Conference Papers
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This collection contains abstracts of conference papers, presented at local and international conferences by the staff of the Faculty of Medicine
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Item 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.Item Incidence, prevalence and demographic and life style risk factors for obesity among urban, adult Sri Lankans: a community cohort follow-up study(Sri Lanka Medical Association, 2017) Niriella, M.A.; de Silva, S.T.; Kasturiratne, A.; Kottachchi, D.; Ranasinghe, R.M.A.G.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Obesity is a global problem. Data from the South Asian region is limited. METHODS: In a cohort follow-up study we investigated obesity among urban, adult, Sri Lankans (35-64y; selected by age-stratified random sampling from Ragama-MOH area; initial screening 2007; re-evaluation 2014). On both occasions structured interview, anthropometry, liver ultrasound, biochemical and serological tests were performed. Total body fat (TBF) and visceral fat percentage (VFP) were assessed by impedance in 2014. General-obesity (GO) was BMI>25kg/m2. Central-obesity (CO) was waist circumference (WC)>90cm males and WC>80cm females. Multinomial logistic regression was fitted to assess associations. RESULTS: In 2007 (n=2967), 614 (20.7%) were overweight [51.9%-women], 1161(39.1%) had GO [65.9%-women] and 1584(53.4%) had CO [71%-women]. Females (p<0.001), raised-TG (p<0.001), low-HDL (p<0.001), diabetes (p<0.001), hypertension (p<0.001), NAFLD (p<0.001), and low household income (p<0.001) were significantly associated with prevalent GO and CO respectively. Additionally, increased-age (p=0.05), low-educational level (p<0.001) and unhealthy eating (p<0.001) were associated with prevalent CO. Inadequate physical activity was not associated with either. 2137 (72%) attended follow-up in 2014. Of those who were initially non-obese who attended follow-up, 189/1270 (14.9%) [64% women] had developed GO (annual-incidence 2.13%) and 206/947 (21.9%) [56.3% women] had developed CO (annual incidence 3.12%) after 7 years. TBF and VFP significantly correlated with incident GO and CO (p<0.001). Female gender (OR-1.78, p<0.001; 2.81, p<0.001) and NAFLD (OR-2.93, p<0.001; OR-2.27, p<0.001) independently predicted incident GO and CO respectively. CONCLUSION: The prevalence and incidence of GO and CO were high in this cohort. Both incident GO and CO were strongly associated with female gender and NAFLD.Item 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.Item Natural history of inflammatory bowel disease in Asia: A follow-up population-based cohort study(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2014) Ng, S.C.; Tang, W.; de Silva, H.J.; Niriella, M.A.; Senanayake, Y.U.; Ooi, C.J.; Ling, K-L; Ong, D.E.; Goh, K.L.; Hilmi, I.; Ouyang, Q.; Wang, Y-F.; Hu, P.; Chen, M.; Zeng, Z.; Zhu, Z.; Wu, K.; Wang, X.; Pisespongsa, P.; Manatsathit, S.; Aniwan, S.; Simadibrata, M.; Abdullah, M.; Tsang, S.; Wong, T.; Leung, V.; Lo, F.H.; Hui, A.R.; Chow, C.M.; Yu, H.H.; Li, M.F.; Ng, K.K.; Ching, J.; Sung, J.J.Y.; Chan, F.K.L.BACKGROUND AND AIM: Data on the natural history of inflammatory bowel disease (IBD) in population-based setting in Asia are scarce. It is not clear if IBD disease course differs between Asian and Western cohorts. METHODS: In a population-based incident cohort from eight countries in Asia, we identified 259 IBD patients diagnosed between 2011 and 2013, including 158 ulcerative colitis (UC) and 101 Crohn's disease (CD) with a median follow up of 15 months (range, 12-31 months). The risk of disease extent and behaviour change according to the Montreal classification, and probability of medical or surgical therapy were prospectively assessed. RESULTS: Median age at diagnosis was 29 years (Interquartile range, IQR, 20-44) for CD, and 41 years (IQR, 30-54) for UC. At diagnosis, in CD, ileo-colonic disease (51%) and inflammatory behaviour (67%) were the most frequent phenotype. At one year, cumulative probability of behavior change from inflammatory to stricturing or penetrating disease was 18%, and cumulative rate of colectomy was 8%. In CD cumulative probabilities of receiving 5-aminosalicylic acid (5-ASA), corticosteroids, immune-suppressants and anti-tumor necrosis factor therapy were 61%, 43%, 66% and 10%, respectively, at one year. In UC, disease extent at diagnosis was evenly distributed including 31% with proctitis, 37% with left sided disease and 32% with extensive colitis. Disease extension occurred during follow-up in 19% of patients. Cumulative rate of colectomy at one year was 1%. In UC