Characteristics and post-operative outcomes of surgery for fistula-in-ano managed at a tertiary care hospital in Sri Lanka: a retrospective study.

OBJECTIVES: Management of fistula-in-ano is associated with recurrence and, occasionally, with anal incontinence. We investigated the clinical characteristics and outcomes of fistula-in-ano. METHODS: We included patients with fistula-in-ano managed at a tertiary care center (2016-2021). We collected clinical characteristics and 1-year outcomes using questionnaires. The chi-square test was used in statistical analysis. RESULTS: In total, 284 patients (231 men, 81.3%; median age 39.5 [range: 7-73] years) were included. Most patients had simple fistulae (n = 191, 67.3%). Transphincteric (n = 110, 38.7%) fistulae were the most common type, followed by intersphinteric fistulae (n = 103, 36.6%). Fistulotomy (n = 157, 55.3%) was the most common procedure. Follow-up details were traceable in 157 (55.3%) patients. At 1 year, the overall healing rate was 88.5% (n = 136). There was no association between type of surgical procedure and incontinence. The mean Vaizey score, used to assess anal incontinence, was 0.84 (range: 0-14). Incontinence was observed in 32 patients (20.9%), and flatus incontinence was the most common type (n = 17, 53.1%). Complex fistulae were associated with higher recurrence rates than simple fistulae (32.6% vs. 2.8%). CONCLUSION: The healing rate in surgical treatment of fistula-in-ano was 88.5%, with acceptable complication rates. There was no association between surgical procedure type and incontinence.

Incidence and age-standardized rates of pancreatic cancer in Sri Lanka from 2001 to 2010: An analysis of national cancer registry data.

BACKGROUND: Varying trends in the incidence of pancreatic cancer (PC) are observed in many Asian countries. This study aimed at describing the incidence and age-standardized rates of PC in Sri Lanka from 2001-2010. METHODS: A retrospective cohort evaluation of patients with PC from 2001 to 2010 was performed using the population-based data published by the Sri Lanka National Cancer Registry. The trends in the incidence of PC was analyzed by age and sex using joinpoint regression analysis. RESULTS: A total of 808 PC patients studied from 2001-2010, of which males were 438 (54.2%). The mean (±standard deviation) age of the total population was 55.7 (±13.8) years [males = 56.5 (±13.3) vs. females = 54.8 (±14.3), P=0.07]. The World Health Organization (WHO) age-standardized incidence of PC in Sri Lanka increased marginally from 0.44 per 100,000 in 2001 (95% confidence interval (CI) = 0.34-0.54) to 0.58 per 100,000 in 2010 (95% CI = 0.46-0.69) which is a 1.3-fold increase (P < 0.05 for trend) with an estimated annual percentage change (EAPC) of 3.5 (95% CI = 0.5-6.6). The proportional increase in incidence was more significant in females compared to males. The analysis of the overall cohort rates of PC in Srilanka between 2001-2010 showed the highest rates in the 60-70-year category with an EAPC of 5.06 (95% CI = 1.3-9.0). CONCLUSION: In our study, we found that there was a marginal rise in the incidence of PC in Sri Lanka with a higher proportional increase in females compared to males.

The role of routine flexible sigmoidoscopy in patients presenting with fistula-in-ano: an observational study.

OBJECTIVE: Flexible sigmoidoscopy is useful to look for an underlying aetiology in fistula-in-ano. This study was aimed to assess the yield of routine flexible sigmoidoscopy in patients presenting with fistula-in-ano. A retrospective analysis of 159 consecutive patients with fistula-in-ano who underwent routine flexible sigmoidoscopy was performed. Sigmoidoscopy findings were recorded on a standard uniform format using a computer database. Those with a known aetiology were excluded. RESULTS: The median age was 39 (range: 14-74) years and the majority were males (n = 128, 80.5%). Forty-nine patients (30.8%) presented with a recurrent fistula-in-ano. On flexible sigmoidoscopy, internal opening was seen in only 23 patients (14.4%). Furthermore, incidental findings of haemorrhoids (n = 5, 3.1%) and polyps (n = 7, 4.4%) were found. One patient (0.6%) had a healed anal fissure, 5 patients (3.1%) had inflamed mucosa and 2 patients (1.3%) had ulcers. Only two patients with inflamed mucosa were diagnosed to have Crohn's disease on histology. Therefore, flexible sigmoidoscopy was not helpful in the majority to locate the internal opening. Only two patients had evidence of an underlying aetiology, which was Crohn's disease. However, they had recurrent complex fistulae and other associated symptoms. Therefore, flexible sigmoidoscopy may be reserved for selected group of patients with symptoms of an underlying aetiology.

