Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Worsening cholestasis and possible cefuroxime-induced liver injury following "successful" therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone: a case report(BioMed Central, 2016) Niriella, M.A.; Kumarasena, R.S.; Dassanayake, A.S.; Pathirana, A.; de Silva, H.J.BACKGROUND: Cefuroxime very rarely causes drug-induced liver injury. We present a case of a patient with paradoxical worsening of jaundice caused by cefuroxime-induced cholestasis following therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone. CASE PRESENTATION: A 51-year-old, previously healthy Sri Lankan man presented to our hospital with obstructive jaundice caused by a distal common bile duct stone. Endoscopic retrograde cholangiopancreatography with stone extraction, common bile duct clearance, and stenting failed to improve the cholestasis, with paradoxical worsening of his jaundice. A liver biopsy revealed features of drug-induced intrahepatic cholestasis. Although his case was complicated by an episode of cholangitis, the patient made a complete recovery in 4 months with supportive treatment and withdrawal of the offending drug. CONCLUSIONS: This case highlights a very rare drug-induced liver injury caused by cefuroxime as well as our approach to treating a patient with paradoxical worsening of jaundice after therapeutic endoscopic retrograde cholangiopancreatography.Item Predicting acute liver failure in dengue Infection(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2013) Ranawaka, C.; Niriella, M.A.; Kumarasena, R.S.; Miththinda, J.K.N.D.; de Silva, A.P.; Premaratna, R.; de Silva, H.J.BACKGROUND: Dengue infections (DI) can range from being asymptomatic to severe illness. Unusual manifestations such as encephalitis, myocarditis, and acute liver failure (ALF) have been recognized. ALF is uncommon, but has a poor prognosis. The aim of this study was to identify predictors of ALF in DI. METHODS: Serologically confirmed patients with DI who were admitted to hospital from January 2009 to March 2010 were included. Patients consisted of direct admissions as well as referrals, some with deranged liver functions. Data was obtained from patient records. Clinical details and serum biochemistry was evaluated for up to five days from onset of illness. ALF in DI was defined as evidence of coagulation abnormality [International normalised ratio (INR) ≥ 1.5], and any degree of mental alteration (encephalopathy) in a patient without pre-existing cirrhosis. RESULTS: Out of 240 patients [57.7% male, 42.3% female; mean age 35.6 years (SD 15.4 years)], 164 had dengue with warning signs, 27 had dengue without warning signs and 49 had severe dengue. 15/49 severe dengue patients had profound shock. Abdominal pain, persistent nausea and vomiting (PNV), bleeding, hepatomegaly and ascites were present in 125, 92, 39, 129 and 28 cases respectively. Elevated aspartate aminotransferase (AST), serum bilirubin (SB), alkaline phosphatase (ALP) and gamma glutamyl transpeptide (GGT) were observed in 208, 20, 18 and 60 patients respectively. Of the 240 patients 41 had AST .1000 IU/ml (this included 4/ 15 with profound shock). 16/41 patients with AST .1000 IU/ml, including 4 with profound shock, developed ALF while none with AST ,1000 IU/ml developed ALF. In patients with AST .1000 IU/ml, presence of 2 or 3 of elevated SB, elevated ALP or PNV predicted the development of ALF with 93.8% sensitivity, 98.7% specificity, 83.3% positive predictive value and 99% negative predictive value (Fisher's exact test). CONCLUSIONS: Dengue patients with AST,1000 IU/ml are not at risk of developing ALF. Patients with AST .1000 (regardless of presence or absence of profound shock), with 2 or 3 of elevated SB, elevated ALP or PNV seem to be at risk of developing ALF. These findings need to be validated in a larger cohort of patients.Item Predicting acute liver failure in dengue infection(Sri Lanka Medical Association, 2016) Kumarasena, R.S.; Niriella, M.A.; Ranawaka, C.K.; Miththinda, J.K.N.D.; de Silva, A.P.; Dassanayake, A.S.; de Silva, H.J.In a retrospective study involving 240 patients with dengue infection, we attempted to identify early predictors of acute liver failure (ALF). Sixteen out of 41 patients with serum AST more than 1000 IU/ml developed ALF compared to none with serum AST less than 1000 IU/ml. Among patients with serum AST more than 1000 IU/ml, presence of two of the three following phenomena, within the first 5 days of illness: elevated serum bilirubin, elevated alkaline phosphatise or persistent nausea and vomiting, predicted development of ALF (93.8% sensitivity, 98.7% specificity, 83.3% positive predictive and 99% negative predictive value). The presence of elevated serum bilirubin, alkaline phosphatase and persistent nausea and vomiting in patients with very high serum AST during the early phase of dengue infection should alert the physician of impending ALF.Item Usefulness of Ileoscopy during