Cirrhosis at the Ouahigouya Regional Teaching Hospital: Status Report and Diagnostic and Therapeutic Challenges in a Region with Limited Resources ()
1. Introduction
Cirrhosis is a major public health problem worldwide, accounting for 2.4% of deaths [1]. In fact, it is the 9th leading cause of death in South-East Asia and Europe, and the 10th in Africa. Along with viral hepatitis and hepatocellular carcinoma (HCC), it accounts for 4% of deaths worldwide [2]. It is a diffuse liver disease characterized by two main lesions: mutilating annular fibrosis and regenerative nodules [3]. This anatomopathological disorganization is often the starting point for HCC, making cirrhosis a precancerous lesion.
Among the causes of cirrhosis, chronic alcoholism is the most common in developed countries, and particularly in France. [2] while chronic viral hepatitis ranks first in Africa. Indeed, the prevalence of hepatitis B virus (HBV) infection remains high, at 8%, with 750 million people infected and 65 millions living with a chronic form of the disease in Africa [4].
The prevalence of HBsAg carriers is estimated at between 9% and 15% [5].
In our countries, it is diagnosed at the stage of complications [4] [6] in relation to its pauci-symptomatic or asymptomatic features and its lack of awareness among our populations.
In Burkina Faso, few studies have been carried out on cirrhosis. In a 2001 study by Tinto et al. at the Yalgado Ouedraogo Teaching Hospital in Ouagadougou, cirrhosis accounted for 5.9% of all hospital admissions and 27.2% of chronic liver disease [7]. Ten years later, in 2012, Sawadaogo et al. at the Sourou Sanou teaching hospital in Bobo-Dioulasso, reported that cirrhosis accounted for 6.5% of all hospitalizations and 46.8% of chronic liver diseases [8]. In recent years, the Hepato-Gastro-Enterology Department of the Ouahigouya teaching hospital has empirically observed a large number of cirrhosis-related hospitalizations, and we have no studies on this condition. In fact, in 2022, 51 patients were consulted for cirrhosis, 43 of whom were hospitalized, according to monthly activity reports.
The aim of this study was to assess the extent of cirrhosis through its epidemiological, clinical, paraclinical and therapeutic aspects at CHUR-OHG in order to improve its management.
2. Patients and Method
Our study took place in the General Medicine office, more specifically in the Hepato-Gastro-Enterology department of Ouahigouya teaching hospital. This was a descriptive cross-sectional study with retrospective data collection, conducted during the period from January 1st, 2021, to December 31st, 2023.
All patients diagnosed with cirrhosis during the study period and meeting the inclusion criteria were selected. Inpatients with a diagnosis of cirrhosis based on clinical, biological and morphological evidence were included. Incomplete files were excluded.
Cirrhosis was defined by a combination of clinical and paraclinical criteria.
Clinical criteria: presence of functional signs such as asthenia, jaundice or asymptomatic patient in compensated cirrhosis.
and/or
Biological abnormalities:
And/or
Imaging abnormality (ultrasound or CT scan):
Biological parameter standards used in our study:
ALAT < 40 IU
ASAT < 40 IU
Total bilirubin: 5 - 17 micromol
Conjugated bilirubin: < 4 μmol/l
Gamma GT: < 28 UI/l
PAL: 20 - 80 IU/L
Prothrombin rate: 70% - 100%.
The sub-chapter on operational definitions clearly specify the diagnostic criteria and the different clinical presentations of cirrhosis.
Data was collected on a pre-established survey form. All medical records were reviewed by a internship physician under the supervision of a senior member of staff, in order to retain only those records that could be used. For each patient:
Check for risk history and functional signs: abdominal pain, signs of upper or lower digestive haemorrhage and personal history of jaundice, blood transfusion, alcohol intake and a notion of liver disease or other known illnesses,
Clinical examination to look for a large liver and its characteristics, splenomegaly, jaundice, ascites, IMO, CVC, fever, hepatic encephalopathy, pathology of other organs through a general systemic examination.
Paraclinical examinations
Blood count for anemia, thrombocytopenia, leukopenia or pancytopenia.
Check for hepatic cytolysis by measuring aminotransferase activity.
Check for hepatocellular insufficiency by measuring prothrombin and bilirubin levels.
Creatinine levels to check for impaired renal function (elevated creatinine levels).
Examination of ascites fluid for bacterial infection.
Etiological testing for HBs antigen and anti-HCV antibodies.
Abdominal ultrasound to assess liver morphology and look for signs of portal hypertension and peritoneal effusion.
Upper GI endoscopy for signs of portal hypertension and VO.
The data collected was entered and analyzed on a computer using EPI info software version 7.2.5.0.
