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ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 228-231  

Study of clinical, laboratory, and upper gastrointestinal endoscopic profile in patients of alcoholic liver disease in Sikkim


Department of General Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Amit Kumar Jain
Department of General Medicine, Central Referral Hospital, 5th Mile, Tadong, Gangtok - 737 102, Sikkim
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_146_17

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  Abstract 


Background: Alcoholic liver disease (ALD) is the most common liver disease in India, caused by excessive intake of alcohol even though being a preventable disease. The three principal types of ALD are fatty liver, alcoholic hepatitis, and cirrhosis. Objectives: Study of clinical presentation, laboratory parameters, abdominal sonographic and upper gastrointestinal endoscopic findings, and complications in patients of ALD in Sikkim. Methods: Descriptive observational hospital-based study was carried on 100 ALD patients admitted in Department of General Medicine in a teaching hospital of Sikkim, who fulfilled the inclusion criteria. Data were tabulated and analyzed using IBM-SPSS statistics version 22 software. Results: The mean age was 48 years with majority being males (84%), occupied in unskilled work (67%), with lower education level (52%), and belonging to middle socioeconomic status (56%). The average intake of alcohol by males was 63 g/day, and in females, it was 40 g/day with average duration of alcohol intake being 16 years. Most common presenting features were nausea (90%), jaundice (67%), and anorexia (64%). The mean total bilirubin (mg/dL), aspartate aminotransferase (IU/L), alanine aminotransferase (IU/L), serum albumin (g/dL), and prothrombin time difference (seconds) were 4.74, 110.2, 59.1, 3.4, and 4.1. Abdominal sonography revealed ascites (53%) and cirrhosis (43%), and upper gastrointestinal endoscopy revealed varices (52%) as common finding. The most common complications were gastrointestinal bleeding (54%) and portal hypertension (51%).
Conclusions: Due to high mortality and morbidity associated with this preventable liver disease along with a multidisciplinary approach to tackle this alcohol menace, a sound regional knowledge of clinical presentation and workup findings can help in effective treatment strategies of the same.

Keywords: Alcoholic liver disease, profile, Sikkim


How to cite this article:
Rishi, Jain AK, Nandy P. Study of clinical, laboratory, and upper gastrointestinal endoscopic profile in patients of alcoholic liver disease in Sikkim. Med J DY Patil Vidyapeeth 2018;11:228-31

How to cite this URL:
Rishi, Jain AK, Nandy P. Study of clinical, laboratory, and upper gastrointestinal endoscopic profile in patients of alcoholic liver disease in Sikkim. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2021 Jun 12];11:228-31. Available from: https://www.mjdrdypv.org/text.asp?2018/11/3/228/235552




  Introduction Top


Alcohol is a major cause of liver disease worldwide. Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis.[1] It is the oldest form of liver injury known to humankind with evidence suggesting that fermented beverages and associated liver disease existed at least as early as the Neolithic period.[2]

Alcohol use is intricately woven into the lifestyle of the Sikkimese population, be it in weddings, social gatherings, and so on. Abuse of alcoholic drinks by certain vulnerable members of the society and the resultant health problems are causes of concern. Data show about 20%–30% of hospital admissions in India are directly or indirectly alcohol related which mainly include cancer, liver diseases, cardiovascular diseases, neurological diseases, dependence, mental health problems, and accidents with no specific data describing percentage of each.[3] Our study reveals ALD alone accounts to nearly 4%–7% of our hospital admissions thus signifying the importance of this disease in Sikkim and need of a local study from the region.

Research-oriented study regarding the clinical, laboratory, and upper gastrointestinal endoscopic profile of the patients admitted with alcohol-related liver disease is lacking from this part of the country. Thus, systemic research on this front could add and/or reinforce to the background data in the mind of the clinician treating such patients. In the long run, the results of this study could be compared with data from similar studies conducted elsewhere, and this would lead to the increase of knowledge regarding the clinical, laboratory, and upper gastrointestinal endoscopic profile of the admitted patients of ALD and thus helping in their better management.


  Methods Top


A hospital-based descriptive, observational study with a cross-sectional design was carried out over 1 year in the Department of General Medicine, at a teaching hospital in Sikkim, after taking approval from the Institutional Ethical Committee. ALD was diagnosed in patients with a history of significant alcohol intake (determined by AUDIT-C score ≥4), physical signs of liver disease, and supportive laboratory data.[4] A total of 100 >18 years ALD patients of both sexes who gave written informed consent were randomly recruited. Liver diseases from other causes such as nonalcoholic fatty liver disease (differentiated from ALD by ALD/nonalcoholic fatty liver disease index combined with γ-glutamyl transferase), viral hepatitis, drug-induced hepatitis and hemochromatosis and ALD with diabetes mellitus and kidney disease were excluded from the study.[5] Categorical data were analyzed using SPSS statistical software (version 22, IBM SPSS Inc, Armonk, NY) with binary logistic regression analysis and Chi-square test with a confidence interval of 95%. Continuous data were presented in the form of mean and median.


