incidence of inflammatory bowel disease (IBD) is increasing in the Asia Pacific, with changes in phenotype and disease course been reported. METHODS: Ulcerative colitis (UC) and Crohn disease (CD) cases from four national referral centres were included. Phenotype was compared for cases [Group-1/G1-diagnosed between June/2003-December/2009, Group-2/G2-January/2010-June/2016]. Early clinical course (ECC) [complicated disease (Comp D-stricturing/penetrating CD, extensive-UC/pancolitis), treatment refractory disease (TRD-frequently-relapsing, steroid-dependent/refractory, biologics), disease complications (DC-perforation/bleeding/colectomy/malignancy)] among disease duration <3 years, and clinical predictors (CP) of CompD/TRD/DC among disease duration >1 year were also assessed. RESULTS: A total of 452-cases [G1: UC-89 (78.8%), CD-24 (21.2%); G2: UC-197 (58.1%), CD-142 (41.9%)] were included. G2 had a higher proportion of CD (p<0.001). In both groups, leftsided colitis (E2) for UC, ileo-colonic (L3)/non-stricturing, non-penetrating (B1) for CD predominated. More penetrating-CD (B3) in G2 (p<0.01) and more stricturing-CD (B2) in G1 (p<0.05) were noted. ECC was assessed in 293 patients [UC-168 (57.3%), CD-125 (42.7%)]. Among UC: extensive/pan-colitis (E3)-40 (24.5%), severe (S3)-38 (42.2%); among CD:severe episodes-15 (25.9%), stricturing (B2)/penetrating(B3)-18 (14.7%), perianal-disease (P)-29 (23.4%). TRD was seen in 19 (11.3%)-UC and 17 (10.1%)-CD. Immunomodulator use was-70 (41.7%)/93 (74.4%), and anti-TNF use was 3 (1.8%)/12 (9.6%) respectively for UC and CD. Complications for UC: bleeding-6 (3.6%), malignancy-1 (0.6%), surgery-3 (1.8%); for CD: stricture-6 (4.9%), perforation-3 (2.4%), malignancy-1 (0.8%), surgery-2 (1.6%). CP were assessed in 373 [UC-266 (71.3%), CD 107 (28.7%)]. EIM of joints predicted CompD in UC/CD (OR-1.94/OR-2.28). Family history (OR=8.64) and EIM of joints (OR=10.07) predicted DC in UC. CONCLUSION: There was an increase in CD during the study period, but no changes in disease phenotype for UC or CD. Although admissions with CompD were common for UC (but not CD), few patients had TRD or DCs indicating a relatively benign early disease course. Family history, EIM of joints predicted poor outcomes in UC, EIM of joints predicted a poor outcome in CD.
Clinical predictors of poor disease outcome for inflammatory bowel disease in Sri Lanka
(Sri Lanka Medical Association, 2016) Niriella, M.A.; Kodisinghe, S.K.; Dassanayake, S.U.B.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.
INTRODUCTION: There is limited data on clinical predictors of poor outcomes of inflammatory bowel disease from Sri Lanka. OBJECTIVES: To study clinical predictors of poor outcomes of inflammatory bowel disease among patients attending National Hospital of Sri Lanka and Colombo North Teaching Hospital. METHOD: Patients with ulcerative colitis (UC) and crohn disease(CD) of at least one year duration were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka. Predictors of complicated disease (CompD) (structuring/penetrating-CD, extensive/pancolitis-UC), treatment refractoriness (TR) (frequently relapsing, steroid dependent, steroid refractory, need for biologics) and disease complications (DC) (perforation, bleeding, colectomy, malignancy) were assessed. Gender, age, duration at diagnosis, extra-intestinal manifestations (EIM), cigarette smoking and family history were assessed as independent risk factors using binary logistic regression. RESULTS: 287 patients were included [UC-208 (72.5%%), 100 (48.1%) males, median follow up (IQR) 74.5 (35.0–127.5) months; CD 79(27.5%), 37(46.8%) males, median follow up (IQR) 50.0 (29.0-84.0) months]. CompD was observed among 65(31.25%) UC and 20(25.31%) CD patients; family history (OR 4.103, adjusted p=0.029) was predictive of CompD in UC. TR was observed among 13(6.31%) UC and 9(11.39%) CD patients; non-smoking was predictive of TR in UC (OR=0.000, adjusted p=0.027). DC was seen in 8(3.86%) of UC and 11(13.92%) of CD. Family history (OR=16.457, adjusted p=0.001), EIM of skin (OR=14.071, adjusted p=0.039) and joints (OR=8.940, adjusted p=0.002) were predictive of DC in UC; eye EIM (OR=4.286, adjusted p=0.047) was predictive of DC in CD. CONCLUSIONS: CompD was not uncommon in UC and CD. TR and DC were uncommon. Family history, being a non-smoker, EIM of skin and joints independently predicted worse outcomes in UC, while EIM of eyes predicted a poor outcome in CD.