Ethical considerations
Data was collected with respect for patient anonymity and confidentiality. The agreement of the hospital senior management was obtained prior to the start of the study.
Operational definitions
The diagnosis of cirrhosis has been established on the basis of a range of clinical and paraclinical arguments.
According to the two stages of cirrhosis:
compensated cirrhosis for asymptomatic patients who have been hospitalized following paraclinical examinations.
decompensated cirrhosis for patients who have presented a decompensation (ascitic, edematous or edemato-ascitic) and/or a complication related to cirrhosis (hepatocellular carcinoma, digestive hemorrhage, etc.).
By the presence of painless, firm, irregular-surfaced hepatomegaly with a sharp lower border, associated with signs of Hepatocellular Insufficiency (cutaneous-epidermal syndrome, signs of hemorrhage and hepatic encephalopathy); portal hypertension (collateral venous circulation, ascites, splenomegaly) or cholestasis (discolored stools, dark urine, jaundice, pruritus).
Paraclinics
Abdominal ultrasound showing atrophic or hypertrophic liver with cirrhotic appearance.
A biological examination showing abnormalities of liver damage: cytolysis or hepatocellular insufficiency.
The complications of interest were:
Hepatocellular carcinoma on the basis of elevated alpha-feto-proteins, whether or not associated with one or more hepatic nodules on liver ultrasound; with a wash-in and wash-out appearance on CT scan.
Upper GI hemorrhage due to rupture of esophageal varices, externalizing as melena or hematemesis.
Infection of ascites fluid by performing an ascites fluid culture, or in the presence of a patient presenting ascites with fever, abdominal pain or hepatic encephalopathy.
Hepatic encephalopathy in the presence of altered consciousness with increased hepatocellular insufficiency in cirrhotic patients.
Hepatorenal syndrome caused by impaired renal function, apart from the administration of diuretics and any other cause of renal impairment.
3. Results
During this period, 3727 patients were hospitalized in the medical department; 116 cases of cirrhosis were identified, and 96 patients were selected. Cirrhosis accounted for 2.6% of the pathologies encountered.
The mean age was 45.72 years, with extremes of 16 and 80 years old. There was a male predominance, with a sex ratio of 3.36. Farmers and housewives accounted for 75% (72/96) of patients (Table 1).
Table 1. Distribution of patients by profession.
Profession |
Numbers (n = 96) |
Percentage (%) |
Farmer |
54 |
56.25 |
Housewife |
18 |
18.75 |
Gold digger |
13 |
13.54 |
Retired |
05 |
5.51 |
Shopkeeper |
03 |
3.12 |
Driver |
01 |
1.04 |
Carpenter |
01 |
1.04 |
Photographer |
01 |
1.04 |
History-taking revealed that a patient could have several histories. Thus, 41 (42.71%) had a history of jaundice, 10 (3.12%) of alcohol consumption, and no patient had been vaccinated against hepatitis B virus.
Distension and abdominal pain were the most frequent reasons for hospitalization. The mean duration between the onset of functional signs and hospitalization was 36 days, with extremes of 1 and 240 days. Symptoms on admission were primarily abdominal distension (56.21%), followed by abdominal pain (51.04%) (Table 2).
Table 2. Distribution of hospitalization reasons.
Hospitalization reasons |
Numbers (n = 96) |
Percentage (%) |
Abdominal distension |
54 |
56.21 |
Abdominal pain |
49 |
51.04 |
Pelvic limb edema |
07 |
07.29 |
Hematemesis |
07 |
07.29 |
Altered general condition |
05 |
05.21 |
General condition was rated WHO Stage 3 in 70 (72.92%) of patients. Of these, 64 (66.67%) had pelvic limb oedema and 62 (64.58%) had jaundice.
Clinical examination revealed hepatomegaly in 44 (45.83%) patients (Table 3). Its anterior surface was irregular 75%, of hard consistency 81.82%, with a sharp lower edge 88.64% and portal hypertension in 40.63% of cases. Ascites fluid puncture in 49 (62.82%) patients was citrine yellow in 39 (79.59%), low in protide in 16 (64%) and ascitoculture negative in 92%.
Table 3. Distribution of patients’ physical signs.
Physical signs |
Number (n = 96) |
Frequency (%) |
Hepatomegaly |
44 |
45.83 |
Abdominal distension |
77 |
80.21 |
Hepatocellular insufficiency |
11 |
11.46 |
Portal hypertension |
39 |
40.63 |
Cholestasis |
30 |
31.25 |
Collateral venous circulation |
35 |
36.46 |
Splenomegaly |
10 |
10.42 |
Biological abnormalities were dominated by cholestasis and hypoalbuminemia. Table 4 summarizes the biological parameters.
