Introduction: Knowledge of morbidity and mortality in a population helps to improve health care. The aim of this study was to describe morbidity and mortality in a hepato-gastroenterology department in Benin.

Methods: This was a descriptive cross-sectional study with retrospective data collection conducted from January 2015 to December 2019. We included the records of all patients admitted during the study period to the hepato-gastroenterology university clinic of the National University Hospital Center of Cotonou.

Results: Of the 2420 patients received, 1505 were followed up on an outpatient basis and 915 were hospitalised. The patients were mainly male (sex ratio: 1.3), with an average age of 44 ± 0.7 years (extremes of 9 and 90 years). Patients were mainly being treated for viral hepatitis B (29.2%) or gastroraphy (17.9%). The crude outpatient mortality rate was 10.8% over 5 years. Inpatients were male (sex ratio: 2.4), with an average age of 50 ± 1.0 years (extremes of 17 and 89 years). They were hospitalised mainly for liver cirrhosis (43.5%) and/or primary liver cancer (34%). The average length of hospital stay was 9.1 ±0.5 days, with extremes of 1 day and 85 days. Male gender, age over 50, alcohol consumption, smoking and hepatitis B and/or C were the factors associated with the occurrence of these pathologies. The crude mortality rate of hospitalized patients was 51.4% over a 5-year period. The main causes of death were liver cancer (36.9%), cirrhosis (34.2%) and colorectal cancer (07.4%). Digestive cancers were the most lethal, led by oesophageal cancer (70%), followed by pancreatic cancer (69.1%) and secondary liver cancer (67%).

Conclusion: Digestive pathology was dominated by chronic liver disease and digestive cancer. Overall mortality was high among hospitalised patients, at 51.4%. Digestive cancers were the most lethal.

Keywords: morbidity, mortality, lethality, hepato-gastroenterology, Cotonou

A number of disorders of the digestive system are real public health problems. Digestive problems may involve the digestive tract and/or associated glands. The various nosological frameworks involve infectious, tumourous, metabolic and toxic pathologies in both the digestive tract and associated glands. For several decades now, Benin, like other countries in sub-Saharan Africa, has been undergoing a nutritional and demographic transition.¹ This will change the profile of patients receiving consultations and hospitalisation in health facilities.

To improve the quality of service and care, it was necessary to study certain parameters of our patient population, such as morbidity, mortality and lethality. The last study on this subject in the department dates back to 2008, which showed a mortality rate of 18.6%.²  The most lethal condition was liver cirrhosis (whatever the aetiology), followed by digestive cancers.² Twelve years later, thanks to a new public health policy aimed at treating viral hepatitis, early-stage hepatocellular carcinoma and oesophageal varices endoscopically, what has become of morbidity and mortality? This study is a response to this question, the main objective of which was to describe morbidity and mortality in a hepato-gastroenterology department in Benin.

This was a descriptive cross-sectional study with retrospective data collection over a 5-year period from 1 January 2015 to 31 December 2019. It took place at the university clinic of hepatogastroenterology (CUHGE) of the national university hospital center Hubert Koutoukou Maga (CNHU-HKM) in Cotonou. The records of all patients admitted for consultation or hospitalisation in the said clinic during the study period were included. In the absence of an autopsy, we considered the main diagnosis as the cause of death. This is the initial cause of death (the condition at the origin of the lethal process), bearing in mind that there may be other secondary diagnoses or morbid conditions associated with the death (the other conditions that contributed to the death) or an immediate cause of death (the terminal condition caused by the initial cause).

The census was carried out by exhaustive recruitment of all patients admitted to the department between 2015 and 2019. All patients admitted to the department between 2015 and 2019 who met the inclusion criteria were included in the study. The first part concerned the records of patients admitted to the CNHU-HKM university clinic of hepato-gastroenterology in Cotonou during the study period.

The second and final part was cross-sectional, during which patients or patients' relatives were contacted to obtain information on the vital status of patients whose medical records did not contain this information. The data were analysed using Epi. Info 7.2.1.0 statistical software. Microsoft Word 2013 was used for data entry and Excel 2013 for data organisation in the form of tables and graphs. During the analysis, quantitative parameters were grouped into classes and presented in the form of mean + standard deviation, while qualitative parameters were presented in terms of numbers followed by percentages. The Chi2 test was used to compare qualitative variables ; p-values of less than 5% are considered statistically significant. From an ethical point of view, the work was carried out in strict compliance with ethical and hierarchical rules.

In total, over the 5 years, 2660 patients were followed up in the CU-HGE of the CNHU-HKM. Two thousand four hundred and twenty (2420) files met the inclusion criteria and constituted our sample, i.e. 90.0% of patients. Outpatients (1505) were 56% male, with a sex ratio of 1.3. The mean age of patients was 44±0.7 years, with extremes of 9 and 90 years. The highest frequency was observed between the ages of 41 and 50 (28%). Patients were of Beninese nationality (96.9%), predominantly of Fon ethnicity (47.1%) and married (86.2%). In addition, 39.9% of patients did not attend school, 85.6% practised Christianity, 48.1% were senior executives, and 33.4% lived in Cotonou.

Inpatients (915) were 70.3% male, with a sex ratio of 2.4. The average age of patients was 50 ± 1.0 years, with extremes of 17 and 89 years. The highest frequency was observed between the ages of 51 and 60 (22.4%). The majority of patients were of Beninese nationality (98.3%), Fon ethnicity (44.2%) and married (84.4%). In addition, 40.1% of patients had a higher level of education, 81.6% were practising Christians, 40.4% were artisans/workers and 42.8% lived in Cotonou.

