Trends of Chronic Liver Disease in a Tertiary Care Centre in the Eastern Part of India: A Retrospective Study

Aim of the study: To assess the relationship between the severity of liver cirrhosis and its outcomes based on laboratory parameters, Child-Turcotte-Pugh (CTP) score, and upper gastrointestinal (UGI) endoscopy findings. Background: Cirrhosis is the end stage of chronic liver disease (CLD) and is characterised by progressive liver fibrosis and distortion of the liver architecture. It is a major cause of morbidity and mortality all over the world. Cirrhosis is compensated in the initial stages and later progresses to the decompensated stage with various complications. The CTP scoring system predicts mortality in patients with cirrhosis. Materials and methods: This retrospective study was done in the Department of Medicine and Gastroenterology of Tata Main Hospital (TMH), Jamshedpur, Jharkhand, India. It was conducted over a period of two years between 1 January 2019 and 31 December 2020, on 150 confirmed cases of cirrhosis. Results: The most common age group was 41-60 years (86, 57.33%) and the mean age ± standard deviation (SD) for all patients was 49.82 ± 11.63 years. In a total of 150 CLD cases, males were 96 (64%). The most common cause of CLD was alcohol (76, 50.67%). Based on presenting symptoms, most CLD patients presented with generalized weakness (144, 96.00%). The most common signs were icterus (68, 45.33%) and ascites (44, 29.33%). Most patients belonged to CTP class A (77, 51.33%), followed by CTP class B (44, 29.33%) and class C (29, 19.34%). The most common UGI endoscopy finding was portal hypertensive gastropathy (mild or severe) (135, 75%). Total deaths were 24 (16.00%), with 17 deaths (70.83%) in patients belonging to CTP class C. Conclusion: CLD is a common entity in eastern India with male preponderance and affects mostly people of the middle age group. Alcohol intake is a major cause of CLD, followed by non-alcoholic fatty liver disease and chronic hepatitis B and C. A significant rise in morbidity and mortality due to alcoholic liver disease (ALD) was observed in the study and needs urgent social and medical intervention. The incidence of ALD in our study was 50.67%.


Introduction
Cirrhosis is one of the most frequent causes of death due to hepatic diseases worldwide. Approximately two million deaths occur per year due to liver diseases, one million due to complications of cirrhosis and one million due to viral hepatitis and hepatocellular carcinoma [1]. Cirrhosis is currently the 11th most common cause of death globally [1]. The structural integrity of the liver is disrupted in cirrhosis and there is progressive replacement of the liver parenchyma by the fibrous tissue. Cirrhosis can be compensated or decompensated. The majority of patients are asymptomatic in the compensated stage and diagnosis at this stage is typically picked up during routine medical visits for other conditions. The mortality and morbidity caused by cirrhosis dramatically rise after decompensation takes place, and the one-year case-fatality rate might reach as high as 80% depending on the cause of decompensation. Lastly, there are only two outcomes for patients, i.e., death or cure by liver transplantation, which impose a heavy financial burden on individuals, healthcare systems, and health spending and governance [1].
Globally, 1.6 billion people had chronic liver disease (CLD) in 2017, with non-alcoholic fatty liver disease (NAFLD) (60%), hepatitis B virus (HBV) (29%), hepatitis C virus (HCV) (9%), and alcoholic liver disease (ALD) (2%) being the most frequent causes. Additionally, cirrhosis contributed to more than 132 million (95% UI:   1  2  3, 4  1  5 127-145) deaths worldwide in 2017, with 883,000 (838,000-967,000, 66.7%) deaths among men and 440,000 (416,000-518,000, 33%) deaths among women. This is a significant increase as compared to 1990 when the total deaths from CLD in both sexes were 899,000 (829,000-948,000 Recent research has demonstrated that systemic inflammatory response syndrome (SIRS), with or without a confirmed bacterial infection, is an independent predictor of survival in critically unwell cirrhotic patients and is also linked to the emergence of problems caused by portal hypertension. In individuals with cirrhosis who develop multiorgan failure, liver function does not appear to be the primary driver of prognosis. In patients with severe or advanced cirrhosis, conventional measures for detecting SIRS lack sensitivity and specificity because of hypersplenism, hyperventilation coupled with encephalopathy, hyperkinetic circulation, and the use of beta-blockers [3]. To predict mortality in CLD patients, the Child-Pugh scoring system, also called the Child-Turcotte-Pugh (CTP) score, was developed. To help in the identification of patients who would benefit from elective surgery for portal decompression, Child and Turcotte first proposed the idea in 1964 [4]. The CTP score is based on five factors, including ascites, hepatic encephalopathy, prothrombin time or international normalized ratio (INR), serum albumin, and serum bilirubin level, which are among the three laboratory criteria and two clinical criteria. The CTP scoring system divides patients into three categories: class A (five to six points), class B (seven to nine points), and class C (10-15 points) [5]. With the use of the CTP score and upper gastrointestinal (UGI) endoscopy results, our study attempted to identify patterns in the relationship between laboratory results and the severity of liver cirrhosis and their association with outcomes.

