|Year : 2020 | Volume
| Issue : 1 | Page : 18-23
A Southwest Nigerian tertiary hospital 5-year study of the pattern of liver disease admission
Olusegun Adekanle1, Oluwasegun Ijarotimi1, Emmanuel Obasi2, Nnenna Grace Anthony-Nwojo2, Dennis A Ndububa1
1 Department of Medicine, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
2 Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
|Date of Submission||26-Jul-2019|
|Date of Decision||18-Oct-2019|
|Date of Acceptance||27-Dec-2019|
|Date of Web Publication||23-May-2020|
Dr. Olusegun Adekanle
Department of Medicine, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife
Source of Support: None, Conflict of Interest: None
Background: Liver disease is a major cause of morbidity and mortality globally. Its pattern varies with different geographical locations and these variations are determined by lifestyle, environmental, and genetic factors. This study determined the pattern, clinical presentations, risk factors, and determinants of morbidity and mortality in patients with liver disease admitted into a tertiary hospital in Ile-Ife, Nigeria, over a 5-year period; 2013–2017.
Methods: Case records of patients admitted into the medical wards of Obafemi Awolowo University Teaching Hospital, Ile-Ife, with a diagnosis of liver disease were retrieved and information relating to demographics, risk factors, and types of liver disease as well as the results of relevant investigations, duration, and outcome of admission was extracted. Data were entered into SPSS version 20 and analyzed using frequencies and percentages which are presented in tabular form.
Results: A total of 5,155 patients were admitted, liver diseases accounted for 324 (6.3%) of medical admissions within the period, with hepatocellular carcinoma (HCC) accounting for 52.8%, liver cirrhosis (LC) – 27.2%, acute hepatitis – 10.38%, metastatic liver disease – 4.1%, autoimmune hepatitis – 1.7%, DILI – 0.7%, liver abscess – 1%, abdominal tuberculosis – 1.4%, and unclassified etiology – 1.76%. A total of 139 cases were HBsAg positive, 64 took alcohol, 67 took herbs, while 57 took self-prescribed medications. Mortality among all patients admitted through the emergency compared with the medical clinic was 81.9% versus 18.1%. Elevated creatinine, coagulation disorder, hypoalbuminemia, and hypokalemia contributed to mortality.
Conclusion: HCC and LC accounted for the majority of liver diseases in hospitalized patients with high mortality among all patients admitted through the emergency department and those with elevated creatinine, coagulopathy, and low potassium and albumin. Major etiologic factors were hepatitis B virus infection, alcohol, and self-prescribed medications.
Keywords: Admissions, liver disease, Nigeria, pattern
|How to cite this article:|
Adekanle O, Ijarotimi O, Obasi E, Anthony-Nwojo NG, Ndububa DA. A Southwest Nigerian tertiary hospital 5-year study of the pattern of liver disease admission. Niger J Gastroenterol Hepatol 2020;12:18-23
|How to cite this URL:|
Adekanle O, Ijarotimi O, Obasi E, Anthony-Nwojo NG, Ndububa DA. A Southwest Nigerian tertiary hospital 5-year study of the pattern of liver disease admission. Niger J Gastroenterol Hepatol [serial online] 2020 [cited 2020 Dec 3];12:18-23. Available from: https://www.njghonweb.org/text.asp?2020/12/1/18/284723
| Introduction|| |
The liver is the largest internal organ in the human body and it weighs 1200–1400 g in adult women and 1400–1500 g in adult men and represents 1.5%–2.5% of the body weight. The liver is important in metabolism, control of infections, and in the processing of toxins. This complex anatomy and physiology of the liver make it vulnerable to damage by infections, toxins, products of metabolism, and immunologic agents. Liver disease encompasses both acute and chronic disease processes that are due to different etiologies. The prevalence of chronic liver disease (CLD) is about 18.5%, globally, while the prevalence of liver cirrhosis (LC) is between 4.5% and 9.5%, the annual incidence of hepatocellular carcinoma (HCC) is around 5.6%, and has an annual mortality rate of 2 million deaths per year. HCC is about the sixth most common cancer worldwide, while CLD, in general, is responsible for 26,151 transplants per year. Worldwide, the common etiologies of CLD are hepatitis B virus (HBV, 43%) infection, hepatitis C virus (HCV, 24%), alcoholic liver disease (ALD, 19%), nonalcoholic steatohepatitis (NASH, 10%), and others (5%). The occurrence of the etiology varies with geographical regions of the world, while HCV, ALD, and NASH are common in Europe and North America, HBV is common in Africa, Asia, and South America. Furthermore, it is predicted that there will be a global increase in nonviral etiology of CLD and a decrease in its viral etiology in the next 10 years. Nwokediuko et al. in a retrospective study in South East, Nigeria, reported that liver disease accounted for 7.9% of medical admissions and HCC and LC accounted for 44.3% and 20.4%, respectively. This study also identified alcohol consumption (52.1%), HBV (49.4%), ingestion of herbs and roots (45.5%), and cigarette smoking (30.1%) as risk factors for CLD. Another study from the South–South zone of Nigeria reported a prevalence rate for HBV and HCV of 62.3% and 12.3%, respectively, among patients with CLD.