cumulative probabilities of receiving 5-ASA, corticosteroids and immunesuppressants were 91%, 28% and 13%, respectively at one year. There were two mortalities at maximal follow-up from lung carcinoma and severe sepsis. CONCLUSION: In this populationbased follow-up study, clinical presentation and early disease course in Asian IBD patients appear comparable to that of Western patients. Progression to complicated behavior and accelerated use of immunesuppressants is common in CD. Early surgical rate for UC in Asia remains low. Understanding the natural history of IBD in our population can help optimize therapeutic interventions. Reference: SC Ng, et al. Incidence and Phenotype of Inflammatory Bowel Disease, Based on Results from the Asia-Pacific Crohn's and Colitis Epidemiologic Study. Gastroenterology 2013; 145(1):158-165Item The role of reflux in the genesis of respiratory symptoms in a cohort of adult asthmatics in Sri Lanka(Wiley-Blackwell, 2010) Amarasiri, L.; Ranasinha, C.D.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION: The oesophagus and airways have a common origin. Reflux related respiratory symptoms may be triggered by aspiration of gastric refluxate into airways or a vagally mediated oesophago-tracheo-bronchial. This association has not been reported previously in Sri Lanka. The aim of this study was to describe the association between gastro-oesophageal reflux (GOR) events and respiratory symptoms in a cohort of adult asthmatics in Sri Lanka. METHODS: Thirty stable, mild asthmatics (American Thoracic Society criteria) underwent dual-sensor ambulatory oesophageal pH monitoring. Respiratory symptoms (cough, wheeze, difficult breathing, chest tightness) during monitoring were recorded and correlated with reflux events. RESULTS: Both proximal and distal GOR parameters were significantly higher in asthmatics than controls (P < 0.050; Mann–Whitney U-test). However, there was no difference in any parameter between asthmatics with and without respiratory symptoms. Abnormal proximal acid reflux was documented in 66.7% and distal reflux in 73.3% of 30 asthmatics. Of 102 respiratory symptoms in all asthmatics, majority (72%) were cough episodes. In total, 93% of coughs, 81% of wheeze and all of chest tightness was reflux-associated, where in most, reflux events preceded respiratory symptoms. Of 15 asthmatics with respiratory symptoms, acid exposure was normal in 4 (26%), abnormally high in proximal oesophagus in 9 (60%) and abnormally high in the distal oesophagus in 11 (73%) and abnormal at both levels in 8 (53%). Most reflux events in asthmatics occurred in the upright position. CONCLUSION: Asthmatics have more GOR and associated respiratory symptoms than non-asthmatic volunteers, with reflux episodes preceding respiratory symptoms in most cases. Distal GOR and upright acid exposure was more prominent than proximal GOR.Item Incidence and risk factors for Non-Alcoholic Fatty Liver Disease in an urban, adult Sri Lankan population – a community cohort follow-up study(Sage Publishing, 2015) Niriella, M.; Kasturiratne, A.; de Silva, S.; Perera, R.; Subasinghe, C.; Kodisinghe, K.; Priyantha, C.; Rishikeshavan, V.; Dassanayake, A.; de Silva, A.; Pathmeswaran, A.; Kato, N.; de Silva, H.J.INTRODUCTION: We previously reported a community prevalence of 33% for NAFLD in an urban, adult Sri Lankan population. We also found a significant association between patatin-like phospholipase domain containing 3 (PNPLA3) gene rs738409 polymorphism, and susceptibility to NAFLD in the same population, after testing 10 selected single nucleotide polymorphisms (SNPs) in a case control study. AIMS & METHODS: The aim of this study was to assess the incidence and risk factors for NAFLD in this population after seven years of follow-up. The study population consisted of 42-71-year-old adults, originally selected by age stratified random sampling from electoral lists from Ragama, Sri Lanka. The target population was screened initially in 2007 and subsequently invited back for re-evaluation in 2014. On both occasions they were assessed using a structured interview, clinical and anthropometric measurements, liver ultrasound, and biochemical and serological tests. NAFLD was diagnosed on established ultrasound criteria for fatty liver (two out of three criteria: increased echogenecity of the liver compared to kidney and spleen, obliteration of the vascular architecture of the liver and deep attenuation of the ultrasonic signal), safe alcohol consumption (Asian standards: 514 units/week for men, 57 units/week for females) and absence of hepatitis B and C markers. Non-NAFLD controls were defined as subjects who did not have any of the ultrasound criteria for NAFLD. We also performed an updated case-control study to investigate associations of selected genetic variants with incident NAFLD [SNPs: PNPLA3 (rs738409), LYPLAL1 (rs12137855), GCKR (rs780094), PPP1R3B (rs4240624) and NCAN (rs2228603), APOC3 (rs2854117 and rs2854116), ADIPOR2 (rs767870) and STAT3 (rs6503695 and rs9891119)]. RESULTS: Of the 2985 original study participants, 2155 (72.2%) (1244 women and 911 men; mean age 59.2 years [SD, 7.7]) participated in the follow-up assessment. 