Table 4. Distribution of biological parameters.
Biological tests |
|
Values |
Number |
Frequency (%) |
Transaminases |
ALAT |
Normal |
23 |
28.05 |
Once the normal |
31 |
37.80 |
Twice the normal |
12 |
14.63 |
More than or equal to 3 times normal |
16 |
19.52 |
ASAT |
Normal |
13 |
15.85 |
Once the normal |
16 |
19.51 |
Twice the normal |
14 |
17.07 |
More than or equal to 3 times normal |
39 |
47.56 |
ASAT/ALAT |
<1 |
08 |
9.76 |
>1 |
74 |
90.24 |
Bilirubinemia |
Bil C |
Hyperbilirubinemia |
61 |
82.43 |
Bil T |
Hyperbilirubinemia |
61 |
82.43 |
Prothrombin rate |
|
under 40 |
37 |
47.44 |
40 - 50 |
13 |
16.67 |
over 50 |
28 |
35.90 |
AFP |
|
Normal |
7 |
13.21 |
|
5 - 500 ng |
27 |
50.94 |
|
over 500ng |
19 |
35.85 |
Albumin |
|
Decreased |
53 |
89.83 |
Normal |
6 |
10.17 |
Hemoglobin |
Haemoglobin |
Anemia |
78 |
83.87 |
Normal |
15 |
16.13 |
White blood cells |
Leucopenia |
4 |
5.26 |
Hyperleucocytosis |
32 |
42.11 |
Platelets |
Thrombocytopenia |
49 |
52.69 |
Thrombocytosis |
02 |
2.15 |
Creatinemia |
|
Normal |
79 |
84.95 |
Renal function impairment |
14 |
15.05 |
Blood ionogram |
|
Normal |
9 |
25 |
Hypocalcemia |
22 |
61.11 |
Hyponatremia |
15 |
42.67 |
Hypochloremia |
04 |
11.11 |
Hypokaliemia |
03 |
8.33 |
Hypomagnesemia |
02 |
5.56 |
Viral markers |
|
HBsAg |
72 |
77.42 |
HbeAg |
04 |
4.30 |
HbeAb |
03 |
3.23 |
HBcAb |
37 |
39.78 |
HBsAb |
05 |
5.38 |
HCVAb |
04 |
4.30 |
Bil C: Conjugated bilirubin. Bil T: Total bilirubin. AFP alpha foeto protein.
Upper GI endoscopy was performed on 43 patients and showed esophageal varices grade I, II, III in respectively 6.97%; 51.16%; 30.23% of cases (Table 5). Other abnormalities included portal hypertension gastropathy in 41.81%, and bulbar and gastric ulcers in 11.63% and 9.3% respectively.
Table 5. Summary of patients’ endoscopic abnormalities.
Endoscopic findings |
Number (n = 43) |
Frequency (%) |
Esophageal varices |
Grade I |
03 |
6.97 |
Grade II |
22 |
51.16 |
Grade III |
13 |
30.23 |
Portal hypertension gastropathy |
18 |
41.81 |
Bulbar ulcer |
05 |
11.63 |
Congestive corporal gastropathy |
05 |
11.63 |
Gastric ulcer |
04 |
9.30 |
Esophageal mycosis |
04 |
9.30 |
Peptic esophagitis |
01 |
2.33 |
Complications were present in 49 (51.04%) patients, hepatocellular carcinoma in 36 (73.47%), hepatic encephalopathy in 11 (22.45%), digestive hemorrhage and ascites fluid infection in 10.20% each, and hepatorenal syndrome in 6 (12.24%) patients (Table 6).
Table 6. Breakdown of complications.
Complications |
Number (n = 49) |
Frequency (%) |
HCC |
36 |
73.47 |
Hepatic encephalopathy |
11 |
22.45 |
Digestive hemorrhage |
05 |
10.20 |
Hepatorenal syndrome |
06 |
12.24 |
Ascites fluid infection |
05 |
10.20 |
The etiological investigation found hepatitis B virus in 72 (75%) patients, followed by alcohol in 7.29%. The cause of cirrhosis could not be determined in 11.46% of cases (Table 7).
Table 7. Distribution of cirrhosis etiologies.