Development of a model for a resource limited setting, to predict the presence of oesophageal varices among newly diagnosed patients with cirrhosis.
(Sri Lanka Medical Association., 2019) Perera, K.; Kodisinghe, S.K.; Ediriweera, D.; Moratuwagama, H.M.D.; Williams, S.; Pathmeswaran, A.; Niriella, M.A.; de Silva, H.J.
INTRODUCTION & OBJECTIVES: In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class. METHODS: A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, from April 20 I 4-April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (FBC with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed. Linear logistic regression model was developed to predict OV using HP and CTP class. RESULTS: 54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P=0.002), CTP-B (P=0.003) and CTP-C (P=0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = - 0.189 - (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on ROC analysis, a model value >-0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89% positive predictive value and 76%-negative predictive value. CONCLUSION: We constructed a model using %SP on peripheral blood smear and CTP class. This model can be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with high sensitivity and specificity, avoiding the need for initial UGIE.
Early clinical course of IBD in Sri Lanka
(Sri Lanka Medical Association, 2016) Niriella, M.A.; Kodisinghe, S.K.; Dinamithra, N.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; Dassanayake, A.S.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.
INTRODUCTION: There is very limited data on the early clinical course of IBD from Sri Lanka. METHOD: Patients with histologically proven IBD [ulcerative colitis(UC), Crohn disease(CD)] of less than 3 years duration, were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka (two main referral centers). Complicated disease behaviour (stricturing or penetrating CD, extensive or pancolitis for UC), treatment refractory disease (frequently relapsing, steroid dependent, steroid refractory, need for biologics) and complications (perforation, bleeding, colectomy and malignancy) were analysed. RESULTS: 177 patients were eligible for inclusion [UC-97(54.8%), 46(47.4%) males, median follow up (IQR) 17.0(5.5-28) months; CD 80(45.2%), 39(48.8%) males, median follow up (IQR) 7(2-21.5) months]. Admissions with severe episodes of extensive or pancolitis for UC were 26(26.8%) and 20(21.1%) respectively. Admissions with severe episodes, stricturing(B2), penetrating(B3) or perianal disease(P) for CD were 7(8.8%), 9(11.5%) and 16(20%) respectively. Treatment refractoriness (steroid dependency, steroid refractory or frequently relapsing) was 6(9.6%) for UC and 6(8.4%) for CD. Immunomodulator use was 35 (37.2%) and 56(72.7%), and Anti-TNF agent use 2(2.1%) and 2(2.6%) respectively for UC and CD. Few had complications [UC-bleeding 5(5.2%), malignancy 1(1%), surgery 2(2.1%); CD-stricture 3(3.8%), perforation 3(3.8%), malignancy 1(1.3%), surgery 3(3.8%)]. CONCLUSIONS: In the early clinical course of this cohort of IBD patients, admissions with complicated disease were common for UC but not CD. Few patients were treatment refractory. Immunomodulator use was more common for CD, but need for biologics was rare for both. Few IBD patients developed complications. This indicates a relatively benign early disease course.