A study conducted in this hospital 15 years before this present one reported LC in 41.4%, chronic hepatitis in 37.2% HCC in 15.9%, and alcohol in 4.1% as well as NAFLD in 1.4% of patients. In most African countries, including Nigeria, there is a paucity of reliable statistics regarding the pattern of liver disease admissions, risk factors, and determinants of morbidity and mortality.
The knowledge of liver disease admissions is useful in formulating policies as well as tackling the disease if its changing pattern can be predicted based on available data. This study therefore looked at the pattern as well as the changes over the years of liver disease admissions in our hospital and the indices that are associated with death among patients admitted with liver disease.
| Methods|| |
This was a hospital-based retrospective study of patients admitted into the medical wards of the Obafemi Awolowo University Teaching hospital, Ile-Ife, from January 2013 to December 2017. Case records of patients with a diagnosis of liver disease during the period under review were retrieved and studied. Liver disease was diagnosed using typical clinical features, abdominal ultrasonography, computerized tomography scans, biochemical tests of liver function, serological tests for viral hepatitis, and liver biopsy in varying combinations depending on the clinical context. The combination of tests was tailored to identify categories of liver disease according to the International Classification of Liver Disease (ICD 10, Version 2004) which included acute hepatitis, LC, HCC, metastatic liver disease, liver abscess, abdominal tuberculosis, drug-induced liver injury (DILI), and an unclassified group. Information on biodata and the results of laboratory tests and diagnosis were extracted. Furthermore, information on the length of hospital stay, outcome of admission, including deaths, discharges, and those that were discharged against medical advice (DAMA), and laboratory tests strongly associated with mortality were studied.
Data obtained were entered into computer software and analyzed using Statistical Package for the Social Sciences (SPSS) version 20 software (SPSS Inc., Chicago, IL USA). Simple descriptive and inferential statistics were performed. The results were presented as frequency tables. Categorical data were summarized as frequencies and percentages, while continuous data were summarized as mean ± standard deviation (SD). Chi-square test was used to compare the relationship between two qualitative variables. P < 0.05 at a confidence interval of 95% was considered statistically significant. The study was approved by the Ethics and Research Committee of our hospital with approval numbers: IRB/IEC/0004553 and NHREC/27/02/2009a.
| Results|| |
A total of 5155 patients were admitted into the medical wards during the 5-year period, of them 324 (6.3%) were liver diseases, but 290 cases had their cases records retrieved making it a case record retrieval rate of 89.5% and liver disease admission rate of 6.3%. There were 223 male (76.9%) and 67 female (23.1%) with an M:F ratio of 3:1. The mean age ([SD]) was 46.7 (15.3) years, the median age was 45 years, and the age range was 18–86 years [Table 1]. Majority, (234 [80.7%]), were married and 40 (13.8%) were single, P = 0.005. Majority, (234 [80.7%]) of the patients were admitted via the accident and emergency department, while 56 (19.3%) was through the medical outpatient department (MOPD), P = 0.005. The mean (SD) duration of admission for all cases was 33.4 (26.5) days [Table 1]. The outcome of admission showed that 106 (36.6%) were discharged home, and by sex, they were 75 (70.8%) males and 31 (29.2%) females. On the other hand, 138 (47.6%) comprising 115 (83.3%) males and 23 (16.7%) females died on admission. Those DAMA were 46 (15.9%) that comprised 33 (71.7%) males and 13 (28.3%) females [Table 2].
|Table 1: Sociodemographic characteristics of patients admitted into the medical wards of Obafemi Awolowo University Teaching Hospitals, January 2013-December 2017|
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|Table 2: Outcomes of patients admitted into medical wards of Obafemi Awolowo University Teaching Hospitals, January 2013-December 2017|
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The most common etiology of liver disease was HBV infection (139 [47.9%]), followed by significant alcohol consumption (64 [22.1%]), ingestion of herbs and roots (67 [23.1%]), use of over-the-counter medication (57 [19.7%]), cigarette smoking (24 [8.3%]), and HCV infections (6 [2.1%]). The risk factors for viral hepatitis were scarification marks (137 [47.2%]), multiple sexual partners (98 [33.8%]), past history of jaundice (58 [20%]), injection from unqualified medical personnel (32 [11%]), and family history of HCC (18 [6.2%]) [Table 3]. Liver diseases were observed to be more common in male than in female: 222 (76.6%) versus 68 (23.4%) (P = 0.000). Furthermore, males had higher rates for HCC, LC, and acute hepatitis than females: 116 (75.8%) versus 37 (24.2%); 65 (82.3%) versus 14 (17.7%), and 23 (76.7%) versus 7 (23.3%), respectively (P = 0.525) [Table 4].
|Table 3: Risk factors for liver disease in patients admitted into medical wards of Obafemi Awolowo University Teaching Hospitals, January 2013-December 2017|
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|Table 4: Type of liver diseases among patients admitted into medical wards of Obafemi Awolowo University, January 2013-December 2017|
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The liver diseases were HCC (153 [52.8%]) followed by LC (79 [27.2%]), acute hepatitis (30 [10.3%]), metastatic liver disease (12 [4.1%]), abdominal tuberculosis (4 [1.4%]), and unclassified liver disease (5 [1.7%]), respectively [Table 4].
