Etiology of chronic liver disease in patients admitted at the National Referral Hospital of Bhutan in 2020

Background and Aim: Chronic liver disease (CLD) is a major cause of morbidity and mortality worldwide. Etiologically there are many factors including hepatitis B virus (HBV) and C virus (HCV) infections, alcohol, non-alcoholic fatty liver disease, autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, Wilson’s disease, hemochromatosis, etc. Though there is evidence in the literature regarding the etiologies of CLD, no study was done in Bhutan in this area. Therefore, this study was conducted to assess the etiology of CLD in patients admitted in the National Referral Hospital, Thimphu. Methods: A descriptive study was conducted with 71 patients admitted to the National Referral Hospital. The study was done after seeking ethical clearance from the Research Ethics Board of Health (REBH) (Annexure 3) and was conducted from 1st January to 31st December 2020. The data were collected in pro forma and entered in Epi Data version 3.1 and analyzed using Epi Data Analysis version 2.2.2.183 and STATA version 15.1. Results: Out of 71 patients who had CLD, majority 80.3 % were due to alcohol and the least 2 (2.8 %) was due to the combination of alcohol and HBV infection. Conclusion: The study found that the commonest cause of CLD in patients admitted at the National Referral The hospital was alcohol. The findings from this study could help in strengthening the implementation of alcohol policy in the country.


Introduction
Chronic liver disease (CLD) is the term used to describe the disordered liver function lasting for six or more months [1]. CLD is defined as deranged transaminases for more than six months or the presence of hepatic parenchyma heterogeneity and/or surface irregularity on ultrasound OR the presence of clinical features suggestive of decompensated liver disease such as ascites, jaundice, and/or hepatic encephalopathy [2].
CLD is a major cause of morbidity and mortality and was responsible In India, although there was significant regional variation in etiology across the country, HBV was the commonest cause of CLD. HCV was the commonest cause in the northern region, HBV in the south According to a study done, in Bhutan, CLD is a major cause of morbidity and mortality [6]. The prevalence of CLD in Bhutan is largely unknown but is assumed to be high. Alcohol is assumed to be the major cause of CLD in Bhutan. However, no proper study was done to find out the other causes of CLD. Alcohol liver disease was reported as the number one cause of death [6]. In Bhutan, although alcohol is the main cause of the chronic liver disease (CLD), causes of liver disease other than ALD are often not described. The layperson is often led to believe that alcohol abuse is the only etiological factor in CLD.
Although some of the causes of chronic liver diseases have no treatments, such as α1anti-trypsin deficiency, cryptogenic hepatitis, and primary sclerosing cholangitis, other causes, such as primary biliary cirrhosis, have treatments that delay progression even though not curable [7]. This study was thus conducted to estimate the proportion of CLD attributable to different etiologies as there is no study in the country on this subject.

Method and Data collection
This is a descriptive study carried out with the aim to explore the • Patients with liver dysfunction secondary to comorbidities such as congestive cardiac failure, biliary obstruction, and septicemia.
Data was collected using a pre-validated pro forma (Annexure 1).
Informed consent was obtained from the patients enrolled in the study. Information on the research was explained to all the patients and/ or patient attendants. For all the patients enrolled in the study, relevant demographic details, clinical history, examination, and investigation findings were collected. Clinical history was obtained not only from the patients but also from the patient attendants. After obtaining the history of alcohol consumption, the total quantity of alcohol consumed was calculated using the guide to standard drinks, NCD STEPS survey (Annexure 2).
All the data were double entered in EpiData Entry (version 3.1, EpiData Association, Odense, Denmark) and checked for data entry errors, and corrected where necessary. All the data were then

Results
A total of 71 patients were enrolled in this study. Of these patients, 46.5 % were male and 53.5 % were female with an average age of  The descriptive statistics on alcohol consumption of CLD patients enrolled in this study are presented in

Child-Pugh score
As shown in

Discussion
The commonest cause of CLD among the study participants was There is an established relationship between the dose, amount, and the likelihood of developing ALD due to alcohol consumption. Fatty liver can be found in the 60 % of those who drink more than 60 g of alcohol per day and the risk of developing cirrhosis is highest in those who drink more than 120 g per day [9]. The alcohol consumption of more than 40 g per day increases the risk of progression to cirrhosis to 30% in patients with uncomplicated fatty liver and to 37 % in those with fibrosis [9].
Similarly in this present study, it was observed that those patients who had CLD with Child-Pugh score C had more amount and longer time of consumption of alcohol. As alcohol was the major cause of CLD we need to strengthen the existing programs for alcohol consumption reduction and develop comprehensive, evidence-based control on alcohol as it has major implications on public health, particularly considering exponential growth in non-communicable diseases in a country. In a study done by Khokar N and Niazi SA, in Pakistan, it was found that CLD was the commonest cause of mortality and it was mainly because of HCV infection [8]. However, in this study none of the participants had HCV infection and the commonest cause of mortality was alcohol.
In the study done by Setiawan et al, NAFLD was the common cause of CLD [5]. Even in this present study, it was observed that two of the participants had CLD due to NAFLD.
The most common presenting complaints in my study was abdominal distention followed by edema (69 % and 66.2 % respectively).
However, in the study done by Khokar N and Niazi SA, the most common presenting complaint was upper gastrointestinal bleeding.
Although it was not found to be common in this study, it was the third most common presenting complaint.