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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Irritable Bowel Syndrome in children: Current knowledge, challenges and opportunities(Baishideng Publishing Group, 2018) Devanarayana, N.M.; Rajindrajith, S.Irritable bowel syndrome (IBS) is a common and troublesome disorder in children with an increasing prevalence noted during the past two decades. It has a significant effect on the lives of affected children and their families and poses a significant burden on healthcare systems. Standard symptom-based criteria for diagnosis of pediatric IBS have changed several times during the past two decades and there are some differences in interpreting symptoms between different cultures. This has posed a problem when using them to diagnose IBS in clinical practice. A number of potential patho-physiological mechanisms have been described, but so far the exact underlying etiology of IBS is unclear. A few potential therapeutic modalities have been tested in children and only a small number of them have shown some benefit. In addition, most of the described patho-physiological mechanisms and treatment options are based on adult studies. These have surfaced as challenges when dealing with pediatric IBS and they need to be overcome for effective management of children with IBS. Recently suggested top-down and bottom-up models help integrating reported patho-physiological mechanisms and will provide an opportunity for better understanding of the diseases process. Treatment trials targeting single treatment modalities are unlikely to have clinically meaningful therapeutic effects on IBS with multiple integrating patho-physiologies. Trials focusing on multiple combined pharmacological and non-pharmacological therapies are likely to yield more benefit. In addition to treatment, in the future, attention should be paid for possible prevention strategies for IBS.Item Prevalence of irritable bowel syndrome in an urban adult Sri Lankan population(Sri Lanka Medical Association, 2016) Rishikesavan, V.; de Silva, A.P.; Niriella, M.A.; Mendis, W.A.S.; Ruston, S.M.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION AND OBJECTIVES: The community prevalence of irritable bowel syndrome (IBS) globally varies from 10 to 25%. Telephone interviews have been widely used to collect data. There is limited data on community prevalence of IBS in South Asia. Objective of the study was to determine the community prevalence of IBS and its subtypes in an urban adult Sri Lankan population. METHOD: The study was conducted in the Ragama medical officer of health (MOH) area. Householders lists of 22 Grama Niladari divisions were used for balanced random sampling. Individuals aged between 18-65 years (stratified into three groups: 18-33, 34-49, 50-65) were included. A random sample of households was selected and the person who had the closest birthday was selected from each household. A telephone interview was conducted. IBS and its subtypes [constipation predominant (IBS-C), diarrhea predominant (IBS-D), mixed (IBS-M)] were defined according to Rome III criteria. RESULTS: 504/1407(35.8%) of selected households were contactable. Of 504 persons invited to participate 500(99.2%) responded [277-females, mean (SD) age: 42.37 (13.2) years]. The overall prevalence of IBS was 18/500 (3.6%) [13-males(5.83%), 5-females(1.81%); p=0.017]. There was significant difference in prevalence among age groups for males (least among 34-49 years; p=0.024) but not for females (p=0.665). Of the males with IBS, 2(15.38%), 5(38.46%) and 6(46.15%) had IBS-D, IBS-C and IBS-M, respectively. Of the females with IBS, 2 (40%), 1(20%) and 2(40%) had IBS-D, IBS-C and IBS-M, respectively. CONCLUSIONS: Using accepted criteria, the overall community prevalence of IBS was low in this population, with a significant male predominance, and IBS-M being the commonest subtype.Item Subtypes and some clinical aspects of irritable bowel Syndrome in children(Sri Lanka College of Paediatricians, 2011) Rajindrajith, S.; Devanarayana, N.M.INTRODUCTION: Irritable bowel syndrome (IBS) is a common paediatric functional gastrointestinal disorder affecting 6-13% of children and adolescents. In adults IBS is divided into four main subtypes: diarrhoea predominant IBS, constipation predominant IBS, mixed IBS and untypable IBS. The subtypes have not been characterised in children. OBJECTIVES: The objective of