1322 [mean age 58.9 years (SD, 7.6), 483 (53.0%) men and 839 (67.4%) women] had NAFLD. Out of 795 [466 (58.6%) women] participants who did not have NAFLD in the original study, 365 [226 (61.9%) women, mean age 58.6 years (SD, 7.9)] had developed NAFLD after 7 years, giving an annual incidence rate 6.6%. On multivariate analysis, increased waist circumference [OR 1.96(1.30 – 2.97), p=0.001], BMI4 23 kg/m2 [OR 2.93(1.99 – 4.30), p50.001] and raised plasma triglycerides (TG) [OR 1.49(1.03 – 2.13), p=0.03] were independently predictive of incident NAFLD in this cohort, while raised BP and reduced HDL, were not. In the updated association study involving 1310 cases and 427 controls, we found borderline association with NAFLD at two of the 10 candidate loci: rs4240624 at PPP1R3B and rs738409 at PNPLA3 (one-tailed P=0.044 and 0.033, respectively). CONCLUSION: In this community cohort follow-up study in an urban, adult population in Sri Lanka, the annual incidence of NAFLD was 6.6%. Incident NAFLD was associated with features of the metabolic syndrome, and showed tendency of association at PNPLA3 and PPP1R3B gene polymorphisms. Disclosure of Interest: None declaredItem Profile of gastric varices among Sri Lankan cirrhotics(Wiley Blackwell Scientific Publications, 2012) Ranawaka, C.K.; Mettananda, K.C.D.; de Alwis, R.; Miththinda, J.K.N.D.; Wijewantha, H.S.; Niriella, M.A.; Dassanayake, A.S.; de Silva, A.P.; de Silva, H.J.BACKGROUND AND AIMS: Gastric varices (GV) can result in life threatening bleeding with a higher mortality than esophageal varices. There have been no studies on the characteristics of GV among Sri Lankan cirrhotics. Aim of this study was to perform a descriptive analysis of GV among a cohort of Sri Lankan cirrhotic population. METHODS: We analyzed medical records of all upper gastrointestinal endoscopies performed on cirrhotics, at the University Endoscopy Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from 2006 to 2011. Characteristics of GV, demographics, indications and fi ndings at endoscopy were analyzed and they were compared among patients with Oesophageal varices (EV). RESULTS: Out of 641 cirrhotics screened, 628 had a complete data set for analysis. GV was detected in 70 (11%) patients; male:female 8.7:1.3; mean age 55 (SD = ± 10.7) years. From these 48/70 had EV (Gastro Oesophageal Varices GOV1 – 18/48, GOV2 – 30/48) in addition to GV. Only 22/70 had Isolated GV (IGV1–10, IGV2–12). Among patients with GV 38 (54%) had portal hypertensive gastropathy and 3 (4%) had gastric antral vascular ectasia. Nineteen (27%) of GV were detected on presentations with UGIB (6 with IGV, 13 with GOV), whereas 51 (73%) were detected on routine screening. EV was detected in 288 (46%) of cirrhotics (Isolated EV 240, GOV 48). Seventy seven (32%) of EV were detected on presentations with UGIB, whereas 163 (68%) were detected on routine screening. There was no statistically significant difference on presentation with UGIB between isolated EV (77/240) vs. IGV (6/22) patients (p = 0.64; χ2 = 0.2). CONCLUSION: The profi le of GV among our cirrhotics is comparable to previous reports from other centres. Findings suggest that in cirrhotic patients presenting with UGIB, a careful search for the presence of GV is as important as identifying EV, even among patients who have EV.Item Association between road accidents and minimal hepatic encephalopathy in a cohort of Sri Lankan cirrhotic drivers(Wiley Blackwell Scientific Publications, 2014) Subasinghe, S.K.C.E.; Nandamuni, Y.; Ranasinghe, S.; Kodisinghe, K.; Niriella, M.A.; de Silva, A.P.; de Silva, H.J.OBJECTIVE: Minimal hepatic encephalopathy (MHE) has no recognizable clinical symptoms of hepatic encephalopathy (HE) but has mild cognitive and psychomotor deficits which can interfere with executive decision making and psychomotor speed. It affects driving ability and 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 cirrhotic drivers. METHODS: A prospective, case controlled study ongoing study has been conducted in the Gastroenterology Clinic, University Medical Unit, North Colombo Teaching Hospital, Ragama, from August 2013. 