INTRODUCTION
Diseases
affecting the Gastrointestinal tract and its accessory organs have become a
public health issue.1 Its variation with geographical locations is
dependent on lifestyle, environmental, and genetic factors.2,3 In
the developed countries, there is an effective data recording and monitoring of
diseases which is deficient in developing countries. Knowledge of the pattern
of Gastrointestinal and liver disease is useful, not only in formulating health
policies and prioritizing health interventions and research, but will also aid
in planning the structure and activities of Gastroenterology units for
provision of standardized patient care.4 Gastrointestinal and liver
diseases are among diseases that show variability in the pattern of their
prevalence, incidence, mortality and morbidity. The burden and outcome of liver
diseases in Sub-Saharan Africa is determined by access to health care,
socioeconomic status, poor sensitization and coverage of HBV vaccination, cultural
inclination to high-risk lifestyle and late presentation of patients, limited
availability of diagnostic and treatment facilities and shortage of trained
specialists. While some countries are still facing challenges with control of
Gastrointestinal infectious diseases, other countries with better economy have
epidemiologically transited from communicable to non-communicable diseases.3
In Africa, Hepatitis B virus (HBV) is a leading cause of chronic liver disease.5
However, the role of hepatitis C virus (HCV) and alcoholic liver disease cannot
be underestimated.6,7 Although
the prevalence of non -alcoholic liver disease(NAFLD) is believed to be low in
Africa compared to developed countries, there could be an under-representation
of the burden of NAFLD considering the rising prevalence of obesity, type 2 DM and HIV which are
recognized risk factors. This study is the first to be done on the pattern and
outcome of Digestive disease admissions in Yenagoa,
Nigeria and will serve as a landmark for other upcoming studies in the area.
Objective
This study was aimed
at determining the pattern and outcome of admissions into the Gastroenterology
unit of Federal Medical Centre, Yenagoa.
METHODS
We retrospectively
reviewed the medical records of patients presenting at the Federal Medical
Centre, Yenagoa, Nigeria over a period of 3 years
from January 2017 to December 2019. The hospital is a major tertiary
institution which serves as a referral centre
for Bayelsans and nearby communities of Delta and
Rivers State. It provides outpatient, in-patient, 24hours emergency services
and other ancillary services to the community. Case records of patients with
various Gastro-Intestinal diseases were retrieved and reviewed for Information
on biodata, diagnosis and outcome. The diagnosis of
the various Gastroenterology conditions was based on ICD-10 classification8
after clinical evaluation and request for laboratory investigations including
liver function test, abdominal ultrasound, serology for hepatitis B and C,
abdominal CT scan, full blood count and α-fetoprotein. These diagnoses
were also confirmed by the specialists, who are also the researchers. Majority
of these patients were either admitted through the accident
and emergency or medical out-patient clinic of the hospital and
transferred to the Gastroenterology unit after initial evaluation. Others were
known patients of the unit who were admitted through the Gastroenterology out-patient
clinic.
Ethical consideration
The study was
approved by the Ethics and Research Committee of the Federal Medical Centre, Yenagoa (FMCY/REC/ECC/2022/499) and all information
gathered in the course of this study was kept confidential.
Data Analysis/calculations
Data was generated
from the medical records and registers in the medical wards. The data collected
included patients’ socio-demographic information, diagnosis at admission,
medical specialty involved in the management of the patient and outcome of the
admission. Patients who had incomplete
information were excluded. Data obtained were analyzed using the SPSS version
22.9 Continuous variables were compared using student T-test and
presented as mean± standard deviation, while Categorical variables were
compared with chi-square test and represented as proportions. P value of
< 0.05 was considered significant.
RESULTS
Sociodemographic and trends of admission into the Gastroenterology unit.