this study was to assess IBS subtypes in 10-16-year old children, their symptomatology and gender difference. DESIGN, SETTING AND METHOD: One hundred and seven children with IBS and 1610 healthy controls aged 10-16years were recruited from 8 randomly selected schools, in 4 randomly selected provinces (out of 9 provinces) in Sri Lanka. Data was collected using a previously validated, self administered questionnaire based on Rome III criteria, it was distributed in examination settings to ensure privacy and confidentiaiity and was filled under the guidance of research assistants. IBS was defined using Rome 111 criteria. RESULTS: Constipation predominant IBS (IBS-C), diarrhoea predominant IBS (IBS-D) and mixed IBS (1BS-M) were present in 27-28%. Untypable IBS (1BS-U) was seen in 17.8%. IBS was more common in girls (59.8% vs. 40.2% in boys, p=0.001; p<0.01). Straining, urgency and feeling of incomplete evacuation were seen in 74-78% children with IBS. Intestinal-related symptoms such as bloating, flatulence, nausea, vomiting and burping, and extraintestinal symptoms such as headache, sleeping difficulty, limb pain and photophobia were significantly higher in affected children (p<0.05). Burping was more commonly seen in boys with IBS (p<0.05). CONCLUSIONS: IBS-C, IBS-D and IBS-M had almost equal distribution while IBS-U had a relatively lower prevalence. Girls were significantly more commonly affected than boys (p<0.01). Intestinal-related and extra-intestinal symptoms were seen in a significantly higher percentage of children with IBS (pItem Constipation and constipation predominant Irritable Bowel Syndrome: a comparative study using Rome III Criteria(Lippincott Williams and Wilkins, 2017) Rajindrajith, S.; Devanarayana, N.M.; Benninga, M.A.OBJECTIVE: The aim of this study is to compare functional constipation (FC) and constipation predominant irritable bowel syndrome (IBS-C) in adolescents. METHOD: A school based survey was conducted involving adolescents aged 13-18 years. A set of validated questionnaires including Rome IIIquestionnaire for functional gastrointestinal disorders in children/adolescents, somatization inventory, quality of life inventory, and childhood traumatic events inventory were used for data collection. FC, and IBS-C were defined using Rome III criteria. RESULTS: A total of 1792 adolescents [975 males (45.4%)] were included in the analysis. Prevalence of FC and IBS-C were 7.7% and 1.6%, respectively. Bowel habits such as stool frequency less than 3 per week (10% vs 44.9%, p < 0.0001), hard stools (20% vs 40.5% p < 0.05) painful defecation (33.3% vs 56.5% p < 0.05), large diameter stools (23.3% vs 50.7% p < 0.01), stool withholding behaviour (20% vs 44.2% p < 0.05), were more commonly associated with FC than IBS-C. Occurrence of faecal incontinence (0% vs 8% p = 0.21), urgency (56.7% vs 66.7% p = 0.65) and straining (56.7% vs 36.9% p = 0.47) were not significantly different between IBS-C and FC. Exposure to physical abuse, emotional abuse, and sexual abuse were equally prevalent among adolescents with FC and IBS-C. There was no difference between somatization scores, and health related quality of life between the two groups. CONCLUSION: Although bowel habits related to stool withholding is more prevalent in FC, than in IBS-C, they are more likely to be a spectrum of a disorder rather than two separate entitiesItem 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 Sub clinical intestinal mucosal inflammation in diarrhea predominant Irritable Bowel Syndrome (IBS) in a tropical setting(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2010) de Silva, A.P.; Manamperi, A.; Hewavisenthi, S.J.de S.; Ariyasinghe, M.P.; Dassanayake, A.S.; Jewell, D.P.; de Silva, H.J.BACKGROUND: There is evidence for potential roles for gut flora and the host immune response in the pathophysiology of IBS, and especially, for low grade colonic mucosal inflammation in the pathophysiology of post-infectious IBS. AIM: To investigate for evidence of sub-clinical intestinal mucosal inflammation in diarrhea- predominant IBS (IBS-D) in a tropical setting. METHODS: In a prospective study over one year, we investigated 49 patients with IBS-D [median age 34 years (range 18-59; M:F 36:13], based on Rome III criteria. None had alarm symptoms: unintentional significant loss of weight, bleeding per rectum or malaena. None were on NSAIDS or proton pump inhibitors. All patients had normal ESR, CRP, TSH and stools reports. 