Colonoscopy(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2011) Wijewantha, H.; de Silva, A.P.; Wijesinghe, N.T.; Kumarasena, R.S.; Dassanayake, A.S.; Hewavisenthi, S.J.; de Silva, H.J.INTRODUCTION: Ileoscopy during colonoscopy adds only three minutes to total procedure time and has no added complications. However, available evidence for recommending the procedure is contradictory. There are few studies adressing this issue in South Asian populations. Aims: To investigate the usefulness of terminal ileoscopy during colonoscopy in a cohort of Sri Lankan patients attending a tertiary care centre. METHODOLOGY: From January 2007, our unit policy was to perform ileoscopy in all patients undergoing colonoscopy. A retrospective analysis of all patients who underwent colonoscopy in the unit from January 2007 to September 2010 was performed. Data were obtained from endoscopy unit and patient records. We compared usefulness of ileoscopy in patients considered to have specific clinical indications for ileoscopy - right iliac fossa pain, diarrhea, anemia, inflammatory bowel disease and raised inflammatory markers (group A) with those that did not (group B). RESULTS: 789 colonoscopies were performed during the study period, and the terminal ileum was successfully intubated in 638 (80.9%). Reasons for not intubating the ileum were technical difficulty and/or severe patient discomfort. Overall, 108/ 638 (16.9%) patients had macroscopic or microscopic abnormalities of the ileum. 51/638 (8%) of these were considered to be significant ileal pathology: Crohn’s disease (34), tuberculosis (5), ileitis-resolving infection (8) or drug induced (4). The other abnormalities, of doubtful clinical importance and which did not alter management, were backwash ileitis in ulcerative colitis (12), and non-specific ileitis (37). 35 patients with ileal abnormalities (Crohn’s disease 6, non-specific ileitis 29) had no abnormalities in the colon. 66 patients with a macroscopically normal terminal ileum had abnormal microscopy: Crohn’s disease (21), ileitis - resolving infection (3) or drug induced (2), backwash ileitis in ulcerative colitis (4), non-specific ileitis (36). In group A [n=511; mean (SD) age 47.7 (16) years; 53.4% males] 47/511 (9.2%) had significant ileal pathology compared to 4/ 127 (3.15%) in group B [n=127; mean (SD) age 53.2 (16) years; 50.4% males] (x2 4.270, df=1, p=0.038). CONCLUSION: Ileoscopy and biopsy during colonoscopy is a useful investigation which detects significant pathology, in some instances where the rest of the colon is normal and sometimes even when the ileum appears macroscopically normal. The procedure should be recommended, especially for patients with right iliac fossa pain, diarrhea, anemia, inflammatory bowel disease and raised inflammatory markers.Item The Prone 12 o'clock position reduces iIleal intubation time during colonoscopy compared to the left lateral 6 o'clock (standard) position(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2010) de Silva, A.P.; Kumarasena, R.S.; Keragala, S.P.; Udayapushpa, K.V.; Niriella, M.A.; Dassanayake, A.S.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION Ileal intubation is the gold standard for evidence of a complete colonoscopy. However, despite evidence of clinical benefit, ileoscopy is not always attempted due to perceived technical difficulty. Although several studies have previously reported on the time taken for ileal intubation, such timings have not been standardized. Aim To compare time taken for ileal intubation using a new position - the prone 12 o’clock position (PP) - with the standard method (left lateral 6 o’clock position-LLP). METHODS We first performed a pilot study using fluoroscopy to determine the best patient position for the most direct (end-on) approach to the ileo-caecal valve. The prone 12 o’clock position appeared to be the best position. We then randomized consecutive patients having colonoscopy, aged 18-80 years and who were not pregnant, to undergo ileoscopy in the standard position or the prone 12 o’clock position. After the ileo-caecal valve was identified during colonoscopy, ileal intubation time was standardized and defined as the time taken for the tip of the colonoscope to be maneuvered from the mid-point of the caecum to entering the terminal ileum. RESULTS Colonoscopy was performed on 150 patients [82 females, mean (SD) age 53 (16) years]. 75 patients were randomized for ileal intubation in the PP and 75 patients in the LLP. Overall, the ileum was successfully intubated in 145 (96%) patients [74 (98.7%) in the PP and71 (94.7%) in the LLP]. The mean (SD) ileal intubation time was 26.4 (63) seconds in the PP and 96.9 (112) seconds in the LLP (p0.0001; Student t-test). The ileum was abnormal in 11 (7.5%) patients: 6 in the PP group and 5 in the LLP group. CONCLUSIONS During colonoscopy, the prone 12 o’clock position gives a more direct approach to the ileo-caecal valve and significantly reduces ileal intubation time when compared to the standard left lateral 6 o’clock position