Clinical Characteristics and Endoscopic Findings of the Patients with Cirrhosis of the Liver in a Tertiary Care Centre in Eastern Nepal

Background Studies on clinical characteristics and upper gastrointestinal endoscopic findings of the cirrhotic patients in a tertiary care centre are sparse from eastern region of Nepal. The aim was to profile these patients clinically and analyse the endoscopic findings. Material and Methods This was a cross-sectional analytical study carried out in the Department of Medicine of Nobel Medical College, Biratnagar from 30 September 2012 to 30 August 2013(one year). After admission, detail medical history and meticulous clinical examination was carried out in every patient with clinical diagnosis of cirrhosis of liver. Routine, biochemical, hematological, imaging and special investigations were sent as per clinical scenario. Upper gastrointestinal endoscopy was carried out in all patients. Basic descriptive statistics were used to present the data. Results A total of 104 patients were enrolled in our study. The mean age was 50.09 years ± 11.79 (Range 26-79), of which 60% were males. Almost 70% of the patients were from productive age group (31-70 years). All the patients were symptomatic. Chronic excessive alcohol consumption was the commonest cause of cirrhosis (80.76%). The major clinical presentations were ascites (83.65%) and jaundice (79.92%). Pedal edema was the commonest (85.6%) presenting sign. Diabetes mellitus and pneumonia were common comorbidities. Gastroesophageal varices were commonest (70.19%) endoscopic finding. Conclusion Cirrhotic patients presented late with complete decompensation in the form of ascites, jaundice and upper gastrointestinal bleeding from esophageal varices. Mostly people with productive age group were affected.


Introduction
Cirrhosis of liver is a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules [1].This has emerged as a major cause of global health burden.It was the cause of 31 million Disability Adjusted Life Years (DALYs) or 1.2% of global DALYs, in 2010 [2].Cirrhosis is among the top causes of death and kills nearly 150,000 people worldwide each year.Alcoholic cirrhosis accounts for nearly (38-50%) of all cirrhosis related deaths.It is the third leading cause of death in people aged between 25-65 years exceeded only by cardiovascular diseases and cancer [3].In Nepal, chronic alcohol abuse is a major public health problem and is the commonest cause of the cirrhosis of the liver [4].Portal hypertension is the major complication and is responsible for the upper gastrointestinal (UGI) bleeding, ascites, hepatorenal syndrome and hepatic encephalopathy.Clinically significant portal hypertension is defined above threshold of 12 mm Hg.Bleeding from the esophageal varices is the most serious complication of portal hypertension with high morbidity and mortality [5,6].Prospective studies have shown that more than 90% of the patients with cirrhosis will develop oesophageal varices sometime in their life and 30% of them will bleed [7,8].Variceal haemorrhage accounts for (10-30%) of all cases of UGI bleeding and accounts for 80-90 % of bleeding episodes in cirrhotic patients [9,10]

Results
During the period of one year, a total of 104 patients with cirrhosis of liver were enrolled in our study.
The above variation in patient's clinical characteristics reported by different studies is probably due to variation in study methodology, geographical location and social-cultural background of the study population.
Regarding stigmatas of chronic liver disease, pedal edema (89%)was the commonest presentation followed by splenomegaly (61%) and pallor (50%) in our study.Nadeem MI et al [16] reported pedal edema in (92%),clubbing (25%), palmar erythema (25%),testicular atrophy (4%), gynecomastia (4%),pubic hair loss (2.4%), parotidomegaly (1.2%),spider naevi (1.2%).Tung T et al [25] found hepatomegaly in (70%), splenomegaly 35-(50%).In our study, chronic alcohol abuse was the commonest cause of cirrhosis (80.76%) followed by chronic hepatitis B virus infection (5.76%) and chronic hepatitis C virus infection (2.8%).In nearly (8%), no cause was found.During the investigation of etiology of the cirrhosis, not all the patient afforded all investigations and few tests were unavailable.Rare cause might have been missed and included in the cryptogenic group.Walsh K [29] found alcohol as a cause of cirrhosis in 80% cases.Morea Ret al [30] found alcohol as cause in (67%), chronic hepatitis C in (15%), combination of chronic hepatitis C and alcohol in (15%) and chronic hepatitis B in (3%).Riepe SP et al [31] reported alcohol as cause in (65%).Mendez-sanchez N et al [32] found alcohol in (39.5%), chronic hepatitis C in (36.6%), chronic hepatitis B in (5%) and cryptogenic in (10.4%).Some of the above findings corroborate with ours whereas some findings donot.Chronic viral infections are increasing in our society adding on or replacing alcohol as a major cause of cirrhosis.Diabetes mellitus, pneumonia and ischemic heart disease were common comorbidities in our study whereas Morea R et al [30] found hypertension, diabetes and ischemic heart disease as common comorbidities in their study.In our study of UGI endoscopic findings, gastro-oesophageal varices were noted in (70.19%) of the patients, congestive gastropathy (3.84%), gastric ulcer (5.8%) and normal (10.57%).Bunay K D et al [26] found gastro-oesophageal varices in (93.3%).Khuram M et al [33] studied 299 patients who underwent UGI endoscopies and gastro esophageal varices were found in (84.6%) patients.They also noted congestive gastropathy in (11%), gastric ulcer in (0.2%), normal endoscopic findings in (14.7%) which is probably due to larger number of cases in their study.Eighteen percent patients died in hospital in our study, the death rate could have been higher because few serious patients left hospital without medical advice and few referred to other centers because of various reasons.

Conclusion
Most of the patients presented late in decompensated state and many were continuing to consume alcohol just before hospital visit which is preventable cause of cirrhosis.Properly planned health education regarding harmful effects of alcohol and hepatitis B and C infection should be implemented in the community.