Effect of audio and visual distraction on patients undergoing colonoscopy: a randomized controlled study
(Stuttgart : Georg Thieme Verlag KG, 2016) de Silva, A.P.; Niriella, M.A.; Nandamuni, Y.; Nanayakkara, S.D.; Perera, K.R.P.; Kodisinghe, S.K.; Subasinghe, K.C.E.; Pathmeswaran, A.; de Silva, H.J.
BACKGROUND AND STUDY AIMS : Colonoscopy can cause anxiety and discomfort in patients. Sedation and analgesia as premedication can lead to complications in the elderly and those with comorbidities. This has led to an interest in the use of audio-visual distraction during the colonoscopy. We compared the effects of audio (AD) versus visual distraction (VD) in reducing discomfort and the need for sedation during colonoscopy. PATIENTS AND METHODS: Consecutive patients undergoing colonoscopy were randomized into three groups: one group was allowed to listen to the music of their choice (AD), the second group was allowed to watch a movie of their choice (VD), and the third group was not allowed either distraction during colonoscopy and acted as a control (C). Patient controlled analgesia and sedation were administered to all three groups. We used 25 mg of pethidine in 5-mg aliquots and 2.5 mg of midazolam in 0.5-mg aliquots. All patients were assessed for perceived pain and willingness to repeat the procedure. Number of "top-ups" of sedation and total dose of pethidine and midazolam were noted. Patient cooperation and ease of procedure were assessed by the colonoscopist. RESULTS: In total, 200 patients were recruited [AD, n = 66 (32 males, median age 57 years); VD, n = 67 (43 males, median age 58 years); C, n = 67 (35 males, median age 59 years)]. The AD group had significantly less pain (P = 0.001), better patient cooperation (P = 0.001) and willingness to undergo a repeat procedure (P = 0.024) compared with VD and C groups. CONCLUSIONS: AD reduces pain and discomfort, improves patient cooperation and willingness to undergo a repeat procedure, and seems a useful, simple adjunct to low dose sedation during colonoscopy.
Evidence-based management of non-alcoholic fatty liver disease
(Endocrine Society of Sri Lanka, 2015) Kodisinghe, S.K.; Niriella, M.A.
Non-alcoholic fatty liver disease (NAFLD)it is the commonest cause of chronic liver disease in developed countries and is rapidly increasing in the Asia-Pacific region. NAFLD has important long term health implications. There is increased overall mortality most commonly from cardiovascular disease, and also increased liver-related mortality. Treatment options available for NAFLD include general measures at managing obesity and correcting the metabolic syndrome and liver-directed therapies aimed at reducing the liver inflammation and hepatocellular injury. This article reviews the current evidence based management of NAFLD and associated metabolic comorbidities.
Genetic associations of inflammatory bowel disease in a South Asian population
(Baishideng Publishing Group, 2018) Niriella, M.A.; Liyanage, I.K.; Kodisinghe, S.K.; Silva, A.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, D.; Silva, T.; Nawarathne, M.; Peiris, R.K.; Kalubovila, U.P.; Kumarasena, S.R.; Dissanayake, V.H.W.; Jayasekara, R.W.; de Silva, H.J.
