Journal of Rawalpindi Medical College Students Supplement; 2015:19(S-1):17-20
Original Article
Hepatic Cirrhosis - Disease Burden
Syed Muhammad Ali Shah*, Syeda Aimen Mashia*,Muhammad Faizan Younus* Aliullah Ghauri*,
Ramzan Ejaz*,Hammam Alshalabi *, Imran Khan Kakar*, Muhammad Umar**
*Final Year Medical Student, Rawalpindi Medical College;**Department of Medicine,
Holy Family Hospital and Rawalpindi Medical College, Rawalpindi
Abstract
Background: To evaluate the burden of hepatic
and gastrointestinal diseases, with a special
emphasize on hepatic cirrhosis, in a medical ward.
Methods: This cross sectional descriptive study
was undertaken to evaluate the disease burden of
the liver and gastrointestinal diseases, from January
2013- December 2013. Ward admissions, emergency
room audits and mortality analysis was evaluated.
The frequency of admission, presentation, and
mortality along with percentages were determine to
highlight the burden of cirrhosis on our health care
setup.
Results: Of the 3570 patient admitted in ward 963
(27%) had gastroenterological pathologies, 652/963
(68%) having decompensated chronic liver
disease(DCLD) , emergency had 2617 (10%) liver
ailment cases reporting with 2388/2617 (92%) having
DCLD. System wise mortality analysis showed that
of the 712 patient 241(33.8%) died of hepatobiliary
causes (34%) with DCLD causative in 189/241
patients (78.4%)
Conclusions: The high frequency of hepatic
pathologies, and late presentation with
decompensation signify the burden.
Key Words: Hepatitis C, Cirrhosis
Introduction
Cirrhosis is defined histologically as an advanced
form of progressive hepatic fibrosis with distortion of
the hepatic architecture and regenerative nodule
formation.1,2 Exact prevalence of cirrhosis worldwide
is unknown, but is reasonably estimated to be around
1%.3 Sizable proportion remain undiagnosed and is
still frequently an autopsy finding.4 Most prominent
cause of cirrhosis are chronic viral hepatitis, prolonged
excessive alcohol consumption and Non-alcoholic fatty
liver disease with great regional variation. 5 In Pakistan
studies attribute Hepatitis as predominant cause of
cirrhosis with Hepatitis C Virus (HCV) responsible for
41%-52%, followed by Hepatitis B Virus (HBV) for
30% of the cases.6
17
Age, gender, race, and viral immune response and
others influence rate of chronic HCV infection with
approximately 75%-85% of progressing to chronic
HCV infection and 20% to cirrhosis 7.Global estimate
put 350million people chronically infected with HBV
and 180-200 million with HCV around 3% global
population8-10.Estimated 75% of patients with Chronic
Hepatitis C remaining undiagnosed.11Majority (70%-
80%) of the persons with chronic hepatitis C have no
symptoms with only 15% developing acute
symptoms.12, 13 The disease distribution is uneven
throughout the world 14, 15.In Pakistan HCV is now
more common as compared to HBV, and a high
frequency of HCV seropositive individuals referred for
chronic liver disease.16,17 Pakistan has the 2nd highest
rate of chronic infection with more than 10 million
people are living with HCV18. Pakistan Medical
Research Council national general population survey
2007-2008 calculated HBsAg as 2.5% and HCV as 4.8%
in general population, making a combined infection
rate of 7.6%.15 Ahmed K estimated 5-8% and 7- 10% of
people as suffering from hepatitis B and C,
respectively terming it the shadow epidemic of
Pakistan.19
Patients and Methods
This cross sectional descriptive study was
undertaken to evaluate the disease burden of the liver
and gastrointestinal diseases in Holy family hospital,
Rawalpindi, from January 2013- December 2013. Ward
admissions, emergency room audits and mortality
analysis was evaluated. The frequency of admission,
presentation, and mortality along with percentages
were determine to highlight the burden of cirrhosis on
our health care setup data was analyzed on SPSS v22.
Results
Of the 3570 patient admitted in ward in 2013, 963
(27%) had liver diseases, with 68% (652) having
decompensated liver disease highlighting that more
than of the ward admission had liver ailments,
similarly emergency reported 2617 (10%) liver
pathology cases with 92% (2407) having DCLD (Table
Journal of Rawalpindi Medical College Students Supplement; 2015:19(S-1):17-20

