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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 The Recto-Anal Inhibitory Reflex (RAIR): abnormal response in diabetics suggests an intrinsic neuro-enteropathy(BMJ Publishing, 1997) Deen, K.I.; Premaratna, R.; Fonseka, M.M.D.; de Silva, H.J.INTRODUCTION: The recto-anal inhibitory reflex (RAIR) is characterized by reflex relaxation of the anal canal in response to electrical stimulation of the rectal mucosa, and is mediated by nitrergic neural plexuses within the gut wall. Impairment of this reflex may lead to incontinence. AIM: To measure anal canal pressures, anal mucosal electrosensation and RAIR in diabetic patients and correlate these measurements with incontinence for gas or faeces. METHODS: Anal canal pressure, RAIR and continence was evaluated in 30 diabetic patients [Male:Female=13:17, median age 57 years (range 37- 70)], and these data were compared with similar data obatained from 22 age and sex matched 'healthy' controls [Male:Female= 9:13, median age 51 years (range 19 - 65 )]. Median duration of diabetes was 8 years (range 3 -30 ). 12 (40%) of the 30 diabetics had impaired continence for gas (n=12) and liquid faeces (n=3). None ofthe controls had incontinence. RESULTS: Maximum resting anal canal pressure (MRP) was [median (range)]: Patients 30mmHg (20-75) vs. Controls 40mmHg (20-105), P=0.61. Maximum squeeze pressure (MSP) [median (range)]: Patients 65mmHg (30- 150) vs. Controls 84mmHg (35-230), P=0.59. Threshold rectal mucosal eletrosensation (RMES-T) [median (range)]: Patients 27 mA (5-40) vs. Controls l3mA (5-28), P=0.03. Maximum tolerable rectal mucosal electrosensation [median (range)]: Patients 40 mA (20-60) vs. Controls 20 mA (10-30), P=0.042 (all comparisons using Wilcoxon rank test). RAIR was present in 8, abnormal in 5 (1 with incontinence), and absent in 17 (II with incontinence) diabetics while it was present in 18 and abnormal in 4 controls (test of proportion, P=0.03 I). CONCLUSIONS: RAIR was impaired in significantly more patients with diabetes than controls implying impairment of intrinsic neuronal function. All diabetic patients with incontinence had impaired or absent RAIR. Impairment of this reflex may be a useful predictor of incontinence in diabetics.Item The recto-anal inhibitory reflex (rair): abnormal response in diabetics suggests an intrinsic neuro-enteropathy(Sri Lanka Medical Association, 1997) Deen, K.I.; Premaratna, R.; Fonseka, M.M.D.; de Silva, H.J.INTRODUCTION: The recto-anal inhihilory reflex (RAIR) is characterized by reflex relaxation of die anal canal in response to electrical stimulation of the rectaJ mucosa, and is mediated by nitrergic neural plexuses within the wall. Im-painnent of this reflex may lead lo incontinence. AIM: To measure anal canal pressures, anal mueosal electrosensation and RAIR in diabetic patients and corre¬late these measurements with incontinence for gas or faeces. METHODS: Anal canal pressure, RAIR and continence was evaluated in 30 diabetic patients [Male : Female = 13:17, median age 57 years (range 37 - 70) ], and these data were compared with similar data obtained from 22 age and sex matched 'healthy' controls [Male:Female = 9:13,age51 years (range 19-65)]. Median duration of diabetes was 8 years(rangc 3-30). 12 (40%) of Uic 30 diabetes had impaired continence for gas (n = 12) and liquid faeces (n =3). None oi'the controls had incontinence. RESULTS : Maximum resting anal canal pressure (MRP) was [median (range)]: Patients 30 mml Ig (20 -75) vs. Controls 40mmHg (20-105). P=0.61. Maximum squeeze pressure (MSP) [median (range)] : Patients 65 mmllg (30-150) vs. Controls 84mmHg (35 -230), P = 0.59. Threshold rectal mueosal elec(rosensation (RMES-T) [median(range)]: Patients 27 mA (5-40) vs. Controls 13mA (5-28), P = 0.03. Maximum tolerable rectal mueosal electrosensation [median(rangc)]: Patients 40mA (20-60) vs. Controls 20mA (10-30), P=0.042 (all comparisons using Wiicoxon rank test). RAIR was present in 8, abnormal in 5 (1 with inconti¬nence), and absent in 17 (11 with incontinence) diabetics while it was present in 18 and abnormal in 4 controls (testof proportion, P = 0.031). CONCLUSIONS: RAIR was impaired in significantly more patients with diabetes than controls implying impairment of intrinsic neuronal