AIM: To estimate prevalence and phenotypic associations of selected inflammatory bowel disease (IBD)-associated genetic variants among Sri Lankan patients. METHODS: A case study of histologically confirmed ulcerative colitis (UC) or Crohn's disease (CD) patients with ≥ 1 year disease duration, who were compared to unrelated, gender-matched, healthy individuals as controls, was conducted at four major centers in Sri Lanka. Phenotypic data of the cases were obtained and all participants were genotyped for 16 selected genetic variants: IL12B:rs1045431, IL23R:rs11805303, ARPC2:rs12612347, IRGM:rs13361189, IL26/IL22:rs1558744, CDH1:rs1728785, IL10:rs3024505, FCGR2A:rs3737240, PTGER4:rs4613763, IL17REL/PIM3:rs5771069, HNF4a:rs6017342, STAT3:rs744166, SMURF1:rs7809799, LAMB1:rs886774, HLA-DRB5, DQA1, DRB1, DRA:rs9268853, MST1, UBA7, and APEH:rs9822268. The genotypes of all variants were in Hardy-Weinberg Equilibrium (P > 10-3). To account for multiple hypothesis testing, P-values < 0.003 were considered significant. RESULTS: A total of 415 patients and 465 controls were recruited. Out of the single nucleotide polymorphisms (SNPs) tested, the majority were not associated with IBD in Sri Lankans. Significant positive associations were noted between rs886774 (LAMB1-gene) and UC (odds ratio (OR) = 1.42, P = 0.001). UC patients with rs886774 had mild disease (OR = 1.66, P < 0.001) and remained in remission (OR = 1.48, P < 0.001). A positive association was noted between rs10045431 (IL 12B gene) and upper gastrointestinal involvement in CD (OR = 4.76, P = 0.002). CONCLUSION: This confirms the heterogeneity of allelic mutations in South Asians compared to Caucasians. Most SNPs and disease associations reported here have not been described in South Asians.
Ideal amount of exercise for a healthy life: have we solved the goldilocks problem? – review of the literature
(Endocrine Society of Sri Lanka, 2016) Muthukuda, D.T.; Kodisinghe, S.K.; Niriella, M.A.
There is an increasing interest in the place of physical activity to counter the increasing risk of non-communicable diseases and its complications in the community. Debate remains just how much exercise is too little, too much or just right to improve health and longevity. This article reviews the present evidence of physical activity on mortality and the possible ideal recommendations on physical activity.
Incidence and risk factors for non-alcoholic fatty liver disease in an urban, adult Sri Lankan population – a community cohort follow-up study
(Sri Lanka Medical Association, 2016) Niriella, M.A.; Kasturiratne, A.; de Silva, S.T.; Perera, K.R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyarathna, T.A.C.L.; Vithiya, K.; Dassanayake, A.S.; de Silva, A.P.
INTRODUCTION: In 2007, we reported a 33% prevalence of non-alcoholic fatty liver disease (NAFLD) and its association with PNPLA3(rs738409) gene polymorphism in an urban, adult Sri Lankan population. OBJECTIVES: This study investigated incidence and risk factors for NAFLD after seven years follow-up. METHOD: The study population (42-71-year-olds, selected by age-stratified random sampling from the Ragama MOH area) was screened initially in 2007 and re-evaluated in 2014. On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. NAFLD was diagnosed on established ultrasound criteria, safe alcohol consumption and absence of hepatitis B/C markers. Non-NAFLD controls did not have any ultrasound criteria for NAFLD. An updated case-control genetic association study for 10 selected genetic variants and incident NAFLD was also performed. RESULTS: 2155/2985 (72.2%) of the original cohort attended follow-up [1244-women, 911-men; mean-age 59.2(SD, 7.7) years]. 1322 [839 women; mean-age 58.9 (SD, 7.6) years] had NAFLD. Out of 795 [466 women] who initially did not have NAFLD, 365 [226 women, mean-age 58.6(SD,7.9) years] had developed NAFLD after 7 years (annual incidence-6.6%). Increased waist circumference [p=0.001], BMI>23kg/m2 [p<0.001] and raised plasma triglycerides [p<0.05] independently predicted incident NAFLD. The updated genetic association study (1310 cases, 427 controls) showed borderline association with NAFLD at 2/10 candidate loci: PPP1R3B(rs4240624), PNPLA3(rs738409) (one-tailed p=0.044 and 0.033, respectively). CONCLUSIONS: In this community cohort follow-up study, the annual incidence of NAFLD was 6.6%. Incident NAFLD was associated with features of metabolic syndrome, and showed tendency of association with PNPLA3 and PPP1R3B gene polymorphisms.