Spontaneous rupture of a parastomal hernia with evisceration of small bowel: a case report.

BACKGROUND: Long standing ostomy related complications such as parastomal hernia and stoma prolapse may be at a higher risk of developing spontaneous rupture and evisceration, especially in patients suffering from chronic cough. Such patients may need early refashioning of the stoma to prevent this serious complication. Parastomal evisceration is a very rare complication of stomas and to date, only few cases have been reported in the literature. CASE PRESENTATION: A 51 year old patient with chronic obstructive pulmonary disease (COPD) and extensive hidradenitis suppurativa of the perineum underwent a temporary defunctioning loop sigmoid colostomy and subsequent perineal skin excision and skin grafting. The ostomy was complicated by a parastomal hernia and stoma prolapse 6 weeks post operatively. Five months later he developed spontaneous rupture of parastomal hernia and evisceration of small bowel. Urgent surgery was done and reduction of small bowel loops and re-siting of the sigmoid colostomy was done. DISCUSSION AND CONCLUSIONS: Parastomal evisceration is an extremely rare life threatening stoma-related complication which requires urgent treatment.

Constipation with megacolon in a 36-year-old man: a rare presentation of MEN2B from Sri Lanka.

Diffuse intestinal ganglioneuromatosis is a rare condition associated with MEN2B. It is also seen in conditions like neurofibromatosis type 1 and Cowden syndrome. This is a report of a patient who underwent total colectomy with end ileostomy creation for a megacolon. He was diagnosed to have diffuse ganglioneuromatosis on histological examination of the resected segment of colon. The definitive management of diffuse ganglioneuromatosis is to resect and anastomose.

Value of three-dimensional endoanal ultrasound scan (3D-EAUS) in preoperative assessment of fistula-in-ano.

OBJECTIVE: The aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound scan (3D-EAUS) in the pre-operative assessment of fistula-in-ano in identifying the fistula tract and comparing with findings at surgery in a South Asian cohort. A retrospective analysis of 87 patients with suspected fistula-in-ano who underwent pre-operative 3D-EAUS between January 2009 and January 2016 was carried out. All patients subsequently had surgical exploration under anaesthesia (EUA), irrespective of 3D-EAUS findings. The 3D-EAUS results were compared with the surgical findings to determine the accuracy of 3D-EAUS. RESULTS: A total of 86 (98.9%) patients (male = 75) were subsequently shown to have a fistula at surgical exploration and of them, 3D-EAUS detected a fistula in 79 (92%) patients. In this cohort, 3D-EAUS correctly predicted the surgical findings in (n = 61, 70.9%) patients with the highest accuracy being for transphincteric fistulae (87.1%). However, the overall concordance in our study was low with a kappa coefficient of 0.318. Additional findings such as sphincter defects were detected by the 3D-EAUS in 37 patients (internal sphincter defects-21, external sphincter defects-7, both-9) which were not evident at EUA. Therefore, 3D-EAUS had a good accuracy in selected types of fistulae and particularly useful in identifying sphincter defects before surgery.

Efficacy of irrigation tubes in the management of para rectal cavities associated with complex fistula-in-ano.

BACKGROUND: Surgical management of complex perianal fistula associated with pararectal cavities can be challenging. We hypothesised that healing of the pararectal cavities prior to healing of the fistula leads to a better outcome. We aimed to assess the efficacy of irrigation catheters in the healing of pararectal cavities associated with fistula-in-ano. METHODS: This study design was consistent with IDEAL stage 2a (development) and was conducted at the Professorial Surgical Unit, National Hospital of Sri Lanka, Colombo. Thirty-two patients with complex fistulae with a pararectal cavity (detected by 2D-Endoanal ultrasounography-EAUS) were included. All patients underwent examination under anaesthesia (EUA), during which insertion of an irrigation catheter to the pararectal cavity and tagging of the primary fistula tract with a drainage seton was done. Patients were advised to irrigate with antiseptic solution and were followed-up at three weekly intervals to assess cavity reduction. RESULTS: The majority were males (96.8%, n = 31). The primary fistula tract in 26 patients (81.2%) was trans-sphincteric and was inter-sphincteric in 6 patients (18.7%). Mean time of cavity contraction was 34.78 (range, 21-112) days. Complete healing was seen in 87.5% (n = 28), with 3 patients (9.37%) being lost to follow-up and 1 patient (3.12%) having a persistent perianal fistula after 6 months of follow-up. Those who had complete healing were followed up for a median duration of 6 (range, 3-20) months and there were no recurrences. CONCLUSIONS: Irrigation in the management of pararectal cavities yielded satisfactory results. A case control trial with larger numbers and assessment of cavity size pre and post procedure by 3D-EAUS/MRI evaluation would be necessary for more objective evaluation of the efficacy of this novel intervention.