  Results Top


In our study, maximum patients fell in the age group of 41–50 years with a mean age of 48.05 ± 11.45 years and males (84%) outnumbering females (16%). Majority of the patients were Hindu (56%), of Nepali ethnicity (57%), married (99%), and lived in a joint family (54%). Majority were occupied in unskilled work (67%) with lower education level, i.e., elementary school and below (52%) and belonged to middle socioeconomic status (56%) according to Udai Pareek socioeconomic scale.

Majority were on mixed diet (74%) with duration of alcohol intake being more than 10 years in most (77%) with average duration of alcohol intake being 16 years. About 58% of the patients also had history of smoking. The average intake of alcohol by males was 63 g/day, and in females, it was 40 g/day.

Cholelithiasis (14%), hypertension (12%), and diabetes mellitus (10%) were the most common associated conditions. Most common presenting features were nausea (90%), jaundice (67%), anorexia (64%), vomiting (56%), and abdominal distension (53%) [Table 1].
Table 1: Clinical presentation of alcoholic liver disease

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The mean hemoglobin (g/dL), total leukocyte count (cells/μL), and platelet count (lakh/μL) were 10.3 ± 2.9, 8788 ± 4166, and 1.6 ± 0.9, respectively [Table 2]. Hemoglobin was <11 g/dL in 64%, platelet count was <1.5 lakh/μL in 51%, and leukocyte count was >11,000 cells/μL in 20% of the patients. The blood groups of the patients were O+ve in 39%, A+ve in 33%, B+ve in 19%, AB+ve in 8%, and O-ve in 1% of the patients.
Table 2: Laboratory parameters of alcoholic liver disease

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The mean random blood sugar (mg/dL), blood urea (mg/dL), serum creatinine (mg/dL), serum sodium (mEq/L), and serum potassium (mEq/L) were 101.2 ± 30.9, 38.1 ± 14.8, 1.2 ± 0.9, 134.1 ± 8.4, and 4.1 ± 1.1, respectively [Table 2]. Random blood sugar was <70 mg/dL in 11%, blood urea was >40 mg/dL in 46%, serum creatinine was >1.5 mg/dL in 21%, serum sodium was <135 mEq/L in 43%, and serum potassium was <3.5 mEq/L in 22%.

The mean total bilirubin (mg/dL), direct bilirubin (mg/dL), aspartate aminotransferase (AST) (IU/L), alanine aminotransferase (ALT) (IU/L), AST/ALT, ALP (IU/L), total protein (g/dL), serum albumin (g/dL), and prothrombin time difference (seconds) were 4.74 ± 3.8, 2.7 ± 1.8, 110.2 ± 96.6, 59.1 ± 47.9, 2.05 ± 1.03, 209.4 ± 137.6, 6.7 ± 1.4, 3.4 ± 0.9, and 4.1 ± 2.3, respectively [Table 2]. Total bilirubin was >5 mg/dL in 23% of the patients and prothrombin time difference was >5 sec in 54% of the patients. Serology for hepatitis B and C was negative in all the patients.

Abdominal sonography was performed in all the patients and it revealed ascites in 53%, cirrhosis in 43%, fatty liver in 37%, Splenomegaly in 31% and portal vein diameter was >13mm in 27% of the patients (total percentage of patients with findings is >100% as many patients had more than one findings). Upper gastrointestinal endoscopy was performed in 85 patients and it revealed Grade 1, 2, and 3 varices in 24%, 16%, and 12% of the patients, portal hypertensive gastropathy in 21%, gastritis in 22%, and gastric and/or duodenal ulcers in 9% of the patients, while it was normal in 14% of the patients (total percentage of patients with abnormal findings comes up to 104% even do only 86% of patients had abnormal findings as 16 patients had findings both in esophagus plus stomach/duodenum).

The most common complications of ALD were gastrointestinal bleeding (54%) and portal hypertension (defined as hepatic venous pressure gradient ≥6 mmHg. As measurement of pressure gradient is an invasive procedure associated with a risk of intraperitoneal bleeding, transabdominal ultrasound with Doppler imaging was used in supporting a diagnosis of portal hypertension) (51%) [Table 3].[6]
Table 3: Complications of alcoholic liver disease

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  Discussion Top


The mean age in our study was 48.05 years which was comparable to other studies.[7],[8],[9] This suggests initiation of alcohol intake occurred around the age of 30 years, which is in the most productive period of life. Males outnumbered the females, which was also comparable to studies from other part of India, which is mainly due to Indian culture and tradition.[7],[8],[9] The majority were Hindu and of Nepali ethnicity which was a reflection of the distribution of community in Sikkim. The majority were married and lived in a joint family adding to the fact that the intake of alcohol is woven into the lifestyle of Sikkimese people and socially acceptable. Majority were of middle socioeconomic status; this was in contrast to most of the other Indian studies where the prevalence was more in low socioeconomic status.[10],[11],[12] This might be changing drinking pattern and a high prevalence of alcohol intake in Sikkim.[11],[12]