Influence of urban/rural and coastal/inland environment on the phenotype and clinical course of inflammatory bowel disease patients from Sri Lanka: a cross-sectional study
(Sri Lanka Medical Association, 2017) Niriella, M.A.; Kodisinghe, S.K.; Dinamithra, N.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.
INTRODUCTION & OBJECTIVES: Rural/urban and coastal/inland environmental influences on inflammatory bowel disease (IBD) is poorly studied. We investigated such environmental influences on IBD. METHODS: Patients with histologically proven IBD [ulcerative colitis (UC), Crohn disease (CD)] with a permanent residence and regular follow up, were included. Urban areas (UA) were defined as those administered by Municipal and Urban councils. Coastal areas (CA) were defined as areas with elevation <30 meters above sea level. Patients in different groups were compared with regard to phenotype of IBD [sex, age at diagnosis, Montreal subgroups, severity, extraintestinal manifestation (EIM) at diagnosis, and highest therapy during follow-up]. Fisher’s exact test was used to compare categorical variables. RESULTS: A total of 387 patients were included [UC-251 (64.8%), males-122 (48.6%), median followup (IQR)-22.5 (2-59) months; CD-136 (35.2%), males-65 (47.8%), median follow-up (IQR)- 63.0 (23-115) months; urban/rural distribution: UC-1.7:1, CD-1.5:1; coastal/inland distribution: both UC and CD-0.7:1]. Urban/rural or coastal/inland location did not affect the distribution of type of IBD, gender, age at diagnosis or presence of EIM. UC patients from rural areas had extensive disease (E3) (42.4% vs 24.5%, p=0.029) and used long term immunomodulator drugs more frequently (60.2% vs 47.3%; P=0.006) than UA patients. CD patients living in CA had more frequent ileo-colonic disease (L3) compared to inland patients (53.2% vs 38.0%, p=0.016). Patients with both UC and CD from inland areas needed immunomodulators or anti-TNF more frequently than coastal patients (56.7% vs 44.9%, p=0.026 and 82.1% vs 69.9%, p=0.023). CONCLUSION: IBD was more common among patients from inland, UA. Urban/rural or coastal/inland location did not affect gender, age at diagnosis or presence of EIM. However, UC patients from rural areas and CD patients from inland areas had more severe disease.
Intestinal tuberculosis masquerading as difficult to treat Crohn disease: a case report
(Biomed Central, 2016) Niriella, M.A.; Kodisinghe, S.K.; de Silva, A.P.; Hewavisenthi, J.; de Silva, H.J.
BACKGROUND: Crohn disease has low prevalence in Sri Lanka while compared to the West, while intestinal tuberculosis is common in the region. Since clinical, endoscopic and investigation features of Crohn disease overlap with intestinal tuberculosis, differentiating these two conditions becomes a dilemma for the clinician in the intestinal tuberculosis endemic setting. An 18-year old Sri Lankan Muslim female presented with chronic abdominal pain and weight loss. Colonoscopy revealed an ulcerated ileocaecal valve and a terminal ileal stricture. Biopsy confirmed Crohn disease with no supportive features to suggest intestinal tuberculosis. Despite treatment with adequate immunosuppression she failed to improve and underwent a limited right hemicolectomy and terminal ileal resection. Histology confirmed intestinal tuberculosis and she made full recover with 6 months of anti-tuberculosis treatment. CONCLUSION: This case illustrates the importance of reviewing the diagnosis to include intestinal tuberculosis in an endemic setting, when already diagnosed Crohn disease is treatment refractory.
Lean non-alcoholic fatty liver disease (lean NAFLD): characteristics, metabolic outcomes and risk factors from a 7-year prospective, community cohort study from Sri Lanka
(Springer, 2019) Niriella, M.A.; Kasturiratne, A.; Pathmeswaran, A.; de Silva, S.T.; Perera, K. R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyaratna, T.A.C.L.; Vithiya, K.; Dassanayake, A.S.; de Silva, A.P.; Wickremasinghe, A.R.; Takeuchi, F.; Kato, N.; de Silva, H.J.
