Pattern of Liver Diseases

Results: Male to female ratio was 2.3:1. The mean age was 41.9 (SD 14.8). Median hospital stay was 8.0 days (Q25-75 6.0-12.0). The top three diseases were alcoholic liver disease 50 (38.5%), viral hepatitis 44 (33.8%), and liver abscess 11 (8.5%). Fifty (38.5%) patients had acute, 74 (56.9%) had chronic liver disease and 6 (4.6%) were malignancy. The main cause of acute disease were infections 41 (82.0%) especially Hepatitis E Virus (HEV). HEV was associated with acute liver failure and pregnancy which was 4 (18.2%) and 2 (12.5%) respectively. Chronic diseases were caused by alcohol 45 (60.8%) followed by infection of hepatitis B and C viruses 11 (14.8%). Cirrhosis was diagnosed in 37 (28.5%) with alcohol as the main cause.


METHODS
A retrospective study involving all consecutive patients admitted to the Liver Unit of Bir Hospital from April 13,  2008 to October 16, 2008 was conducted.After institutional approval data was entered and analyzed.Demographic profi le and the pattern of liver diseases were studied in relation to acute or chronic based on duration and the presence of portal hypertension (PHTN) or cirrhosis; etiology viz.alcohol, infections, autoimmune, mixed in patients more than one agent capable of causing liver damage, malignancy, cholelithiasis and miscellaneous; geographical location based on district of residence; months of hospital stay; gender and age.Patients were grouped into Brahmins, Chettris, Newars, Tibetomongoloids including Magar, Gurung, Sherpa, Rai, Limbu and Lama, and indigenous groups including Tharus.The duration of hospital stay was also calculated using date of admission and date of discharge.Descriptive analysis was used to calculate frequencies, percentage and relations.The data was analyzed using Microsoft offi ce Excel 2007 and statistical packages for social sciences SPSS version 16.0 for windows.

RESULT
There were 130 patients admitted during the study period.Among them 91 (70%) were males and 39 (30%) females with the ratio of 2.3:1.The mean age of patients was 41.9 (Standard Deviation 14.8) with minimum and maximum being 18 and 89 respectively.In decreasing frequency patients fell in the following age groups: 33 (24.81%) in 41-50 years followed by 29 (22.30%) in age 31-40 years and 25 (19.23%) in age 21-30 years.
The main cause of acute liver disease was infections (viral hepatitis and liver abscess) constituting 41 (82.0%) (Table 4).There was one (2.0%)patient with acute viral hepatitis complicated with herbal medicine (Table 5).There were two (4%) patients diagnosed as peptic ulcer disease with urinary tract infection and missed abortion with hepatic dysfunction (Table 4).
Among the 37 cases with cirrhosis the main cause was alcohol (Table 6).One study has reported that the most common cause of Acute liver diseases is Infection and Chronic Liver Diseases are Alcohol, HBV and HCV. 3 However community prevalence of HBV and HCV infection in Nepal are low. 3ith comparison to this fact our study shows similar result with 41 infectious liver diseases among 50 Acute cases and 45 Alcoholic liver diseases among 74 Chronic cases.

Pattern of Liver
The most common cause of Cirrhosis in our study is Alcoholic Liver disease 28 (75.7%).In the United States, Alcohol accounts for 80% of Cirrhosis. 5Hepatitis B is predominant cause of Cirrhosis in China, Southeast Asia and Africa. 6,7In contrast to this, our study shows that Hepatitis B is the third common cause for Cirrhosis.However HBV and HCV accounts for 40% and 14% of the Cirrhosis in Nepal respectively. 8thmandu valley is a hyper-endemic area for hepatitis E, where during last 30 years three large epidemics and many focal outbreaks have occurred. 9About 56% of the sporadic cases of acute hepatitis in Kathmandu valley are caused by hepatitis E. 10 One of the study carried out by infectious Diseases Unit shows that majority (95.4%) of HEV patients were from developing countries which included 69.5% patients from Nepal, 52.7% from Bangladesh, 48.8% from India and 30.7% from Pakistan. 11mong the 56 cases due to infection, hepatitis E virus (HEV) was most common cause followed by Liver abscess, hepatitis B virus (HBV) and Hepatitis C virus (HCV).It was found that all the cases of HCV were associated with CLD.
Almost all Nepalese get infected with Hepatitis A by the age of fi ve years usually asymptomatically and develops lifelong immunity. 12In our study total 6 (10.7%) cases of acute viral hepatitis were unidentifi ed, this may be probably due to hepatitis A. There was 1 (1.8%) coinfection of HBV and HEV and 1 (1.8%) of liver abscess and HCV.One (1.8%) of the CLD case was associated with Herpes simplex virus infection.
Among 130 cases, most of the patient, 30 (23.1%), came from Kathmandu district, 8 (6.2%) from Bhaktapur.The geographic pattern of liver disease is known to vary widely 3 however this observed pattern in our study is probably due to proximity and easy accessibility to the centre.The presence of patients from far fl ung districts is probably due to the fact that Bir hospital is a well known tertiary care centre.
As the study design was retrospective, secondary data was taken from case fi les which were not always uniform and sometimes incomplete which had become one of the limiting factors of our study.

Pattern of Liver Diseases
The study period is only six months and fails to include winter months which probably accounts for the lack of temporal difference in etiology of acute liver disease.

CONCLUSION
The liver disease has been seen more in male that too in early forties which indicates that there is large disease burden in the community.Average length of hospital stay was more than a week.The top three diseases observed in the study population were ALD, viral hepatitis, liver abscess.Majority of cases had CLD.The most common cause was alcohol, followed by HBV and HCV infection.Among acute cases there was a preponderance of infectious viral hepatitis especially HEV.Based on the study, the liver unit should plan priority programs to deal with alcoholic liver disease and acute viral hepatitis.There should also be educational programs to raise awareness about HEV, HBV and HCV and prevention of their transmission.An initiative needs to be taken to reduce alcohol at various levels through awareness campaigns, strict control and legislation to limit the further abuse.

Table 2 .
Diseases in decreasing order of frequency

Table 5 . Diagnosis of patients with liver disease due to mixed etiology
* ATT = Anti Tubercular Therapy