function. All diabetic patients with incontinence had impaired or absent RAIR. Impairment of this reflex may be a useful predictor of incontinence in diabetics.Item Psychometric analysis and emotional state in the irritable bowel syndrome (ibs)(Sri Lanka Medical Association, 1997) Kuruppuarachchi, K.A.L.A.; Deen, K.I.INTRODUCTION: Data are lacking on psychometric scores and the emotional state in Sri Lankan patients with the irritable bowel syndrome. AIM: To evaluate patients with IBS using a Hospital Anxiety Depression (I IAD) scale and to assess the accuracy of clinical prediction of the emotional state by a non psychia¬trist clinician. METHODS: Data from 30 patients (20 male, median age - 27 years, range 20 - 50) with IBS titling me manning criteria were compared with 44 age and sex matched controls without IBS. Anxiety rating (median, range) was : Patients 11 (5-17) versus Controls 6 (1-17); P<0.05. Depression rating was : Palients 7 (2 -14 ) versus Controls 5 (0-16) P>0.05, Wilcoxon lest. Prediction of emotional state in patients with IBS correlated well with HAD scores in 17 (56%), was inaccurate in 6 (20%) and equivocal in 7 (24%). All patients in whom clinical prediction of emotional state was inaccurate had combined high anxiety and depression scores. CONCLUSION: Sri Lankan patients with IBS have greater prevalence of anxiety state disorders compared with controls. Clinical prediction of the emotional state by an untrained physician was inaccurate. The HAD scale may be of value in clinical decision making for patients with the irritable bowel syndrome associated with emotional state disorders.Item Altered pelvic floor physiology in women with uterovaginal prolapse (UVP)(Sri Lanka Medical Association, 1997) Deen, K.I.; Gunasekara, P.C.INTRODUCTION: Although an association between Uterovaginal prolapse (UVP) and urinary incontinence is known, the prevalence of anoreetal dysfunction in UVP remains largely unexplored. AIM: To evaluate the prevalence of u re ih roves Seal and anorectal dysfunction in UVP. METHODS: 27 women (median age - 52 years, range 31 - 68 years) with UVP were evaluated by functional and anoreetal physiologic assessment. Data were compared with 20 age matched controls without UVP. Urethrovesical fimcfion was assessed by a 5 point functional score (micturitition frequency, nociuria, urgency, stress incontinence and residual sensation of urine), where 0- no dysfunction, 1,2-minimal, 3,4 - moderate and 5 implied severe dysfunction. Anoredal function was evaluated by clinical assessment and anoreetal physiology. Anal canal pressures were measured by microballoon manomelry. RESULTS : Moderate to severe urethrovesical dysfunction was seen in 33% of patients compared with none of (lie control group (P = 0.052, test of proportions). Anorectal mucosal prolapse was seen in 63% of patients compared with 13% of controls (p = 0.045, test of proportions). Maximum resting (MRP) and squeeze anal pressures (MSP) did not differ significantly between patients and controls. MRP [median, (range)] - Patients; 51 mm Hg (20 - 87) vs. Controls; 60mm 1 Ig (25 - 80), P>0.05; MSP [median, (range)] - Patients; 82 mm Hg (39 - 165) vs. Controls; 100mm Ilg (60 - 185, p>0.05, Wiieoxon test. However, the length of Hie high pressure zone (I IPZ) was significantly less in patients compared with controls (111*2 I cm - Patients = 56% vs. IIPZ 1cm - Controls = 10%, P=0.038, test of proportions). Abnormal anal electroscnsilivity (> 14 inAmps) was seen in 52% of patients compared with none in the control group (P=0.024) and abnormal vaginal electrosensation (> 12mAmps) in 55% of patients vs. 10% Of controls (P = 0.031), test of proportions. CONCLUSION: A greater proportion of women with UVP exhibited either urethrovcssical or anoreetal dysfunction or both compared with controls indicating a pan-pelvic floor weakness. Theses abnormalities should be considered in overall management of women with UVPItem Sapheno-peritoneal shunting for treatment of resistant ascites(Sri Lanka Medical Association, 1998) Deen, K.I.; Jayakody, M.; de Silva, A.P.; Bodhipakse, S.; de Silva, H.J.INTRODUCTION: Prosthetic peritoneovenous shunts are useful to manage resistant ascites due to portal hypertension. However, they are expensive and not widely available. AIM : To assess the