INTRODUCTION: While patients with non-alcoholic fatty liver disease (NAFLD) are mostly overweight or obese, some are lean. METHODS: In a community-based follow-up study (baseline and follow-up surveys performed in 2007 and 2014), we investigated and compared the clinical characteristics, body composition, metabolic associations and outcomes, and other risk factors among individuals with lean (BMI < 23 kg/m2) NAFLD, non-lean (BMI ≥ 23 kg/m2) NAFLD and those without NAFLD. To investigate associations of selected genetic variants, we performed a case-control study between lean NAFLD cases and lean non-NAFLD controls.RESULTS: Of the 2985 participants in 2007, 120 (4.0%) had lean NAFLD and 816 (27.3%) had non-lean NAFLD. 1206 (40.4%) had no evidence of NAFLD (non-NAFLD). Compared to non-lean NAFLD, lean NAFLD was commoner among males (p < 0.001), and had a lower prevalence of hypertension (p < 0.001) and central obesity (WC < 90 cm for males, < 80 cm for females) (p < 0.001) without prominent differences in the prevalence of other metabolic comorbidities at baseline survey. Of 2142 individuals deemed as either NAFLD or non-NAFLD in 2007, 704 NAFLD individuals [84 lean NAFLD, 620 non-lean NAFLD] and 834 individuals with non-NAFLD in 2007 presented for follow-up in 2014. There was no difference in the occurrence of incident metabolic comorbidities between lean NAFLD and non-lean NAFLD. Of 294 individuals who were non-NAFLD in 2007 and lean in both 2007 and 2014, 84 (28.6%) had developed lean NAFLD, giving an annual incidence of 4.1%. Logistic regression identified the presence of diabetes at baseline, increase in weight from baseline to follow-up and a higher educational level as independent risk factors for the development of incident lean NAFLD. NAFLD association of PNPLA3 rs738409 was more pronounced among lean individuals (one-tailed p < 0.05) compared to the whole cohort sample. CONCLUSION: Although lean NAFLD constitutes a small proportion of NAFLD, the risk of developing incident metabolic comorbidities is similar to that of non-lean NAFLD. A PNPLA3 variant showed association with lean NAFLD in the studied population. Therefore, lean NAFLD also warrants careful evaluation and follow-up.
Lean non-alcoholic fatty liver disease (Lean-NAFLD): characteristics and risk factors from a community cohort follow up study
(Sri Lanka Medical Association, 2016) Niriella, M.A.; de Silva, S.T.; Kasturiratne, A.; Perera, K.R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyaratna, T.A.C.L.; Vithiya, K.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.
INTRODUCTION AND OBJECTIVES: Non-alcoholic fatty liver disease (NAFLD) is usually associated with obesity. However, some NAFLD patients are lean. We assessed the characteristics and risk factors for lean-NAFLD. METHOD: In a community cohort follow up study (initial screening-2007, re-evaluation-2014), NAFLD was established on USS criteria and exclusion of alcohol overuse and secondary causes. Lean (BMI <23 kg/m2) and non-lean (BMI ≥23 kg/m2) NAFLD were compared. The two groups were compared for differences in gender, diabetes, hypertension, hypertriglyceridemia, low-HDL, weight and waist circumference (WC) at baseline. They were also compared for differences in development of incident diabetes, hypertension, hypertriglyceridemia, low-HDL, and change in weight and WC. RESULTS: 678 (69.6%) individuals with NAFLD detected in 2007 presented for follow up in 2014. 78(11.5%) [males-32(41%); mean-age 53.7(SD-7.1) years] were lean and 600(88.5%) [males-191(31.8%); mean-age 52.3(SD-7.5) years] were non-lean. Hypertension (p=0.007) and a smaller WC (<90cm for males, <80cm for females) (p<0.001) were associated with lean-NAFLD. After 7 years, change in BMI was less (p=0.022) among lean-NAFLD. There were no differences in change in WC or incident metabolic co-morbidities. Of those who did not have NAFLD in 2007, 746 developed incident NAFLD in 2014; lean-NAFLD 193/746 (25.9%) [males-100(51.8%); mean age 59.6(SD-7.5)], non-lean-NAFLD 553/746 (74.1%) [males-201(36.3%); mean age 58.2(SD-7.7)]. On logistic regression analysis, presence of diabetes (p=0.002, OR 2.1) and raised WC (p=0.003, OR 1.7) were associated with incident lean-NAFLD. CONCLUSIONS: Among individuals with NAFLD, lean-NAFLD is associated with hypertension and smaller WC. In the community, diabetes and bigger WC predict incident lean-NAFLD.