Mortality was highest in those presenting with symptom duration of between 1 and 6 months (82/138 [59.4%]), particularly among males than females, 67/82 versus 15/82 (P = 0.000), respectively. This was followed by those with symptom duration of >6 months (41/138 [29.7%]), and again, more males than females died, 35/41 versus 6/41 respectively (P = 0.000). Mortality was least in those with symptom duration of <1 month (5/138 [10.9%]). Mortality was higher in patients admitted via the accident and emergency department compared with those from the gastrointestinal clinic MOPD, 113/138 (81.9%) versus 25/138 (18.1%) (P = 0.000) [Table 2].
A statistically significant higher mortality was also observed in those with a high international normalized ratio (INR) >1.3 compared with those with INR less than this figure, P = 0.019, and in those with an elevated creatinine of >110 umol/l compared with those with value less than this figure, P = 0.027. Furthermore, patients who had hypokalemia and those with low albumin also had a statistically significant number of deaths compared with normal values of these parameters [Table 5].
|Table 5: Indices of death among patients admitted into medical wards of Obafemi Awolowo University Teaching Hospitals, January 2013-December 2017|
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| Discussion|| |
The liver disease admission rate from this study was 6.3%, and the patients had a mean age of 46.7 years. This mean age is comparable to an earlier study by Ndububa et al. and that by Nwokediuko et al. Equally, the age range of the study patients also agrees with that of a study from Calabar and Ilorin both in Nigeria., This shows that liver disease in this country occurs between the fourth and fifth decades of life, while in Europe, it is between the fifth and sixth decades of life. The type of liver disease seen in this study also differed from that by Mukherjee et al. in India where liver disease without background cirrhosis was the most common liver disease. The admission rate is also higher than that reported from two European countries., This higher admission rate compared with that from Europe is due to the hepatitis B hyperendemic infection in Nigeria, while alcohol etiology is responsible for those in Europe. More than two-third of our patients were male and this agrees with reports from Nigeria, Europe, and Asia that majority of patients with CLD are male., Male sex is probably a risk factor for CLD, because males are at higher risk of infection with the viral hepatitis and consume more alcohol and in addition, the male sex hormone factors may also play a role. Males have a low level of estrogen which is a potent antioxidant. Estrogen is able to suppress hepatic fibrosis and inhibit the proliferation of hepatic stellate cells as well as differential gene transcription in response to liver injury besides differences in immune regulation which may also contribute.,
The most common etiology of CLD was HBV in 47.9% and this is similar to other reports in Nigeria and West Africa with figures between 36.7% and 64%.,, The high prevalence of HBV in Nigeria is likely due to a low HBV vaccine coverage and practices like scarification marks and injection from unqualified medical personnel which were also found to be high in this study. Alcohol etiology was found to be high at 22.8%, and this value is higher than that reported in Calabar, Nigeria. This high value is however lower than what was reported by Ndububa et al. 15 years ago in this same hospital. This reflected a reduction in the alcohol drinking pattern in our environment.
About 23.9% of our patients used herbs and roots. Some herbs cause direct liver injury such as Teucrium chamaedrys, Senecio vulgaris, Morinda citrifolia, Ephedra sinica, and Mentha pulegium.
In Nigeria, common herbal preparations are obtained from green leaves, bark of mango, shoot of cashew leaf, pawpaw leaf, lime, and potato leaf. Most herbs are prepared in an unhygienic condition and could be water or alcohol based and contains multiple hepatotoxins. Herbal-induced liver injury is similar to DILI and could cause hepatotoxic or cholestatic patterns of liver injury.
Liver disorder is a common cause of death among hospital admissions in Nigeria. Gastrointestinal and liver disorders were the fourth common cause of death after infectious agents in a report from another tertiary hospital in South-West Nigeria. This study recorded 138 (47.6%) deaths among patients with various forms of liver diseases; hence, mortality is high. The mortality figure is more than twice that reported from Pakistan among patients with liver disease. This shows that death due to liver disease is very high in this part of the world. Mortality was observed to be higher in males with symptom duration of 1–6 months and patients admitted via the accident and emergency department as well as in those with elevated INR, creatinine, low albumin, and hypokalemia. This suggests that patients with liver disease decompensation and coagulopathy and those presenting with emergencies and hepatorenal syndrome had higher death rates.
| Conclusion|| |
Liver disease constituted 6.3% of admissions into our medical wards. HCC and LC accounted for more than two-third of all liver disease admissions. Common etiologies were HBV, alcohol, and herbal remedies, while the risk factors were scarification marks, use of sharps, injection from unqualified medical practitioners, past history of jaundice, multiple sexual partners, and family history of HCC. Factors associated with mortality included coagulopathy, elevated creatinine, and low albumin and potassium.
There is a need for public awareness and universal HBV vaccination, discouragement of alcohol and herbal remedy use, and scarification practices, as these will significantly reduce infection from viral hepatitis and consequent liver disease.
The study is limited by the fact that it is a retrospective study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]