The average duration of alcohol intake was 16 years with average intake by males being 63 g/day and in females being 40 g/day. This average duration of alcohol was comparable with other studies, but average intake in males and females could not be compared due to paucity of data.[7],[8],[9] Females are more susceptible to ALD as lesser quantity of alcohol dehydrogenase is released in their gastrointestinal tract, along with higher proportion of body fat in females.[13] About 58% of the patients also had history of smoking, with smoking being a concomitant risk factor for various diseases.

Cholelithiasis was the most common associated condition which was in contrast to various studies which showed alcohol intake was associated with reduced incidence of gallstone formation.[14],[15] This might be due to increased incidence of cholelithiasis in the Himalayas.[16] Nausea, jaundice, and anorexia were the most common clinical presentation, with pedal edema, hematemesis, and fever being uncommon. Dupuytren's contracture, testicular atrophy, finger clubbing were present in none.

The hemoglobin, total leukocyte count, and platelet count values were comparable to other studies.[7],[8],[9] O+ve followed by A+ve were the most common blood group which was similar to the blood group pattern of the Sikkimese people.[17] Blood group was analyzed as patients of ALD are more prone to anemia and also blood is very important component in the management of acute gastrointestinal bleeding which is known and common complication of chronic liver disease.[18]

Random blood sugar, renal function tests, serum electrolytes, and liver function tests values were comparable to other studies with typical ratio of AST/ALT of ≥2 being found in 81% of the cases.[7],[8],[9] Abdominal sonography revealed ascites and cirrhosis as the most common findings while upper gastrointestinal endoscopy revealed varices and gastritis as the most common finding. These findings were comparable to other studies.[7],[8],[9]

Gastrointestinal bleeding and portal hypertension were the most common complications while hepatorenal syndrome, spontaneous bacterial peritonitis and coagulopathy were uncommon. Hepatopulmonary syndrome was present in none. This was also comparable to other studies.[8],[9]

The limitation of our study was that it was a cross-sectional study and patients were not followed up. A prospective study could have improved our study.


  Conclusions Top


Along with the social and economic problems associated with alcohol, it can affect almost any system of the body, being an important cause of morbidity and mortality throughout the world. ALD is one of the important causes of this morbidity and mortality, ranging from simple fatty liver to cirrhosis and associated complications with a wide spectrum of clinical presentation. Alcoholism menace requires a multidisciplinary healthcare approach along with the involvement of society, nongovernment organization, and government.

Acknowledgments

We are grateful to Dr. Bidita Khandelwal, Professor and Head of Department, Department of General Medicine, SMIMS and Dr. O. P. Dhakal, Professor, Department of General Medicine, SMIMS for their continuous guidance throughout the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wang J, Li P, Jiang Z, Yang Q, Mi Y, Liu Y, et al. Diagnostic value of alcoholic liver disease (ALD)/nonalcoholic fatty liver disease (NAFLD) index combined with γ-glutamyl transferase in differentiating ALD and NAFLD. Korean J Intern Med 2016;31:479-87.  Back to cited text no. 5
    
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Pandey SK, Datta D, Dutta S, Verma Y, Chakrabarti A. Socioeconomic characteristics of alcohol and other substance users, seeking treatment in Sikkim, North East India. J Pharm Bioallied Sci 2015;7:151-5.  Back to cited text no. 12
    
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Menon KV, Gores GJ, Shah VH. Pathogenesis, diagnosis, and treatment of alcoholic liver disease. Mayo Clin Proc 2001;76:1021-9.  Back to cited text no. 13
    
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Scragg RK, McMichael AJ, Baghurst PA. Diet, alcohol, and relative weight in gall stone disease: A case-control study. Br Med J (Clin Res Ed) 1984;288:1113-9.  Back to cited text no. 14
    
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Kono S, Shinchi K, Ikeda N, Yanai F, Imanishi K. Prevalence of gallstone disease in relation to smoking, alcohol use, obesity, and glucose tolerance: A study of self-defense officials in Japan. Am J Epidemiol 1992;136:787-94.  Back to cited text no. 15
    
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Kotwal MR, Rinchen CZ. Gallstone disease in the Himalayas (Sikkim and North Bengal): Causation and stone analysis. Indian J Gastroenterol 1998;17:87-9.  Back to cited text no. 16
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Gonzalez-Casas R, Jones EA, Moreno-Otero R. Spectrum of anemia associated with chronic liver disease. World J Gastroenterol 2009;15:4653-8.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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