Non-resolution of non-alcoholic fatty liver disease (NAFLD) among urban, adult Sri Lankans in the general population: A prospective, cohort follow-up study.
(Public Library of Science, 2019) Niriella, M.A.; Kasturiratne, A.; Beddage, T.; Ediriweera, D.S.; de Silva, S.T.; Perera, K.R.; Subasinghe, C.E.; Kodisinghe, S.K.; Piyaratna, T.C.; Rishikesawan, V.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.
BACKGROUND: There are few studies investigating the natural course of non-alcoholic fatty liver disease (NAFLD) in the community. We assessed resolution of NAFLD in a general population cohort of urban Sri Lankans adults. METHODS: Participants were selected by age-stratified random sampling from electoral lists. They were initially screened in 2007 and re-evaluated in 2014. On both occasions structured interview, anthropometric-measurements, liver ultrasonography, and biochemical/serological tests were performed. NAFLD was diagnosed on ultrasound criteria for fatty liver, safe-alcohol consumption (<14-units/week for men, <7-units/week for women) and absence of hepatitis B/C markers. Non-NAFLD was diagnosed on absence of any ultrasound criteria for fatty liver and safe-alcohol consumption. Resolution of NAFLD was defined as absence of ultrasound criteria for fatty liver. Changes in anthropometric indices [Weight, Body-Mass-Index (BMI), waist-circumference (WC), waist-hip ratio (WHR)], clinical [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and biochemical measurements [Triglycerides (TG), High Density Lipoprotein (HDL), Total Cholesterol (TC), HbA1c%] at baseline and follow-up were compared. RESULTS: Of the 2985 original study participants, 2148 (71.9%) attended follow-up after 7 years. This included 705 who had NAFLD in 2007 and 834 who did not have NAFLD in 2007. Out of 705 who had NAFLD in 2007, 11(1.6%) changed their NAFLD status due to excess alcohol consumption. After controlling for baseline values, NAFLD patients showed significant reduction in BMI, weight, WHR, HDL and TC levels and increase in HbA1c levels compared to non-NAFLD people. Despite this, none of them had complete resolution of NAFLD. CONCLUSION: We did not find resolution of NAFLD in this general population cohort. The observed improvements in anthropometric, clinical and biochemical measurements were inadequate for resolution of NAFLD.nal Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.
Patterns of alcohol use and occurrence of alcoholic fatty liver disease: a prospective, community cohort, 7-year follow-up study
(Sri Lanka Medical Association, 2017) Niriella, M.A.; de Silva, S.T.; Kasturiratne, A.; Perera, K.R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyaratna, T.A.C.L.; Vithiya, K.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.