Etiologies |
Number (n = 96) |
Percentage (%) |
HBV |
72 |
75 |
Indeterminate |
11 |
11.46 |
Alcohol |
07 |
7.29 |
HCV |
04 |
4.17 |
Toxic |
02 |
2.08 |
The therapeutic management of patients in our series was essentially medical, with the use of several classes of drugs. Analgesics and diuretics were the most commonly used, respectively 93.75% and 91.67% (Table 8). No patient benefited from endoscopic or surgical treatment. The analgesics used were paracetamol for stage 1 pain, tramadol for stage 2 and morphine sulfate for stage 3 pain. The diuretic treatment strategy was based on spironolactone more or less combined with furosemide in a 10/4 ratio (i.e., 100mg spironolactone to 40 mg furosemide). The beta-blocker available was propranolol, and the antiviral treatment for HBV was tenofovir. For HCV, the molecules were sofosbuvir-velpatasvir or sofosbuvir-daclastavir.
Table 8. Breakdown of patients by types of treatment.
Types of treatment |
Number (n = 96) |
Frequency (%) |
Analgesic |
90 |
93.75 |
Diuretic |
88 |
91.67 |
Evacuation puncture |
70 |
72.92 |
Beta blocker |
27 |
28.13 |
Antivirals |
24 |
25 |
Antibiotics |
15 |
15.63 |
Blood transfusion |
06 |
6.25 |
Prognostic evaluation using the Child Pugh score was carried out on 67 patients, classifying them as Grade C 55.22%, Grade B 35.82% and A 8.96%.
In our study population, 28.13% of patients were discharged after clinical improvement, and 43.75% died during hospitalization, of which primary liver cancer was the main cause in 52.38%.
4. Discussion
4.1. Limitations and Constraints
Our study was cross-sectional, with retrospective data collection, and its limitations include incomplete or poorly completed medical records. Similarly, the lack of financial resources prevented us from carrying out certain imaging and histological examinations. Incomplete medical records sometimes lead to a significant loss of data, resulting in the exclusion of certain patients from our sample. In addition, as not all paraclinical examinations were carried out on all patients, some calculated proportions are reported for the entire study population, but with missing data.
The diagnosis of cirrhosis was based on a combination of clinical, biological and ultrasound evidence.
4.2. Sociodemographic and Epidemiological Data
The hospital prevalence of cirrhosis was 2.6%. Our result is similar to that of Toure et al. in Mali in 2008, who reported a frequency of 2.8% [9], but remains lower than those of Sawadogo et al. at Chuss in 2012 and Some et al. at Chu Yo in 2021, respectively 5.9% and 33.9% [8] [10]. The low prevalence of cirrhosis in our study could be explained by the low prevalence of hepatitis B in the Nord region. The prevalence of viral hepatitis B was recently estimated at 7%, while the overall prevalence of infection in the country is approximately 9.1% [7].
The mean age was 45.72 years, with extremes of 16 and 80 years. It is similar to those reported by Some et al. at Chu Yo in 2021, Tinto et al. in Ouagadougou in 2002 and Sawadogo et al. at Chuss de Bobo Dioulasso in 2012 in respectively 46.5 years; 46.9years and 47.5 years [7] [8] [10]. However, our results are lower than those observed in France and America, where the average age is 70 [11]. These observations can be explained by contrasting differences in risk factors and living conditions: in France, cirrhosis is most often diagnosed in the elderly and is linked to alcohol and chronic (metabolic) diseases, whereas in Africa, infection with the hepatitis B virus at an early age is the main cause [12].
Males predominated, with a sex ratio of 3.36. This male predominance was observed by Agbozo et al. in Ghana in 2022, with a sex ratio of 3.1. [13]; of Terefe T et al. in 2019 in Ethiopia with 3.54 [11]; Toure in Mali (4.7) [9] as well as Driouiche et al. in Morocco (1.19) [14]. In Burkina Faso, the same observation was reported by Sawadogo in Bobo-Dioulasso [8] and Some et al. in Ouagadougou [10] with sex ratios of 2.3 and 2.7 respectively. This male tendency could be explained in part by men’s risky behaviours, such as alcohol and tobacco consumption.
The data we report on cirrhosis at an epidemiological level may reflect under-reporting of cirrhosis and could only be generalized in the context of resource-limited countries. Indeed, we report 96 cases of documented cirrhosis in 3 years in our hospital, whereas worldwide, compensated cirrhosis is estimated to have a prevalence of 112 million patients, with a ratio of 1395 cases per 100,000 inhabitants (1, 17). This could be explained by the fact that teaching hospitals are not the first level of care in our country, and only patients who are financially accessible and have accepted the health referral are admitted. Moreover, ascetic cirrhosis is perceived by our populations as a pejorative disease of mystical origin, whose treatment is mainly traditional and requires recourse to traditional healers.
