D. N. Samarasekera

Long-term anal continence and quality of life following postpartum anal sphincter injury.

Objective  Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long‐term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3).

Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease.

BACKGROUND--An increasing number of patients with severe or refractory ulcerative colitis involving only the rectum and sigmoid colon are being offered restorative proctocolectomy with ileal reservoir but very few data are available concerning the outcome for these patients. AIM--This study was designed to compare the outcome of ileal pouch procedures for distal ulcerative colitis with procedures performed for more extensive disease. PATIENTS--A consecutive series of 177 patients undergoing restorative proctocolectomy for ulcerative colitis between January 1984 and December 1994. METHODS--Data were collected prospectively in a dedicated ileal pouch database and included demographic details, indication for surgery, surgical procedures performed, early (< 30 days) and late morbidity, functional outcome, and histopathology. RESULTS--There was no mortality in the series. The incidence and range of early morbidity (< 30 days) and the functional outcome (daytime stool frequency, nocturnal frequency, and the incidence of incontinence) were similar for all groups. Log rank analysis of Kaplan-Meier estimates showed no significant difference between groups in the likelihood of developing pouchitis (p > 0.2). CONCLUSIONS--Patients undergoing restorative proctocolectomy for distal colitis experience a similar outcome to patients with more extensive disease. These data refute the hypothesis that pouchitis is more common in patients with total colitis.

Unexpected outcome from Trousseau syndrome

BackgroundUnprovoked superficial thrombophlebitis and subsequent venous thromboembolism are well-described albeit rare presenting features of advanced visceral malignancy that often manifest too late for curative intervention to be beneficial.Case PresentationWe present the first reported case of early gastric carcinoma presenting with these paraneoplastic phenomena in an otherwise healthy farmer. The early presentation allowed for a curative partial gastrectomy, which itself was complicated by the presence of a deep vein thrombosis extending into the inferior vena cava. Fortunately, stabilization of the clot allowed for surgery to proceed without the need for a caval filter. The patient was referred for adjuvant chemotherapy and has since made an excellent recovery.ConclusionsThis case provides new evidence for the presentation of superficial thrombophlebitis in early gastric carcinoma and the potential for curative surgery in such instances. A high index of suspicion and a prompt diagnostic workup are essential for timely planning and execution of surgery in these early albeit rare presentations.

Patterns and trends of medical student research

BackgroundOur study describes the change in the research output, trends and content of published research involving medical students over the last century.MethodsPubmed® and Scopus® were searched for keywords ‘Medical Student’ in the affiliation field. The search results were combined in Endnote® and duplicate entries removed and the multiple variables described below were assessed.ResultsThe combined searches after excluding duplicates yielded 416 results and 66 articles were excluded. There was an exponential increase in medical student research from 1980–2010. Medical student was the first author in 170 (48.6%) studies and 55 studies were authored by a single medical student. The 3 most common areas of research in descending order were Psychiatry (n = 26, 7.4%), General Medicine (n = 24, 6.9%) and Medical Education (n = 21, 6%). The commonest type of articles, in descending order were review articles (n = 48, 13.7%), Cross sectional studies (n = 47, 13.4%) and Case reports (n = 43, 12.3. The majority of these articles (n = 207, 59.1%) have never been cited subsequently. The trend of increasing number of articles was seen equally among all article types, fields and countries.ConclusionsThere is an exponential increase in articles by medical students but the majority of articles have not been cited. The numbers of medical student authors per publication have remained static while the total numbers of authors have increased. The proportions in the type of articles, fields of study and country of origin have largely remained static. Publishers and authors should strive to enhance the quality and quantity of data available in indexing services.

Factors influencing the approaches to studying of preclinical and clinical students and postgraduate trainees.

BackgroundStudents can be classified into three categories depending on their approaches to studying; namely, deep approach (DA), strategic approach (SA) and surface apathetic or superficial approach (SAA). The aim of this study was to identify factors affecting the approaches to studying among Sri Lankan medical undergraduates and post graduate trainees and to analyze the change in the pattern of study skills with time and experience.MethodPre-clinical and clinical students of the Faculty of Medicine, University of Colombo and postgraduate trainees in Surgery at the National Hospital of Sri Lanka were invited to complete the Approaches and Study Skills Inventory for Students (ASSIST) questionnaire.ResultsA total of 187 pre clinical (M: F = 96:91), 124 clinical (M: F = 61:63) and 53 post graduate trainees (M: F = 50:3) participated in the study. Approaches of male and female students were similar. SA was significantly affected by age among the preclinical students (p = 0.01), but not in other groups. Among pre-clinical students, males preferred a teacher who supported understanding (p = 0.04) but females preferred a passive transmission of information (p < 0.001). This, too, was not visible among other groups. A linear regression performed on group (batch), gender, island rank at GCE Advance Level (AL) examination, self appraisal score and the preference scores of type of teacher only managed to explain 35% or less of variance observed for each approach in individual groups.ConclusionDifferent factors affect the approach to studying in different groups but these explain only a small fraction of the variance observed.

