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 Elective cholecystectomy is associated with increased morbidity and mortality in patients with severe Thalassemia: A retrospective case control study.(Ferrata Storti Foundation, 2015) Premawardhena, A.; Fernando, R.; Kumarage, S.; Nishad, N.; de Silva, I.BACKGROUND: Haemoglobin disorders including thalassemia and sickle cell disease are often complicated with gall stone formation. The co-existence of Gilbert's syndrome together with these diseases further increases the risk of gall bladder disease. Some of these patients develop symptomatic disease which necessitates surgical intervention. At present the timing of cholecystectomy for thalassemia is no different from that of the general population with the exception of removal of the gall bladder at the time of splenectomy. This is no longer the case in sickle cell disease where, laparoscopic cholecystectomy is recommended even in asymptomatic patients. This practice however has not been extended to other types of haemoglobin disorders. AIM(S): 1.To assess the perioperative complications of patients with thalassaemia during cholecytetomy and to compare it with non thalassaemics who undergo the procedure. 2. To see if there is enough evidence to recommend elective cholecystectomy for thalassaemics. METHOD(S): We retrospectively studied case notes of thalassemia patients who had cholecystectomy (cases) in two of the biggest thalassaemia centres in Sri Lanka and also of 62 non-thalassaemics (controls) with gall bladder disease who had been scheduled to have gall bladder surgery in the same hospitals and looked at their peri-operative complications. RESULT(S): 98 out of 540 (18%) thalassaemics in the two centres had gall stones. Mean age of cases was 26.8 (SD 10.9) years and of controls 47.5 (SD 19.7) years. 19 (19%) thalassaemics with gall stones had undergone cholecystectomy. Ten patients had cholecystectomy simultaneously with splenectomy. The majority of non-thalassaemic "controls" had laparoscopic cholecystectomy 53/55 (96.3%) whilst the patients with thalassaemia were mostly operated with laparotomy 13/19 (68%). There was a significant excess complications occurring in both early (42.11 vs. 18.1%) and late (31.5 vs. 12.7%) phases in the thalassaemic patients compared with the controls. Among the early complications, sepsis (10.5% vs. 1.8%) and liver abscess formation (5.2 vs. 0%) was significantly different in the groups, adversely affecting the thalassaemics. Recurrent abdominal pain was more common among the thalassaemics as a late complication (P<0.05). Six thalassaemic patients with gall stone disease died during this study, 5(5%) while awaiting surgery and 1(1%) after surgery. There were no deaths among the controls. Out of the deaths, 3 (50%) were directly attributable to gallstone disease. In all three septicemia precipitated heart failure. We found a significant increase of both early and late post-surgical complications in the thalassemia group and also increased mortality most of which was related to severe sepsis. Higher perioperative mortality and morbidity were seen among symptomatic thalassaemic patients with gall stone disease undergoing cholecystectomy. This seems to suggest a strong case for supporting elective cholecystectomy in thalassemics before they develop symptoms. SUMMARY AND CONCLUSION(S): We suggest that laparoscopic elective cholecystectomy be considered for non-sickle, thalassemia patients too who have asymptomatic gall bladder disease, in an attempt to reduce this morbidity and mortality.Item Idiopathic pancreatitis: is it a consequence of an altering spectrum of bile nucleation time?(BMJ Publishing, 2009) Abeysuriya, V.; Deen, K.I.; Navarathne, N.M.M; Kumarage, S.K.INTRODUCTION: The pathogenesis of idiopathic pancreatitis (IP) remains poorly understood. Our hypothesis is that IP is a sequel of the microcrystallisation of hepatic bile. AIMS AND METHODS: A prospective case–control study compared 55 patients (symptomatic cholelithiasis, 30: 14 men, 16 women, median age 36 years, body mass index (BMI) 25.1 ¡ 0.33 kg/m2 ; gallstone pancreatitis, nine: six women, three men, median age 35 years, BMI 24.86 ¡ 0.23 kg/m2 ; and idiopathic pancreatitis, 16: seven women, nine men, median age 34 years, BMI 23.34 ¡ 0.2 kg/m2 ) with 30 controls (15 men, 15 women, median age 38 years, BMI 24.5 ¡ 0.23 kg/m2 , undergoing laparotomy and who had normal gallbladder and no demonstrable stones on ultrasonography). Ultrafiltered bile from the common hepatic duct in patients and controls was anaerobically incubated and examined by polarised light microscopy, for nucleation time (NT). Ethical approval was obtained. RESULTS: Patients were similar to controls. Mean NT in all groups of patients was significantly shorter than controls (established gallstones cumulative mean NT, 1.73 ¡ 0.2 vs controls, 12.74 ¡ 0.4 days vs, p = 0.001, t test and IP patients mean NT, 3.1 ¡ 0.24 days vs controls, 12.74 ¡ 0.4 days, p = 0.001, t test). However, NT in those with IP was significantly longer compared with those with established gallstones (mean NT in IP, 3.1 ¡ 0.24 SEM days, vs cumulative mean in patients with established symptomatic gallstones, 1.73 ¡ 0.2 days, p = 0.002, t test). CONCLUSION: NT in bile in patients with IP is abnormal and is intermediate in NT of lithogenic and non-lithogenic bile.Item Hyperhomocysteinaemia and stroke: a case-control study(Sri Lanka Medical Assosiation, 2004) Ranawaka, U.K.; Niriella, M.A.; Hewamadduma, C.A.A.; Kanakkahewa, N.; Thilakarathna, N.T.; Wickremasinghe, A.R.; Wijesekera, J.C.OBJECTIVES: We sought to identify the importance of hyperhomocysteinaemia as an independent risk factor for stroke. METHODOLOGY: This was a case control study of patients with stroke (n=48) and pair matched controls (age and sex matched; n=48) at the Institute of Neurology, NHSL. Prior ethical approval was obtained from the Ethical Review Committee of the SLMA. Fasting total plasma homocysteine (tHcy) was compared between the two groups. Logistic regression analysis was performed to determine the contribution of hyperhomocysteinaemia as a risk factor for stroke, after controlling for other risk factors, using the 50th percentile of tHcy among controls (tHcy 50) as cut-off value. All strokes (n=48) and ischaemic strokes (n=43) were analysed separately. RESULTS: Cases (mean age = 55.69 years) and controls (mean age = 54.64 years) were well matched. tHcy among controls (mean=16.5l umol/1) was higher than observed from elsewhere, even after excluding those with vascular risk factors (mean=13.8 umol/1). The mean tHcy levels were significantly higher in cases (23.12 umol/1) than in controls (16.51 umol/1, p<0.001). There was no significant difference in tHcy between ischaemic and haemorrhagic strokes, and lacunar and non-lacunar strokes. Logistic regression analysis showed that tHcy 50 was an independent risk factor for haemorrhagic strokes (OR 2.583, p=0.05), and for ischaemic strokes (OR 2.663, p=0.05). CONCLUSION: tHcy levels may be higher than usual among Sri Lankan populations. Hyperhocysteinaemia is an independent risk factor for stroke.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 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 MHE