4.3. Medical History
In both our study and that of Some et al. [10], none of the patients had been vaccinated against the hepatitis B virus, the only effective method of preventing hepatitis B infection. This situation could be due either to the inaccessibility of the vaccine due to its high cost, or to insufficient awareness-raising campaigns on the necessity and importance of vaccination.
4.4. Consultation Period
The average delay between the onset of functional signs and hospitalization was 36 days, with extremes ranging from 1 to 240 days. This long delay was also reported by Abgozo et al. in Ghana, which was 35 days [13].
Some et al. in 2021 found an even longer average delay of 99 days [10]. These relatively long delays may be linked to several factors. Firstly, a misperception of the severity of the disease, linked to the insidious onset of abdominal distension and the absence of pain. Secondly, the traditional misperception of abdominal distension as a “curse” that cannot be treated by modern medicine, justifying late recourse to medical care. Finally, there is geographical inaccessibility in certain areas due to the security crisis.
4.5. Clinical Data
Abdominal distension (56.21%) and pain (51.04%) were the main reasons for hospitalization. Our data corroborate those of Agbozo et al. in Ghana in 2022, who reported abdominal distension in 94.37% of cases and pain in 86.25% [13]. Ndow et al. in Gambia in 2023 observed the same symptoms in 60% of patients admitted for cirrhosis [15]. These reasons for hospitalization suggest the decompensation of cirrhosis, and testify to the late consultation of patients.
The majority of patients in our series (51.04%) were admitted at the complication stage. Hepatocellular carcinoma was the most common complication, accounting for 73.47%. Sawadogo et al. made the same observation in Bobo Dioulasso [8]. On the other hand, Driouiche et al. in Morocco reported digestive haemorrhage as the primary complication in 51% of cases [14]. The insidious progression of cirrhosis, together with late detection of esophageal varices and prophylactic treatment against rupture, explains why patients are seen at the complication stage.
Hepatitis B virus remains the most common etiology of cirrhosis in our setting, with a prevalence of 75%. This etiological profile is similar to the findings of the Global Burden of Disease 2017, which highlights the high prevalence of post-viral B cirrhosis in Africa (5% to 7%) [11]. Similarly, Toure in Mali [9]; Some et al. in Ouagadougou [16] and Ndow et al. in Gambia reported a prevalence of hepatitis B of 73.91%, 76.5% and 75% respectively. These results differ from those in Europe and America, where chronic alcoholism is the main etiology of cirrhosis (60%) [2] [17].
The high prevalence of hepatitis B as the main cause of cirrhosis in sub-Saharan Africa could be explained by mother-to-child transmission, combined with limited access to vaccines and antiviral treatments. Indeed, hepatitis B vaccination was not included in the Expanded Program on Immunization in our context until 2006.
4.6. Treatment
The main objective of the treatments received by the patients in our study was essentially based on managing complications and improving their quality of life.
None of our patients received endoscopic treatment for esophageal varices or liver transplantation. Only drugs normally used in the management of cirrhosis were administered. Our results are similar to those of Sawadogo in Bobo-Dioulasso [8], Toure in Mali [9] and Driouche et al. In Morocco [14].
Since the major etiology of cirrhosis in our country is HBV, the most effective treatment remains prevention through vaccination. This vaccination, which has been effective in our country for children since 2006, should be intensified and extended to the adult population through awareness, screening and vaccination campaigns. In addition, this community awareness campaign should take into account the socio-cultural constraints that hinder the management of ascetic decompensation of cirrhosis. In addition, training specialist doctors and assigning them to primary care centers could further improve patient care. Another salutary intervention of health policies would be the adequate equipping of health centers. Our hospitals lack the resources needed to care for patients. For example, our patients have not benefited from esophageal varicose vein ligations. For the management of complications of portal hypertension, vasoactive drugs such as glypressin or octreotide are not available. Radiological techniques such as TIPS, radiofrequency and chemoembolization are not feasible, nor is liver transplantation.
4.7. Prognostic Evolution
Treatment resulted in remission of symptoms in 28.13% of cases. On the other hand, death occurred in 43.75% of cases, the main cause of which was primary liver cancer in 52.38% of cases. Our results are similar to those of Sawadogo W.A. in Bobo, who reported mortality due to hepatocellular carcinoma in 50% of cases [8].
5. Conclusion
Cirrhosis is a frequent reason for hospitalization in our hospital, affecting the active adult population. Patients are present at a stage of decompensation or complications of the disease. Viral hepatitis B and C and alcohol are the main causes. Mortality remains high despite treatment. Efforts must be made for screening, vaccination and mass treatment campaigns to reduce the prevalence and prognosis of cirrhosis in our community. Hope lies in the expected fruits of universal childhood vaccination, which began in our country in 2006.