Comparison of vector symmetry index and endoanal ultrasonography in the diagnosis of anal sphincter disruption

BackgroundAnal pressure vectography is an anorectal physiology study that evaluates the radial pressures in the anal canal from which a symmetry index that indicates the anatomical integrity of the anal sphincter can be calculated. However, there are conflicting opinions of its validity. Since endoanal ultrasonography (EAUS) has been recognized as the gold standard for detecting anal sphincter disruption, the aim of this pilot study was to observe whether a vector symmetry index (VSI) determined at the level of injury shown in EAUS has a better sensitivity than the overall VSI in detecting anal sphincter disruption.MethodsA group of 11 women in whom EAUS had shown defects in both the internal and the external anal sphincters underwent anorectal manometry using a water-perfused vector manometry catheter, and the overall VSI and the VSI at the level of sphincter disruption (shown on EAUS) were calculated.ResultsOverall VSI at rest indicated internal sphincter injury in 7 women (64%) but the VSI at the level of disruption indicated internal sphincter injury in all 11 women (100%, p=0.0137). Similarly, the overall VSI at squeeze indicated external sphincter injury in 6 women (55%), but the VSI at the level of disruption indicated external sphincter injury in 10 women (91%, p=0.0049).ConclusionsOur pilot study showed that EAUS and VSI are equally sensitive in diagnosing a localized anal sphincter defect, provided a segment-for-segment comparison is carried out.

Structured endoscopic ultrasonography (EUS) training program improved knowledge and skills of trainees: Results from the Asian EUS Group

A major reason impeding the growth of endoscopic ultrasound (EUS) in Asia is the lack of training availability. We aimed to prospectively evaluate the effectiveness of a short‐term structured EUS training program in improving the knowledge and skill of EUS among trainees.

The value of routine histopathological analysis in patients with fistula in-ano.

Objective  To determine the positive yield of routine histopathology in patients undergoing surgery for fistula in‐ano.

Faecal incontinence and health related quality of life in inflammatory bowel disease patients: Findings from a tertiary care center in South Asia.

AIM To analyze the frequency and severity of faecal incontinence (FI) and its effect on the quality of life (QOL) in inflammatory bowel disease (IBD) patients. METHODS All patients who attended surgical and medical gastroenterology outpatient clinics in a tertiary care center with an established diagnosis of either ulcerative colitis (UC) or Crohns disease (CD) over a period of 10 mo were included in this study. Before enrollment into the study, the patients were explained about the study and informed consent was obtained. The patients with unidentified colitis were excluded. The data on demographics, disease characteristics, FI (Vaizey score), and quality of life (IBD-Q) were collected. Data were analyzed using SPSS version 21. RESULTS There were 184 patients (women = 101, 54.9%; UC = 153, 83.2%) with a female preponderance for UC (male/female ratio = 1:1.5) and a male preponderance for CD (male/female = 2:1). Forty-eight (26%) patients reported symptoms of FI. Among the patients with FI, 70.8% were women (n = 34) and 29.2% were men (n = 14) with an average age of 52.7 years (range, 20-78 years). Average age of onset of FI was 48.6 (range, 22-74) years. Ten percent (n = 5) reported regular FI. Incontinence to flatus was seen in 33.3% (n = 16), to liquid faeces in 56.2% (n = 27), to solid faeces in 6.2% (n = 3) and to all three in 4.1% (n = 2). Twenty-one percent (n = 10) complained of disruption of their physical and social activity. There was no association between FI and type of IBD. Significant associations were found between FI and age (P = 0.005) and gender (P < 0.001). QOL in our cohort of patients was significantly affected by FI. CONCLUSION In our study, nearly a quarter of patients reported FI. There was a significant correlation between FI and QOL. Therefore, enquiring about FI in IBD patients can lead to identification of this debilitating condition. This will enable early referral for continence care in this group of patients.

Intestinal helminths detected in capsule endoscopy

Herein is a report on three patients who were diagnosed incidentally by capsule endoscopy (CE) as having worm infestations in the digestive tract. All patients underwent CE after upper esphago-gastro-duodenoscopy and colonoscopy did not reveal a causative pathology. The first patient was a 65-year-old woman who was investigated for melena with microcytic hypochromic anemia without eosinophilia. Her colonoscopy showed blood coming from the ileocecal valve. CE identified multiple roundworms (Ascaris lumbricoides) in the lumen of the stomach and duodenum (Fig. 1). She was treated with anti-helminthics. The second patient was a 64-year-old man investigated for iron deficiency anemia. His full blood count showed eosinophilia, and histology of the colon was reported to be eosinophilic colitis. However, no parasites were seen in colonoscopy. CE identified hookworms (Necator americanus) adherent to the mucosa from the duodenum up to the cecum, with bleeding from probable previous attachment sites of the worms (Fig. 2). The third patient was a 45-year-old man who underwent a follow-up colonoscopy after colectomy in 1999 for fulminant colitis. CE showed hookworms adherent to the ileal mucosa. CE is still a novel technique in developing countries; only small case series have been conducted. Intestinal helminthiasis in the tropics is less common, but it is still an important differential diagnosis of iron deficiency anemia. There have been reports of intestinal helminthiasis first detected by CE. In two of the three patients, worm infestation did not account for the disease that was being investigated. However, given the prevalence of intestinal helminthiasis in the tropics, we would recommend a course of anti-helminthics prior to CE. There are no serological tests for the diagnosis of intestinal helminthiasis, and repeating CE to confirm the success of the cure was not financially feasible. However, in patients with anemia, the cure was confirmed by the rise of hemoglobin level.