Browsing by Author "Navarathne, N.M.M."

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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.
Comparison of one week and two weeks of triple therapy for the eradication of Helicobacter pylori in a Sri Lankan population: a randomised, controlled study
(Sri Lanka Medical Association, 2004) de Silva, H.A.; Hewavisenthi, J.; Pathmeswaran, A.; Dassanayake, A.S.; Navarathne, N.M.M.; Peiris, R.; de Silva, H.J.
INTRODUCTION: Resistance of Helicobacter pylori to antibiotics may be particularly high in parts of the tropics. Infection may prove difficult to eradicate in such situations, and there is some evidence of benefit in increasing the duration of treatment (triple therapy) from 1 week to 2 or 3 weeks. AIM: To assess the efficacy and tolerability of 1 week versus 2 weeks of triple therapy for eradication of H. pylori in a Sri Lankan population. METHODS: Eighty two patients aged 18-70 years with gastritis or peptic ulcer and testing positive for H. pylori infection were randomly allocated totwo treatment groups. Both groups received omeprazole 20 mg, clarithromycin 250 mg, and tinidazole 500 mg. Group A (n = 42) received the trial medication twice daily for 1 week and the Group B (n = 40) twice daily for 2 weeks. H. pylori eradication was defined as a negative 14C labelled urea breath test at 2 weeks after completion of the therapy. RESULTS: H. pylori infection was eradicated in 36 (85.7%) patients in Group A and 36 (90%) patients in Group B (p = 0.9). Twenty three (55%) patients in Group A and 17 (43%) in Group B reported adverse effects attributable to trial medication (p = 0.387); none were serious. Three (7.5%) patients in Group B discontinued treatment due to adverse events that developed on days 7, 9 and 10. CONCLUSION: Twice daily treatment with clarithromycin, tinidazole, and omeprazole for 1 week is well tolerated and provides as good a rate of H.pylori eradication as 2-week therapy in Sri Lankan patients.
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.
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.
Serious thiopurine adverse effects and discontinuation among inflammatory bowel disease patients in Sri Lanka
(Sri Lanka Medical Association, 2017) 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 & OBJECTIVES: Thiopurines such as azathioprine and 6-mercaptopurine use for long term is not uncommon for patients with inflammatory bowel disease (IBD). Severe thiopurine adverse effects are dependent on thiopurine methyltransferase (TPMT) activity. TPMT testing prior to commencing thiopurine has been suggested to identify individuals with low TPMT activity, so that thiopurine use can be avoided in such patients. There is very limited data on thiopurine adverse effects among IBD patients in South Asia. METHODS: Patients with histologically proven IBD [ulcerative colitis (UC), Crohn’s disease (CD)], diagnosed over a ten year period from May 2005 to April 2015, with at least one year of regular follow up, were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka (two main IBD referral centers). Frequency of thiopurine use, thiopurine adverse effects (myelosuppression and hepatotoxicity), and drug discontinuation were noted. RESULTS: A total of 214 patients were eligible for inclusion [UC-148 (69.2%), 75 (50.7%) males, median follow up (IQR) 55.0 (30-81) months; CD-66 (30.8%), 31 (47.0%) males, median follow up (IQR) 41.5 (26.5-68) months]. Thiopurine was used in 74 (50.0%) and 60 (90.9%) of UC and CD patients, respectively. Very few had severe thiopurine adverse effects that led to discontinuation of treatment [UC-4 (2.7%); CD-4 (6%)]. These were myelosuppression (6 patients) and hepatotoxicity (2 patients). CONCLUSION: In this cohort of Sri Lankan IBD patients, severe thiopurine adverse effects resulting in discontinuation of treatment was uncommon. Routine TPMT testing prior to thiopurine use does not seem warranted in the Sri Lankan setting.
The standard versus locally improvised banding for bleeding oesophageal varices: case control study
(Sri Lanka Medical Association, 2010) Navarathne, N.M.M.; Abeysuriya, V.; Wanigasuriya, I.W.M.P.
INTRODUCTION: Endoscopic band ligation is one of the effective therapeutic modalities in variceal bleeding. However the availability of endoscopic banding is mainly overshadowed by its overwhelming cost; especially in a country like Sri Lanka. This study assesses the therapeutic outcome of standard verses locally improvised endoscopic banding in oesophageal varices. METHODS: A study was carried out among 446 (90- standard band ligation, 356-locaIly improvised) patients with acute oesophageal variceal bleeding who were referred to gastroenterology unit of National Hospital of Sri Lanka between January 2005 to December 2008. Consecutive patients with oesophageal variceal bleeding were recruited either uTreceive standard or locally improvised bands, based on the availability of standard banding sets in the unit. The early re-bleeding and hospital mortality rates were compared. RESULTS: Ninety patients (M: F^ 68: 22, mean age: 49.3 years, range- 35 years to 68 years) were treated with standard (Six shooter or Super?) variceal bands, whilst, 356 (Male: 272, Female: 84, mean age: 48.3 years, range- 34 years to 71 years) had locally improvised bands. Early re-bleeding rate with locally improvised band therapy was 8.4% whereas with standard banding, it was 3.3% (p=0.02). In-hospital mortality (of any cause) rates for standard and locally improvised bands were 6/90 (6.6%) and 26/356 (7.3%) respectively (p=0.02). The cost for each standard banding set is LKR 20000±2000 and locally improvised bands approximately LKR 5±0.57 (p=0.001) CONCLUSION: There are differences in re-bleeding and in-hospital mortality with the use of locally improvised band therapy. However the cost of locally improvised band therapy is low.