1 to 3). Mortality analysis system wise analysis showed Discussion

that of the 712 patient 241 died of hepatobiliary causes About a decade back Ahmad K in the Lancet wrote
(34%) with DCLD causative in 189 patients (Table 4). Pakistan as the cirrhotic state terming hepatitis The
Shadow Epidemic but without original research
Table 1: Liver pathologies-Disease Burden results to back him, is the claim cannot be adequately
Total Liver Decompensated established.19 Researches on the disease burden of
diseases liver disease liver diseases in Pakistan are few and far in between,
No(%) No(%)
although numerous review article are available on the
Ward 3570 963/3510 (27) 652/963 (68)
subject internationally. 20In spite of the rapid progress
Emergency 26668 2617/26668(10) 2407/2617 (92) in HCV virology and pathogenesis, still little is known
Mortality 712 241/712 (34) 189/712 (78.2) about its current and future burden throughout the
world.21
Table 2: Hepatic and gastrointestinal diseases- Our 1 year data on the burden of liver disease
Ward distribution (n=963) indicates it as a predominant cause of hospital
Disease No(%) admission (27%) followed by Cardiovascular condition
Decompensated chronic liver disease 655(68) (16.2 %), contradicting sharply with the international
Acute gastroenteritis 153(16) studies indicating cardiovascular diseases as the most
Upper gastrointestinal bleed 48(5) common hospital admission pathology (Australia 29%
Enteric fever 29(3) Hong Kong 30.3%).22-24 Review of Pakistani literature
Acute viral hepatitis 29(3) verifies liver diseases as a frequent cause of admission
Liver abscess 19(2) in our local hospitals.25,26 Ten percent emergency
Jaundice 10(1) room cases report with liver diseases.
Acute peptic disease 10(1) More alarming is the result that 68% of the ward
Inflammatory bowel disease 10(1) admissions, and 92% of ER liver patients presented
with complications of CLD which defies the
international trend but is consistent with the regional
Table 3: Hepatobiliary disease-Emergency room
literature.27 This can be owing to the majority of
distribution
patient having non-specific symptoms, and thus
Disease Percentage
developing complications of cirrhosis and could also
Chronic liver disease 2407(92) be attributed to non-treatment because of the expenses
Acute viral hepatitis 89(3.4) involved.28 According to present study 34% of the
Chronic active hepatitis 62(2.3) total fatalities were attributed to liver ailments, while
Hepatocellular carcinoma 15(0.6) WHO factoid states non-communicable disease as
Liver abscess 13(0.5) responsible for 68% mortality worldwide in 2012, with CVS
Fulminant hepatic failure 26(2.6) at the helm, having 3 in 10 deaths attributed to it. Liver
Obstructive jaundice 5(0.2) diseases wasnt present in the top ten mortality causes,
but regional and economic factors lead to substantial
Table 4: Hepatic and gastrointestinal diseases- variation in causes of death.29
Mortality (n=241) It is evident from the above results and after
Disease No(%) reviewing the national and international literature that
Decompensated chronic liver 189(78.42) the burden of liver disease in our country is
substantially higher than the world. These statistics
disease
highlight liver diseases as a major health concern in
Acute fulminant failure 19(7.88) Pakistan, thus authorities should formulate vigorous
Hepatocellular carcinoma 14(5.8) programs to prevent disease transmission in our
Obstructive jaundice 7(2.9) country, and evaluate the programs already running.
Chronic pancreatitis 5(2.07) Although etiology is unexplored in our study,
Carcinoma pancreas 3(1.2) chronic hepatitis has been attributed unanimously as
Cholangiocarcinoma 2(0.8) the leading cause of chronic liver disease,
Carcinoma gall bladder 2(0.8) cirrhosis, liver-related morbidity and
mortality worldwide and especially in Pakistan,

18
Journal of Rawalpindi Medical College Students Supplement; 2015:19(S-1):17-20
predisposing to fibrosis and end-
stage liver complications 6,9,30-33
Numerous studies attribute substantial health care
resources and very high cost to treatment of liver
disease associated with chronic hepatitis C
worldwide.34, 35Pakistan being the 6th most populous
country in the world, and with an extremely limited
health budget. Hepatitis C health and economic
burdens likely affects all the health sector negatively.
Estimation of the problem regionally is likely to guide
better management programs and prevent
complications. 34, 36 Kanwal F et al estimate prevalence
of cirrhosis and decompensated cirrhosis patients
more than doubling from 1996-2006, whereas Hepato-
Cellular-Carcinoma(HCC) is increasing approximately
20-fold (0.07% in 1996 to 1.3% in 2006). The cause for
concern is whether the disease is still increasing 38
unchecked or have we succeeding in retarding its
rampant onslaught. 37
Although present study is a limited regional effort
in this regard, a country wise liver disease burden
should be estimated to determine red zones and efforts
should be focused for better utilization of health
resource in a country like Pakistan.
Recommendation of adding hepatitis to notifiable
disease, adoption of safe injection practices, screening
for HCV as being cost affective are all down the line
once we can estimate the acuteness of the problem.34
Since the ailment is preventable and treatable, with
true commitment, dedication and effective resource
utilization, we hope that hepatitis can be preferentially
prevented rather than treated since it much more cost
effective for underdeveloped country like ours. 33 With
the real cost of treatment in excess of tens of thousands
of dollars and limited efficacy and side effects push
the treatment out of reach of the government and the
people, 39,40. The need is for mass procurement of
cheaper newer anti HCV drug and devising extensive
prevention programs for hepatitis C to curtail the
smouldering epidemic before it consumes a nation.
Conclusion
1.Pakistan has 2nd highest estimated prevalence of
hepatitis C worldwide, with very high frequency of
cirrhosis.
2.Liver pathologies especially cirrhosis is a major
burden on our health care facilities, reaching to
epidemic level, and a major mortality case in our
setting.
3. As the disease is preventable with cure being
expensive and partly successful. We need to undertake
concrete measure for primary prevention. If due
19
measures are not undertaken the problem would soon
swell to unmanageable proportions.
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