efficacy to direct sapheno-peritoneal shunting (SPS) in the treatment of resistant ascites due to portal hypertension. SETTING : University Medical and Surgical Units, Colombo North General Hospital. METHODS : Six male alcoholic cirrhotics (age range 39-68 years) with ascites resistant to diuretics and paracentesis were offered this procedure. Two had evidence of early encephalopathy. SPS was performed under general anaesthesia in 5 and spinal anaesthesia in one. Procedure consisted of division of the saphenous vein 5-6 cms distal to the saphenofemoral junction and connecting the proximal cut end to the peritoneal reflexion above the inguinal ligament. RESULTS : There was no surgical mortality. Control of ascites was considered satisfactory in 5 of the 6 patients (reduction in discomfort, abdominal girth, diuretic requirement and no further paracentesis necessary). The Childs grade improved in 3 of the 6 patients and remained unchanged in 3. One patient required repeated paracentesis, developed severe hepatic encephalopathy and died three months after surgery. Wound infection was seen in 3 patients and a temporary peritoneal fluid leak was seen in another 3. At the time of discharge from hospital Doppler ultrasound showed that the shunt was patent and EEC showed no evidence of encephalopathy in any-patient. CONCLUSION : Although our numbers are small, in the short-term, SPS appears to be useful and relatively safe for control of resistant ascites. It is appropriate for poor countries as an alternative to prosthetic shunts.Item Microbiology of hand towels on surgical wards.(Sri Lanka Medical Association, 1998) Deen, K.I.; Welgama, V.; Perera, C.INTRODUCTION : Frequent ablution followed by hand drying is recommended in surgical wards as prophylaxis against cross infection. It is recommended that hands are dried using " clean" towels. Aim : This study was designed to evaluate the microbiological flora of towels routinely used for hand drying in surgical wards at General Hospital Ragama. METHODS : Fifteen towels which were in use from 15 wards visited on a single occasion were sampled using a sterile microbiological swab (one swab per towel). Each towel was sampled on both sides and at 20-24 randomly chosen sites. Four laundered towels were also sampled in a similar manner prior to use in the wards. Specimens were transported in brain heart infusion and plated on culture media within 2 hours. RESULTS : All towels used in the wards compared with none of the laundered towels revealed either mild or moderate growth of micro-organisms, (test of proportions P -0.00025 Organisms isolated number of towels were Acinetobacter species (10 ). Enterococcus species (14), Bacillus species (5) , Klcbsiella species (2), Staphylococcus aureus (2) and Escherichia coli species in one towel. Only one towel appeared clean. Fourteen appeared stained and visibly dirty to the naked eye. All 15 towels were damp. All control towels appeared clean and dry. CONCLUSION : All towels sampled in this study were found to harbour micro-organisms. This may contribute to cross infections on surgical wards. We believe, hand wiping using towels is unsafe-and suitable alternative methods should be sought.Item Anorectal physiology and transit in patients with disorders of thyroid metabolism(Blackwell Scientific Publications, 1999) Deen, K.I.; Seneviratne, S.L.; de Silva, H.J.BACKGROUND: Data on anorectal physiology in patients with disordered thyroid metabolism are lacking. This prospective study was performed to evaluate anorectal physiology in patients with either hyperthyroidism and diarrhoea, or hypothyroidism and constipation in order to assess slow transit in hypothyroid patients. METHODS: Thirty patients with hypothyroidism and constipation (24 females, median age 59 years, range 23-80) and 20 patients with hyperthyroidism and diarrhoea (12 females, median age 46 years, range 36-62) were evaluated by anal manometry, rectal balloon sensation and whole-gut transit markers. Data were compared with anorectal physiology and whole-gut transit in 22 healthy controls (13 females, median age 51 years, range 24-65). RESULTS: In the hypothyroid patients, maximum resting pressure (MRP) and maximum squeeze pressure (MSP) were similar to controls (patients, median MRP 55 mmHg (18-98); controls, median MRP 41 mmHg (20-105) and patients, median MSP 83 mmHg (39-400); controls, median MSP 88 mmHg (30-230); P 0.05 for both resting and squeeze pressures). In hyperthyroid patients, median MRP and MSP were significantly lower than controls (patients, MRP 33 mmHg (8-69); controls MRP 41 mmHg (20-105) P = 0.04 and patients, MSP 60 mmHg (26-104); controls, MSP 88 mmHg (30-230); P = 0.03). Threshold sensation for impending evacuation in hypothyroid patients was significantly higher than controls, while in hyperthyroid patients, threshold sensation was significantly lower compared with controls. Maximum tolerable rectal volumes in hypothyroid patients was significantly lower compared with controls, while no significant difference was found between maximum tolerable rectal volumes in hyperthyroid patients and controls. Prevalence of delayed whole-gut transit in both hypothyroid and hyperthyroid patients was similar to controls. Furthermore, 33 percent of hypothyroid patients and 40 percent of hyperthyroid patients experienced symptoms of bowel dysfunction prior to the onset of their thyroid disorder. CONCLUSIONS: Patients with altered thyroid function and bowel dysfunction demonstrated abnormalities of anal manometry and rectal sensation.Item Rectovestibular fistula complicating vaginal intercourse in a patient with a narrow vaginal orifice (case report)(Blackwell Scientific Publications, 1999) Deen, K.I.; Sirisena, J.L.Item Closed loop small bowel obstruction caused by a retained faecolith complicating acute appendicular perforation(College of Surgeons of Sri Lanka, 1999) Gunawardena, P.A.H.A.; Deen, K.I.Case report of an 11 year old boy presented with a 36 hour history of central abdominal pain which localized in the right iliac fossa, vomiting and fever. A diagnosis of appendicitis was made. He developed abdominal distension and vomitting on the third post-operative day. The primary cause of the complication was the retained faecolith which was not found at the time of apendicectomy, despite extension.Item Prospective clinical and functional audit of emergency and elective haemorrhoidectomy(College of Surgeons of Sri Lanka, 1999) Deen, K.I.; Paris, M.A.S.; Ariyaratne, M.H.J.; Samarasekera, D.N.Background Traditionally, prolapsed thrombosed haemorrhoids have been treated conservatively because of the popular belief that the incidence of complications are greater after emergency operation compared with elective operation for haemorrhoids. An audit comparing emergency operation for prolapsed thrombosed haemorrhoids with elective operation for third and fourth degree haemorrhoids is presented. Patients and methods 104 patients (82 male, median age 47 years, range -18 to 80 years) undergoing emer- gency (65) or elective haemorrhoidectomy (39) were evaluated for complications after operation, hospital stay and postoperative bowel function which was assessed at 3 months by mailed questionnaire. Results Trainees performed as many operations as consultants (trainee 48 (46 percent) vs. consultant 56 (54 percent) although consultants performed more emergency operations (trainee-20, consultant-45). Postoperative complications were seen in 13 (12percent) ; emergency-9 versus elective-4 (p=0.69). There was no difference in complications after trainee performed operation (8) compared with operation by consultant (5). Median (range) duration of hospital stay after emergency operation was 2 days (1-17) compared with elective operation -2 days (1-10). A subset of 41 patients responded to a questionnaire on bowel function at 3 months: 5 of twenty five (20 percent) after emergency haemorrhoidectomy and 2 of sixteen (12.5 percent) after elective haemorrhoidectomy reported transient incontinence to gas or stool up to 3 weeks after operations but none were incontinent at 3 months. After emergency haemorrhoidectomy, 9 (36 percent) reported a sense of anal narrowing compared with 2 (12.5 percent) after elective haemorrhoidectomy (p=0.13). None required corrective surgery for anal stenosis. Conclusion There were no significant differences in complications, hospital stay and postoperative bowel function in patients after emergency and elective haemorrhoidectomy. Emergency haemorrhoidectomy is likely to result in low morbidity when undertaken by trained persons.