During the study period, Gastroenterology admissions
accounted for 207(11.7%) of all medical admissions (1782)
There were
more males than females with a ratio of 1.3:1. The ages of the patients admitted
ranged from 18 years to 83 years. The 5th and 6th decades
accounted for majority of the admissions while the least prevalence was above
the 7th decade as illustrated in table 1
DISCUSSIONS
Diseases
affecting the gastrointestinal tract accounted for 207(11.7%) of all medical admissions(1782) over the 3-year study period. This is
slightly higher than the prevalence of 7.9% reported by Nwokediuko
et al.4 This can be explained
by the differences in the population of patients studied. Their study was on
pattern of liver disease admission and hence patients with other
gastrointestinal disorders were excluded. Generally, more males were admitted
into the medical wards compared to females and this is consistent with the
findings in other studies.2,4 Males are
more likely to abuse alcohol and substances that may have a negative impact on
their overall well-being or it could be that they generally have a better
health seeking behaviour. In this study, diseases of the liver accounted for
the majority of the digestive disease admissions with alcoholic liver disease
being the most prevalent. The high burden of liver diseases in sub-Saharan
Africa can be attributed to chronic HBV, HCV and alcohol ingestion. In Nigeria,
the burden of alcoholic liver disease is more likely to be more among the Niger
Deltans, because there is a cultural inclination to
excessive alcohol consumption.10 Chronic
consumption of alcohol produces a variety of hepatic lesions. Hepatic steatosis is the earliest feature of alcoholic liver
disease that develops in more than 90 percent of drinkers
who consume 4–5 standard drinks per day.11However, with continued
drinking, there is a gradual progression to steatohepatitis,
fibrosis, cirrhosis, and hepatocellular carcinoma. In the present study, a
significant number of patients had unexplained liver disease (12.6%). This is
similar to an Ethiopian study where a high prevalence of unexplained liver
disease was also reported.12 This could be as a result of limited
use of liver biopsy to detect the aetiology of liver diseases, owing to its
associated risk of complications and sampling error.13 In a recent
meta-analysis by Mecuria et al,14 aflatoxins were
significantly associated with liver cirrhosis and therefore could contribute to
the majority of idiopathic liver disease in Sub-Saharan Africa.14 The
increased ingestion of herbal supplements and hepatotoxic recreational drugs also
predispose to cryptogenic liver diseases in Africa.12 The prevalence
of NAFLD in this study is low despite the global rising trend of obesity.
Clinically, the differentiation between ALD and NAFLD is usually by history
taking including patient’s alcohol consumption as well as laboratory and
imaging; however, these methods are not always reliable.15 The 2nd
leading cause of Digestive disease admission were diseases of the upper GI
tract with upper gastrointestinal bleeding being the most common. Peptic ulcer
disease is a frequently cause of upper
gastrointestinal bleeding in Gastroenterology practice9,16 The low
prevalence of endoscopically diagnosed peptic ulcer
disease and acute gastritis in this study, mirrors the impact of the severity
of medical illnesses to the physicians’ decisions on admission of patients.
Therefore, cases of acute gastritis and acute exacerbation of peptic ulcer
disease were more likely to be discharged from emergency room for follow-up at
gastroenterology clinic. In this study, the prevalence of GI neoplasms and
infections are low, which is inconsistent with a population-based study in
Hong-Kong, where both conditions contributed significantly to hospitalization.17
The disparity with the findings in an Asian country portrays the cultural and
geographical variations in the pattern of digestive diseases.
The highest number of admissions was
recorded in 2019 (37.1%), the year, 2018 had the lowest number of admissions
(29.5%) as well as the highest mortality (27.9%). This could be attributed to
incessant industrial actions which corresponds to the
findings by Guiliano et al 18 in low-income countries. Strike is a common
occurrence in the Nigerian health sector associated with increased mortality
and morbidity, as well as a significant decline in patients admission19,20 Cumulatively, diseases of the liver were the
commonest cause of mortality among the admitted patients. Chronic liver disease
associated with liver cirrhosis is a major cause of morbidity and mortality
globally. It is responsible for 1-1.3million deaths annually.21,22
and reported as the 11th most common cause of death worldwide.15
Decompensated chronic liver disease has a poorer prognosis because of an
increased risk of complications such as variceal
bleeding, hepatic encephalopathy, ascites, spontaneous bacterial peritonitis
and hepato-renal syndrome.23 The mortality
from upper Gastrointestinal bleeding which is 18.5% in our study, is similar to
the reported mortality of 18.7% in a Tanzanian study.24 Age, high
rock all scores, severity of bleeding, co-morbidities and hemodynamic
compromise are predictors of severity in UGIB.24,25 Inflammatory bowel
disease was also a major cause of mortality, although the population of
patients who were diagnosed with IBD cannot be used to make a reasonable
scientific conclusion. There is an increasing burden of inflammatory bowel
disease (IBD) globally, with substantial variation in levels and trends of
disease in different countries and regions.26 However studies on the
true prevalence of IBD is still lacking in Nigeria. The patient who died of
gastroenteritis associated complications also had background HIV infection. The
gastrointestinal tract is an accessible site for clinical expression of HIV, Diarrhoea
is one of those varied presentation whose severity and overall mortality is
dependent on the level of immunosuppression.27
CONCLUSION
There is
need for public awareness and investment in hepatology
services in Nigeria, considering the enormous burden of gastrointestinal and
liver disease. This should encompass infrastructural rehabilitation,
institution of cancer registries and electronic recoding of patient’s data.
There should also be governmental and non-governmental efforts to reduce the
general consumption of alcohol in Niger Delta, considering its overall impact
on the nature of liver disease admissions.
Limitations
Owing to the
retrospective nature of the study, there were missing and incomplete data and
therefore, these findings may not reflect the actual prevalence of these
medical disorders.
Acknowledgements
The authors wish to appreciate the medical registry and the nurses in the
hospital who assisted in providing the data for this study.
Conflict of
Interest
The authors
declare no conflict of interest.
Funding: There was no funding for this study
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