14 individuals with a family history of colon cancer [median age 46.5 years (range 23-56); median 46.5, M:F 6:8] were selected as controls. Stools of patients and controls were tested for calprotectin. During colonoscopy, serial biopsies were obtained from the ileum, caecum, ascending, transverse and descending colon, and rectum. In addition to histology, tissue expression of IL-8 and IL-10 were assessed in biopsy specimens using semi-quantitative RT-PCR. RESULTS: Colono-ileoscopy was macroscopically normal and faecal calprotectin was undetectable in cases and controls. Microscopic colitis not otherwise specified(MNOS) was seen in 10/49 cases and 1/14 controls (p=0.43, Fisher's Exact test). Histology was normal in others. A history suggestive of an episode of infectious diarrhea (ID) was seen in 16/49 cases and 0/14 controls (p=0.013). There was no significant association between ID and the presence of MNOS. Tissue expression of IL-8 was significantly higher and IL-10 significantly lower in cases compared to controls (target/standard cDNA ratio, median (range) IL-8: 1.25 (0.75-2) Vs 0.85 (0.63-1.3), p<0.0001, Mann-Whitney U test; IL-10: 0.33 (0-0.63) Vs 0.55 (0.5-0.7), p<0.0001). There was a significant inverse correlation between IL-8 and IL-10 expression (Pearson Correlation, (-) 0.509; p<0.01). In patients with IBS-D, cytokine abnormalities were not significantly different in those with or without a history of ID or the presence or absence of MNOS. CONCLUSION: There is evidence for subclinical intestinal mucosal inflammation in patients with IBS-D in a tropical setting, whether or not a history of ID or MNOS was present or absent.Item Quality of life of inflammatory bowel disease at diagnosis in 8 countries in Asia: The ACCESS study(Wiley Blackwell Scientific Publications, 2013) Ng, S.C.; Tang, W.; de Silva, H.J.; Mettananda, K.C.D.; Weerasinghe, S.K.; Ling, K.L.; Ho, L.; Ong, D.; Ooi, C.J.; Hilmi, I.; Goh, K.L.; Manatsathit, S.; Aniwan, S.; Pisespongsa, P.; Abdullah, M.; Zeng, Z.; Hu, P.; Chen, M.; Ouyang, Q.; Wang, Y.F.; WU, K.; Ng, K.K.; Yu, H.H.; Ching, J.; Sung, J.; Chan, F.K.OBJECTIVE: Health-related quality of life (QOL) is an important outcome measure in inflammatory bowel disease (IBD). QOL of Asian patients with IBD at presentation has not been studied. AIM: This study evaluates the QOL of IBD patients at diagnosis from an inception cohort across eight countries in Asia. METHODS: Health-related QOL was measured by the validated IBD Questionnaire (IBDQ) in patients with newly diagnosed IBD between 2011 and 2012. Disease activity was assessed by the Simple Clinical Colitis Activity Index and Harvey-Bradshaw index for ulcerative colitis (UC) and Crohn’s disease (CD), respectively. Demographic and disease characteristics were recorded. RESULTS: 284 incident IBD cases (CD 93; UC 147; IC 14) were included. Median age was 37 (IQR: 26–49). Median duration from symptom onset to diagnosis was 6 months (IQR:2– 24). Overall mean IBDQ score was 159 ± SEM 2.2 (Remission: IBQ≥170). The median IBDQ Score of South Asians (Thailand, Malaysia, Indonesia, Sri Lanka) (150; IQR:117–181) was significantly lower than the Han Chinese (Mainland China, Hong Kong, Singapore, Macau) (167; IQR:139–190; p = 0.003). IBD patients with active disease had significantly lower scores for all 4 dimensions of IBDQ (bowel, systemic, emotional and social functions) compared with those in remission (p < 0.001). Multiple regression analyses identified only disease activity index to be associated with variations in QOL (p < 0.001). There was no significant difference in QOL between patients with CD, UC or IC (p = 0.403). QOLwas not significantly affected by disease behavior for CD (B1, B2, B3, or perianal) but worsened with increasing mucosal involvement in UC (extensive > distal > proctitis; p = 0.014). QOL score was not affected by employment status, education level or smoking history. CONCLUSION: QOL is impaired in newly diagnosed IBD patients, and varies across ethnic groups in Asia. Active disease and more extensive disease are associated with worse QOL in IBD.Item The epidemiology of irritable bowel syndrome among children and adolescents in Asia: a systematic review(Belgian Society of Paediatric Gastroenterology, Hepatology and Nutrition (BeSPGHAN),, 2013) Rajindrajith, S.; Gunawardena, N.K.; Abeygunasekara, C.; Devanarayana, N.M.Aims: Irritable bowel