Duration taken for the anal sphincter pressures to stabilize prior to anorectal manometry.

OBJECTIVES: Anorectal manometry (ARM) is an integral part of evaluating the anal sphincter function. The current recommendation of waiting for 5 min (lead-in-time) prior to beginning the recording has no evidence. A prolonged procedure may reduce patient compliance. RESULTS: We analyzed data from 100 consecutive patients who underwent 3-dimensional ARM at a single center. Their pressure studies were analyzed in consecutive 10-s segments, beginning from the time of insertion of the probe into the anal canal. We defined stabilization of the pressure as the absence of a pressure difference among two consecutive 10-s segments. The study population had 31 males. Their mean age was 33.0 years (SD-14.4). The mean time for the pressure to stabilize was 84.2 s (SD-29.5), range 17.2-203.7 s, 95th percentile 136.2 s. Eleven and one participant(s) took longer than 120 and 150 s for the pressure to stabilize, respectively. There was no correlation of sex (Mann-Whitney U test, p = 0.89) and the time to pressure stabilization. Age and the time to stabilize (Spearman rho - 0.246, p = 0.017) showed a weak negative correlation. A lead-in-time of 5 min, as recommended by present guidelines may be unnecessary. Waiting for 150 s/2½ min may be sufficient and will minimize the procedure duration.

Inflammatory myofibroblastic tumor of the esophagus presenting with hematemesis and melaena: a case report and review of literature.

Esophageal inflammatory myofibroblastic tumors (IMT) are extremely rare, and the understanding on the clinical presentation is limited. IMT of esophagus should be considered as a differential diagnosis in the context of unexplained upper gastrointestinal bleeding and rapidly progressing dysphagia in young patients.

Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study.

BACKGROUND: Anal incontinence is a known complication following operative treatment of fistula-in-ano which can significantly impact the quality of life. This study was aimed to objectively assess the impact of operative treatment of simple fistula-in-ano on quality of life related to anal incontinence. Therefore, a prospective study was conducted in 34 patients who underwent surgery for fistula-in-ano over a period of 24 months. Quality of life and incontinence were assessed using fecal incontinence quality of life (FIQL) scale and Cleveland clinic incontinence score (CCIS) preoperatively and after a minimum of 12 months follow up (mean-27 months, range 12-40 months). The difference in FIQL and CCIS was analysed using Wilcoxon Rank test and Mann-Whitney U test. RESULTS: The median age of the participants was 42.5 years (range 22-63, males = 30). The majority had a trans-sphincteric tract (n = 22, 65%). Superficial tracts and inter-sphincteric tracts were found in 8 (24%) and 4 patients (12%). The overall preoperative and postoperative rates of incontinence were 18 and 38% respectively, but the severity was low. The mean overall FIQL was 16.0 (SD ± 0.4) preoperatively and 16.1 (SD ± 0.4) postoperatively. Considerable difference was seen in the scale measuring "depression/self-perception" (p = 0.012). Only 1 patient (3%) had reduction in scale "lifestyle" which measures the impact of incontinence on day-to-day activities. CONCLUSIONS: Analysis of a cohort of simple cryptoglandular fistula-in-ano with low pre-operative incontinence showed no worsening in the FIQL following successful treatment despite minor worsening of incontinence. Since greater improvement was noted in scale measuring depression/self-perception, psychological interventions may be helpful before surgery to improve quality of life.

Human Epidermal Growth Factor Receptor-2 in Sri Lankan Gastric Carcinoma Patients with Clinicopathological Association and Survival.