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 used to detect MHE. Road accidents were recorded for both cirrhotic drivers with MHE and controls. Accidents were categorized as major when they resulted in hospitalization of the involved person/s, and minor when there were no serious injuries. RESULTS: Among 55 cirrhotic drivers with MHE [males, median age 53 years (range 30-60)], 7 (12.7%) reported any type of accident compared to 6 (10.9%) among 55 controls [males; median age 51 years (range 30-60)]. 2/55 (3.6%) cases and 2/55 (3.6%) controls reported minor accidents. There were no major accidents in either group. CONCLUSION: Preliminary results of this ongoing study do not indicate an increased frequency of road accidents in a cohort of Sri Lankan cirrhotic drivers with MHEItem Genetic variants of NAFLD in an urban Sri Lankan community(Wiley Blackwell Scientific Publications, 2013) Niriella, M.A.; Kasturiratne, A.; Akiyama, K.; Takeuchi, F.; Isono, M.; Dassanayake, A.S.; de Silva, A.P.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.OBJECTIVE: Recently, genome-wide association studies (GWAS) have successfully identified loci associated with susceptibility to non-alcoholic fatty liver disease (NAFLD) in populations of European descent. No large-scale genetic studies have been performed thus far in South Asian populations. Therefore, as part of a community-based cohort study in an urban adult population of Sri Lankans, we investigated associations of genetic variants with NAFLD, diagnosed on established ultrasound criteria, and its related phenotypes. METHODS: We selected 10 single nucleotide polymorphisms (SNPs), all previously reported to be associated with NAFLD in populations of European and/or South Asian ancestry, for a case-control replication study. They included loci derived from GWAS [PNPLA3 (rs738409), LYPLAL1 (rs12137855), GCKR (rs780094), PPP1R3B (rs4240624) and NCAN (rs2228603)] plus those from candidate gene studies [APOC3 (rs2854117 and rs2854116), ADIPOR2 (rs767870) and STAT3 (rs6503695 and rs9891119)]. Genotype data of 2988 participants were used for the analysis. RESULTS: A significant NAFLD association was observed for PNPLA3 (rs738409) [OR = 1.25, 95% CI 1.08–1.44, P = 0.003)]; rs738409 was also associated with a trend towards lower serum triglycerides APOC3 variants were significantly (P = 7.3–7.5 × 10–8) associated with higher triglycerides, but not with NAFLD (OR = 0.86). Apart from SNP–lipid associations previously reported at the GCKR, PPP1R3B and NCAN loci, there were no other prominent associations. CONCLUSION: Our data confirm that the PNPLA3 gene variant is significantly associated with NAFLD in the general Sri Lankan population but could not replicate previously reported disease associations at other loci, reinforcing the importance of further large-scale study on genetic variants in diverse populations to better understand the pathophysiology of NAFLD.Item Low prevalence of Hepatitis B and C molecular markers in a cohort of Sri Lankan patients with hepatocellular carcinoma(Sri Lanka Medical Association, 2007) Dassanayake, A.S.; Manamperi, A.; Gunawardena, N.K.; Abeyewickreme, W.; de Silva, A.P.; de Silva, H.J.INTRODUCTION: Hepatitis B (HBV) and C (HCV) infections are leading causes of hepatocellular carcinoma (HCC). Although HCV is the predominant aetiological factor in many parts of the world, HBV remains more important in South Asia. Detection of molecular markers is the most reliable means of diagnosing infection. Molecular studies on HBV and HCV infection in HCC have not been performed in Sri Lanka. OBJECTIVES: To investigate the prevalence of HBV and HCV using molecular markers of infection in a cohort of Sri Lankan patients with HCC. DESIGN, SETTING AND METHODS: 34 consecutive patients with HCC were investigated for evidence of HBV and HCV infection. In addition to serology, serum was tested for HBV DNA and HCV RNA by PCR (sensitivity 500 copies/ml serum) and RT-PCR (sensitivity 200 copies/ml serum ) respectively. A detailed clinical work-up, screening for diabetes mellitus and iron studies were also performed. RESULTS: Of the 34 patients, 32 (94%) -were males; median age was 68 years. All had evidence of background cirrhosis. Five had evidence of past or present HBV infection, four were HBV DNA positive, one was anti-HBc positive but HBV DNA negative, and one was HCV RNA positive. In addition, 23 (67%) had a history of alcohol abuse and 18 (52%) had long standing diabetes. None had evidence of haemochromatosis. CONCLUSIONS: Prevalence of HBV and HCV infection was low in this cohort of Sri Lankan patients with HCC. This is in keeping with the low prevalence of these infections in the community.