Materials And Methods
This retrospective study was done at the Department of Medicine and Gastroenterology of Tata Main Hospital (TMH), Jamshedpur, Jharkhand. It was done over 150 confirmed cases of CLD admitted to the Department of Medicine and Gastroenterology between 1 January 2019 and 31 December 2020. The cases were diagnosed by ultrasonogram (USG) of the whole abdomen, UGI endoscopy, clinical features, and laboratory investigations. USG findings of CLD included shrunken liver with a nodular surface, ascites, and splenomegaly. Laboratory investigations suggestive of CLD were reversed albumin-globulin ratio with low albumin levels and deranged INR. Their records were retrieved from the hospital management system (HMS), a database of the patients coming to the TMH. Inclusion criteria included cases of CLD (compensated or decompensated) above the age of 18 years. Exclusion criteria included the existence of any concurrent infectious or systematic inflammatory diseases, significant haematologic disorders, thyroid dysfunction, and/or severe renal insufficiency (end-stage renal disease or chronic dialysis treatment) and non-hepatic malignant tumours and patients on warfarin, steroids, and hormone replacement therapy.
Clinical findings, laboratory investigations, including complete blood counts, liver function tests, kidney function tests, serum electrolytes, coagulation parameters (prothrombin time and INR), blood sugar, autoimmune profile, hepatitis B surface antigen, anti-HCV antibody, HBV DNA quantitative, and HCV RNA quantitative (where required), USG of the abdomen, chest X-ray posteroanterior view, ascitic fluid, total leucocyte count (TLC), differential leucocyte count (DLC), cultures, serum ascites albumin gradient (SAAG), and UGI endoscopic data were all collected. The statistical analysis was completed using Statistical Package for Social Sciences (SPSS, IBM Corp., Armonk, NY) and Microsoft Excel (Microsoft Corporation, Redmond, WA). The Student's t-test and the chi-square test were employed in the data analysis to compare continuous and dichotomous variables, respectively. Descriptive statistics were also used as necessary. To investigate distributional differences, the data were tabulated and presented as frequency (n) and percentage (%), and the continuous parameters were presented as mean ± standard deviation (SD). The correlation of different CTP classes with outcomes was done with a one-way ANOVA method. Statistical significance was determined to be a p-value of 0.05 or less. Informed permission was acquired from participants before they were enrolled in our research.

FIGURE 1: Gender distribution of studied CLD patients.
CLD: chronic liver disease.
The most common UGI endoscopy findings in the present study were portal hypertensive gastropathy (mild or severe) (135, 75%) and grade I varices (63, 42%) (  Means and SDs of serum bilirubin, serum albumin, alanine transaminase (ALT), aspartate aminotransferase (AST), haemoglobin, WBC, platelets, INR, serum creatinine, and serum electrolytes in different CTP classes were evaluated and it was found that all findings were statistically significant with p-value < 0.001, but serum creatinine and serum potassium levels showed statistically insignificant results ( Table 6).  The total number of deaths in the present study was 24 (16.00%). A total of 17 (58.62%) deaths belonged to CTP class C and seven deaths (18.92%) belonged to CTP class B ( Table 7). There were no deaths in CTP class A. The survival in CTP classes A, B, and C was 100%, 81.08%, and 41.38%, respectively.

Discussion
This was a retrospective study conducted on 150 CLD patients visiting a tertiary care centre over a period of two years. The most common age group was 41-60 years (86, 57.33%), followed by 21-40 (43, 28.67%) and 61-80 years (11, 07.33%  [11]. Thus, the male preponderance of cases of CLD in our study matches those of other studies and this was probably due to higher alcohol-related CLD in males. In the present study, the most common cause of CLD was alcohol (76, 50.67%), followed by NAFLD (37, 24.67%). Hepatitis B, hepatitis C, cryptogenic, and autoimmune CLD cases were 11 (07.33%), seven (04.67%), 15 (10.00%), and four (02.66%), respectively. Sreenivas et al. showed that out of 50 CLD cases, alcohol was the aetiological factor in 41 patients, HCV infection in three patients, HBV infection in one patient, alcohol and HBV in three patients, and alcohol and HCV infection in one patient, respectively [6]. In contrast to the present study, Sungkar et al. enrolled 54 patients with cirrhosis and found that HBV infection (53.7%) was the major infection followed by an unknown causative agent (non-B and C) in 44.4% of patients [8]. Also, Acharya et al. showed that among 171 patients, end-stage liver disease was caused by alcohol in 88 (51.46%) patients and by both alcohol and a virus in 11 (6.43%) patients. A pure viral aetiology was present in 51 patients (29.82%), i.e., hepatitis B in 36 cases (21.05%), hepatitis C in 11 cases (6.43%), hepatitis B + C in three cases (1.75%), and hepatitis B + A in one case (0.58%) [9]. End-stage liver disease was due to nonalcoholic steatohepatitis in 13 (7.60%) patients, autoimmune hepatitis in seven (4.09%) patients, and Wilson's disease in one (0.58%) patient [9].