BACKGROUND: HER2 protein expression indicates adverse prognosis in gastric adenocarcinoma (GCa). GCa HER2 positivity ranges from 10 to 22.8%. Similar data are scarce in South Asia and unavailable in Sri Lanka. AIM: To evaluate HER2 protein expression, its clinicopathological relationship and survival in a Sri Lankan GCa cohort. METHODS: One hundred consecutive GCa patients were recruited prospectively for 2 years. Histological diagnosis was confirmed on endoscopic biopsies/gastrectomy specimens. Clinicopathological and overall survival data were collected. HER2 expression was assessed using immunohistochemistry. 2+ and 3+ scores were considered positive. HER2 expression and clinicopathological parameters were analyzed by Chi-squared test and multivariate analysis with logistic regression using SPSS-21. Kaplan-Meier method and log-rank test were used for survival analysis. RESULTS: Study includes 56 biopsies and 44 resections. Male/female ratio was 1.9:1. Mean age of diagnosis was 61.1 years (range 32-82). Majority tumors were proximally located (58%). HER2 positivity was 9%. Even though intestinal subtype predominated HER2 positivity was mostly among diffuse variant (14.8%). In multivariate analysis, mitotic count >5/hpf, high nuclear grade and tumor necrosis were significantly associated with HER2 positivity, while poor differentiation, signet cells, extracellular mucin, perineural invasion and pathological nodal metastasis (all p < 0.05) showed a correlation in univariate analysis. Mean follow-up duration was 37.4 weeks (range 0-104). HER2 positivity was associated with a significantly lower median overall survival (p = 0.046). CONCLUSION: GCa HER2 positivity was 9%, associated with a lower median overall survival. Adverse histological features had a positive correlation with HER2 positivity. These histological features could direct patients for confirmatory HER2 testing in limited resource settings.

Psychological Adaptation to Alteration of Body Image among Stoma Patients: A Descriptive Study.

BACKGROUND: Creation of an ostomy leads to significant change in the body image of the patient. However, adaptation to this alteration of body image is necessary for rehabilitation following surgery. The objective of this study was to identify the factors that influence adaptation to altered body image. MATERIALS AND METHODS: An analytical cross-sectional study was conducted among 41 ostomy patients who were treated at a single tertiary care unit. Body image disturbance questionnaire (BIDQ) was used to assess the perception of body image. Data were analyzed using independent samples t-test (unpaired), Chi-square test, and Spearman's correlation. RESULTS: In our study, the mean BIDQ score was 2.22 (standard deviation ± 0.88). The body image disturbance was significantly associated with younger age (P < 0.05). The prevalence of body image disturbance was significantly higher among overweight patients (P < 0.05). Males had a higher BIDQ score than females. Those who had temporary stoma had significantly higher BIDQ score (P < 0.05). Those who felt depressed or had thoughts of self-harm soon after surgery had significantly high body image disturbance score (P < 0.05). There was a significant negative correlation with the perception of self-efficacy and body image disturbance (P < 0.01). There was no significant association between body image disturbance and the diagnosis, type of surgery, or time duration after surgery. CONCLUSIONS: Poor adaptation to alteration of body image was associated with younger age, overweight, and temporary stoma. Individuals at risk of poor adaptation should be identified before surgery and counseled before surgery, after surgery, and during follow-up visits.

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 Crohn's 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.

Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

INTRODUCTION AND HYPOTHESIS: The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. METHODS: One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. RESULTS: Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. CONCLUSIONS: Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.

A distinct variant of papillary thyroid carcinoma indicating familial adenomatous polyposis (FAP): a case report and brief review.

BACKGROUND: Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited intestinal polyposis syndrome with an incidence of about 1/8300 births and accounts for about 1% of all colorectal cancers. It has a spectrum of extra-intestinal manifestations including thyroid carcinoma which occur in 1-2% of affected. The cribriform morular variant (CMV) is a rare but distinct histological subtype of papillary thyroid carcinoma (PTC) associated with FAP. Most of the reported cases describe the above entity in the background of well-established FAP. We report a case where both entities presenting simultaneously in a previously undiagnosed patient with FAP without a family history of polyposis. CASE PRESENTATION: A 24 year old Asian female presented to the surgical clinic with a goitre of eight months duration and recent onset of altered bowel habits with features of anaemia. She was previously healthy and there was no family history of adenomatous polyposis, colorectal carcinoma or thyroid neoplasms. Colonoscopy revealed large bowel polyposis and fine needle aspiration of thyroid revealed a smear suspicious for malignancy. She underwent total thyroidectomy which revealed CMV PTC. Histology was characterized by a prominent cribriform pattern of growth with interspersed cell clusters arranged as morules along with papillary structures which are the key features of this subtype. CONCLUSION: Diagnosis of CMV warrants ruling out of underlying FAP, irrespective of family history or gastrointestinal symptoms.

Correlation of three dimensional anorectal manometry and three dimensional endoanal ultrasound findings in primi gravida: a cross sectional study.