syndrome (IBS) is characterized by chronic abdominal pain and changing bowel habits including frequency and consistency. The aim of this study was to systematically review published literature on prevalence, risk factors and comorbid factors of IBS among children living in Asia. METHOD: A computer assisted search of PUB MED, CINHAL, and Index Medicus for South East Asia was carried out. Study selection criteria were; 1) Asian population based samples of children/adolescents; 2) Clear diagnostic criteria for IBS (Rome I, II or III); 3) Full manuscripts published in English. Selected articles were reviewed in depth; data were extracted and presented in descriptive form. RESULTS: Thirteen cross sectional studies which reported prevalence of IBS were included in the final analysis. Preva¬lence of IBS among Asian children and adolescents ranges from 2.8% to 25.7%. Nine studies have shown a higher prevalence of IBS in girls compared to boys. Studies from China have indicated untyped IBS as the commonest IBS subtype, while studies from Sri Lanka have shown approximately even distribution of all four subtypes. Clearly identi¬fied predisposing factors to develop IBS in Asian children included psychological stress, anxiety, depression, consump¬tion of alcohol and fatty food, smoking, and exposure to gastrointestinal infections. Comorbid factors of IBS reported among Asian children included an array of somatic symptoms, fatigue and psychological problems such as depression. CONCLUSIONS: According to published data, IBS is a significant problem among Asian children and adolescents. Female gender, exposure to stress, certain food habits, life styles and gastrointestinal infections predispose children to develop IBS in Asia.Item Gastric emptying and antral motility according to the subtypes of irritable bowel syndrome: a paediatric study(Lippincott Williams & Wilkins, 2011) Devanarayana, N.M.; Rajindrajith, S.; Bandara, C.; Shashiprabha, G.; Benninga, M.A.BACKGROUND: Irritable bowel syndrome (IBS) is a common paediatric functional gastrointestinal disorder. It is subtyped into diarrhoea predominant (IBS-D), constipation predominant (IBS-C), mixed (IBS-M) and untypable (IBS-U) IBS depending on stool consistency. Several studies have reported differences in colonic motility in children with different IBS subtypes. However, gastric motility has not been assessed according to subtypes yet. AIM: To assess gastric motility in children with different IBS subtypes using a non-invasive ultrasound method. METHODS: Seventy six children with IBS [33 (43%) males, age 4–14 years, mean 7.9 years, SD 3.0 years) referred to the Gastroenterology Research Laboratory, Faculty of Medicine, University of Kelaniya, Sri Lanka, for gastric motility studies and 20 healthy controls [8 (40%) males, age 4–14 years, mean 8.4 years, SD 3.0 years] were recruited. Children with IBS were divided into IBS-D(n=21), IBS-C(n=31), IBS-M (n=19) and IBS-U (n=5) according to Rome III definitions. None of the patients recruited had clinical or laboratory evidence of organic disorders. Liquid gastric emptying rate (GER) and antral motility parameters were assessed using a previously reported ultrasound method. RESULTS: Compared to healthy controls, the mean GER (43.8% vs. 66.2% in controls), amplitude of antral contractions (A) (56.4% vs. 89%) and antral motility index (MI) (5.1 vs. 8.3) were significantly lower and fasting antral area (FA) (1.6 vs. 0.6) was higher in children with IBS ( p<0.0001). Frequency of antral contractions (F) (8.9 vs. 9.3) did not show a significant difference between the two groups. Patients exposed to recent stressful life events had a significantly lower mean GER (40.3%), compared to those who were not (45.7%) ( p=0.03). No significant relationship was observed between severity of symptoms and motility abnormalities. No significant differences were found between IBS-D, IBS-C and IBS-M with respect to GER (42.%, 46.3%, 39.6%), FA (1.4 cm2,1.8 cm2, 1.8 cm2), A (53%, 58.9%, 51.8%), F (8.7, 8.9, 9.2) and MI (4.7, 5.3, 4.8). CONCLUSIONS: GER and antral motility parameters were significantly impaired in children with IBS compared to controls. No significant difference observed in gastric motility parameters between different IBS subtypes. GER was lower in those exposed to recent stressful eventsItem Irritable bowel syndrome(State Pharmaceuticals Corporation, 1996) de Silva, H.J.; Samarasekera, D.N.