INTRODUCTION & OBJECTIVES: Data is limited on alcoholic fatty liver disease (AFLD). We investigated patterns of alcohol use and AFLD, among urban, adult, Sri Lankans. METHODS: Study population (selected by age-stratified random sampling from Ragama MOH-area) was screened initially in 2007 (35-64 years) and re-evaluated in 2014. On both occasions they were assessed by structured-interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. AFLD was diagnosed on ultrasound criteria, unsafe alcohol consumption (Asian standards: males>14units, females>7units per week) and absence of hepatitis B/C markers. Controls were individuals with unsafe alcohol consumption, but had no ultrasound criteria of AFLD. Case-control genetic-association for PNPLA3 (rs738409) polymorphism for AFLD was performed. RESULTS: A total of 2983/3012 (99%) had complete data. 272/2983(9.1%) were unsafe-drinkers [males- 70; mean-age 51.9 (SD-8.0) years]. 86/2983 (2.9%) of the cohort and 86/272 (31.6%) of unsafe-drinkers had AFLD [males-85; mean-age 50.2 (SD-8.6) years]. Males [p<0.001], increased waist circumference (WC) [p=0.001], BMI>23kg/m2 [p<0.001], raised triglycerides (TG) [p<0.001], low education level (LEL-not completed secondary-education) [p<0.01] and low monthly household-income (23kg/m2 [p<0.001], raised TG [p<0.001] and LEL [p<0.05] independently predicted incident-AFLD. The genetic association study [133-cases (combined 2007-2014), 97-controls] showed no association with AFLD at PNPLA3 (rs738409). CONCLUSION: The prevalence of AFLD was 2.9% in 2007 and annual incidence among heavy drinkers, after 7-year follow-up was 5.7%. Incident-AFLD was associated with males, obesity, raised TG and LEL.
Percentage of small platelets on peripheral blood smear and Child-Turcott-Pugh class can predict the presence of oesophageal varices in newly diagnosed patients with cirrhosis: development of a prediction model for resource limited settings
(BioMed Central, 2019) Perera, K.; Kodisinghe, S.K.; Ediriweera, D.S.; Moratuwagama, D.; Williams, S.; Pathmeswaran, A.; Niriella, M.A.; de Silva, H.J.
BACKGROUND:In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class.METHODS:A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014-April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class.RESULTS:54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = - 0.189 - (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > - 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value.CONCLUSIONS:We constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settings
Prevalence and risk factors for metabolic syndrome among aging adults in an urban Sri Lankan population
(Sri Lanka Medical Association, 2015) Kasturiratne, K.T.A.A.; Niriella, M.A.; de Silva, S.T.; Perera, K.R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyaratna, T.A.C.L.; Vithiya, K.; Kottachchi, D.; Ranawaka, U.K.; Jayasinghe, C.; Rajindrajith, S.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; de Silva, H.J.
INTRODUCTION AND OBJECTIVES: Metabolic syndrome (MetS) is assumed to be of high prevalence in the Asian region. However, its community prevalence and risk factors in South Asia is poorly studied. We determined the prevalence and risk factors for MetS among adults in an urban Sri Lankan population. METHOD: The study population consisted of 42-71 year old adults, selected by stratified random sampling from the Ragama Medical Officer of Health area. MetS was defined by the International Diabetic Federation criteria with ethnic specific cutoffs. Anthropometric measurements, blood pressure (BP) and body fat distribution estimates were made. Glycosylated hemoglobin, fasting serum lipids, serum alanine aminotransferase (ALT) and serum creatinine (SCr) with estimated glomerular filtration rate (eGFR) were determined. CKD was defined as GFR<60ml/min/1.72m2 (KDIGO/KDOQI classification), USS abdomen was performed to detect fatty liver and non-alcoholic fatty liver disease (NAFLD) was diagnosed on safe alcohol consumption (< 14 units/week for men, < 7 units/week for females) and absence of hepatitis B and C markers. RESULTS: 2155 (1244 [57.7%] women, mean age 59.2 years [SD, 7.7]) participated. 1014 (47.1%) [mean age 59.2 years (SD, 7.7), 256 (28.1%) men; 758 (60.9%) women] had MetS. On multivariate analysis female gender, abnormal total body fat and abnormal visceral fat level (>10%) and presence of NAFLD were independently associated with MetS. Age 65 or more, raised ALT and CKD were not associated with MetS. CONCLUSION: The prevalence of MetS among adults in this aging urban Sri Lankan community was high and is independently associated with female gender, abnormal body fat distribution and presence NAFLD.