BACKGROUND: 3-dimensional anorectal manometry (3DARM) and 3-dimensional endoanal ultrasound (3DEAUS) have not been used to assess the anal sphincter complex (ASC) in primi gravida. This study was conducted to identify any correlation that may exist between 3DARM and 3DEAUS. METHODS: We analyzed 3DARM and 3DEAUS data of 101 consecutive primi mothers assessed in the late second trimester or early 3rd trimester. 3DARM was performed using the Given Imaging(®) Manoscan system and 3DEAUS was performed with the Olympus(®) RU 12M-R1 probe and EU-ME1 ultrasound system. RESULTS: The mean age was 24.7 (SD-5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD-18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD-52.96) mmHg. The mean length of the high pressure zone was 3.67 (SD-0.52) cm. On 3DEAUS, there were three characteristic segments of the ASC that were identified; upper, middle and lower. Mean thicknesses for both internal anal sphincter (IAS) and external anal sphincter (EAS) were identified for primi gravida. IAS was thicker anteriorly and at 9 o' clock positions and EAS was thicker posteriorly. There was good correlation in the length of the ASC at each quadrant between 3DARM and 3DEAUS. There was no correlation between either RP or SP thickness of IAS or EAS at each level and quadrant. CONCLUSION: Correlation is seen only in the length of ASC at each quadrant. No correlation exist between RP or SP and thickness of IAS and EAS.

Types and patterns of colonic polyps encountered at a tertiary care center in a developing country in South Asia.

PURPOSE: To identify the prevalence, types, and patterns of colonic polyps in a cohort of patients presenting to a tertiary care referral center in Sri Lanka. METHODS: Endoscopy and pathology reports of a single unit from 2006 to 2013 were analyzed retrospectively. Spearman's correlation coefficient and chi-square test were used to identify correlations. RESULTS: There were a total of 158 patients (M : F, 10 : 57) who had polyps encountered on colonoscopy (n = 1408) and flexible sigmoidoscopy (n = 2402) with an incidence of 4.1%. Mean age was 56.5 years (SD 16.4) and the incidence of polyps increased with age. The majority (81.6%) had one polyp. A total of 188 polyps were assessed and most were seen in the rectum (33.5%) followed by sigmoid colon (22.9%). The commonest histological type was tubulovillous adenoma (33.5%) followed by tubular adenoma (24.5%). Most polyps were benign (91.5%). There was no statistically significant correlation with age or gender with malignancy, site, or histology. DISCUSSION AND CONCLUSION: The incidence of colorectal polyps was lower than the values reported in the west. More polyps were identified in males. There was no statistically significant association between age, gender, or multiplicity and malignant change in the polyps.

Patterns and trends of medical student research.

BACKGROUND: Our study describes the change in the research output, trends and content of published research involving medical students over the last century. METHODS: Pubmed® 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. RESULTS: The 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. CONCLUSIONS: There 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.

Disease characteristics of inflammatory bowel disease (IBD): findings from a tertiary care centre in South Asia.

BACKGROUND: Inflammatory bowel diseases (IBD) include ulcerative colitis (UC) and Crohn's disease (CD), which are chronic inflammatory conditions affecting the gastrointestinal tract. There are only few published data on disease characteristics of IBD related to South Asia. OBJECTIVE: To provide the disease characteristics of the IBD patients who presented to a tertiary care hospital in South Asia. METHODS: Patients with an established diagnosis of IBD were identified after a review of their medical records and demographics, and disease characteristics and indications for surgical treatment were analyzed. RESULTS: A total of 184 patients (women = 101, 54.9%; UC = 153, 83.2%) were included. Female preponderance was observed for UC (male/female ratio =1:1.5) and male for CD (male/female = 2:1). Mean age at the time of diagnosis was 36.3 (range 7-71) years. CD was diagnosed at a significantly younger age than UC (27.35 ± 10.22 vs. 38.14 ± 13.05 years, p < 0.0001). CD showed a peak age of onset in the third decade and that for UC was in the fourth decade. The mean duration of IBD was 8.17 (range 1-28) years. Presenting complaint of the majority (73.7%) of UC patients was blood and mucous diarrhea and that for CD (77.4%, 24/31) was left-sided abdominal pain. Only 9.5% (n = 18) had at least one extra-intestinal manifestation. Among UC patients, 51.7% (n = 79) had left-sided colitis and panproctocolitis was found in 18.3% (n = 28). In IBD patients, 14.1% (n = 26) underwent surgery. Only one patient developed malignancy. CONCLUSIONS: The majority of UC patients had left-sided colitis. CD compared to UC was diagnosed at a younger age. However, compared to data reported for some Western countries, extra-intestinal manifestations and malignancy rates were lower.