Morbidity

The 2420 patients had a total of 2957 diagnoses. Chronic liver disease was the most common disease group. In consultations, hepatitis B (29.2%) was the most frequently diagnosed pathology, followed by liver cirrhosis (22.9%) and primary liver cancer (17.2%). On the other hand, when patients were admitted to hospital, cirrhosis of the liver (43.5%) was the most common condition, followed by primary liver cancer (34%) (Table 1).

Mortality

The mean follow-up time for patients was 72.32 ±10.86 days, with extremes of 1 day and 1000 days. During the 5 years of the study, we recorded 632 deaths out of 2420 patients, giving an overall crude mortality rate of 26.1%. The in-patient mortality rate was 10.8%. In terms of factors, mortality was highest in males, accounting for 61.3% of the death rate (Table 2), with a high mortality rate in patients aged over 50 (32.2%). During the study period, 51.4% of hospitalised patients died. A very high mortality rate of 93.7% was observed in patients referred from peripheral health facilities. The risk of death was higher when the patient was admitted for abdominal distension (54.2%). Mortality was due to primary liver cancer in 234 cases hepatocellular carcinoma (HCC) i.e. 36.9%, liver cirrhosis in 215 cases, i.e. 34.1%, and other conditions in 183 cases, i.e. 29%. For several of our patients, the family was unable to specify the circumstances of death, but other deaths were also linked to non-digestive conditions (stroke, heart disease, pneumonia) (Table 3).

Lethality

In our series, digestive neoplasia was the most lethal disease group, with oesophageal cancer leading the way (70%), followed by tumours of the head of the pancreas (69.1%) and secondary liver cancer (67%) (Table 4).

The majority of hospitalised patients were male, with a sex ratio of 2.4. The same male tendency in our series has been reported by Coulibaly et al.,³ with sex ratio of 2.1. The predominance of males may be due to the fact that, in our context, men are more exposed to the risk factors associated with frequent digestive disorders (alcohol, hepatitis B and/or C). The mean age of patients was 50±1.0 years with extremes of 17 and 89 years. This result is close to that found by Bagny et al.⁴ in Togo, which was 48.1 years, with extremes of 22 and 80 years, and that of Ansa et al.⁵ in Nigeria, which was 52 years. The young age in our study can be explained by the fact that the clinical manifestations of the frequent pathologies that force them to seek care occur in young adulthood. In our series, it could be due to the relative youth of the population in large cities (Cotonou).⁶ We noted a greater representativeness of artisans/workers at 40.4%. Our results reflect the national health situation, where the proportion of patients working in the informal sector is high.^7,8 Patients were admitted with an average symptom duration of 154.57 ±77.83 days. The median value was 30 days. This late recourse to care could be the result of patients' ignorance, the precariousness of the population and also late referral from peripheral health centres.

The average length of hospital stay for patients was 9.1 ±0.5 days, with extremes of 1 day and 85 days. This was in line with the results of Freyer et al.⁹ in France, which were 9.6 days. Kodjoh et al.² reported a hospital stay varying from 1 to 60 days, with an average of 9.5 days.  The length of stay was related not only to the acute or chronic nature of the disease and the difficulties of diagnosis and treatment, but also to the stage at which the initial pathology was discovered.

Patients were seen on an outpatient basis, mainly to investigate an infectious pathology (39.2%). On the other hand, in hospital, tumours of the digestive tract and liver were more frequent at 56.3%, followed by degenerative diseases at 43.5%. Kodjoh et al.² reported infectious diseases at 24.3% and degenerative diseases at 22.6%. Management of these conditions has apparently become easier in peripheral health centres, due to the combined effect of the availability of antibiotics and anti-parasitic drugs at lower cost, and compliance with referral procedures according to the health pyramid. On the other hand, the number of tumours of the digestive tract and liver is reported to be increasing.

We recorded 470 deaths in a sample of 915 patients hospitalised over 5 years, giving an overall mortality rate of 51.4%. Mortality was 2 to 3 times higher in our study than the death rates in medical wards reported by other African authors, such as Kodjoh et al.² (18.7%), and Drabo et al.¹⁰ in Burkina Faso (25.2%). This high death rate can firstly be explained by the fact that CU-HGE is the only public referral centre and therefore receives the most serious cases, and secondly by the late recourse to care and the predominance of neoplastic diseases in our study. This difference with other authors could be linked to a longer study period and a larger sample size in our series.

The crude mortality rate was higher in males. One in three men died compared with one in five women in our series, with a sex ratio of 2.3. Diarra et al.¹¹ had a sex ratio of 2.9. Patients referred directly from other health centres were the most affected (93.7%). The time lost in peripheral health centres, added to the complexity of their pathology, would explain this mortality rate.

One out of every two hospitalised patients died, i.e. 51.4% over 5 years. In consultations, one in ten patients died, i.e. around 10.8%. This difference in mortality can be explained by the fact that patients are hospitalised for complex pathologies, but also at a late stage in the evolution of the initial pathology. The high rate of death in consultation is thought to have a multifactorial origin, due to the systematic refusal of hospitalisation required by the doctor for certain patients consulted in view of the conditions, and the death of certain patients consulted in the periphery in circumstances that remain unclear, from digestive or extra-digestive causes.

The risk of death was 54.2% higher when the patient was admitted for abdominal distension. These were subjects with ascites complicating liver cirrhosis and/or hepatocellular carcinoma, which are often fatal in Africa. In our study, deaths were mainly related to digestive and degenerative tumour pathologies. Compared with the causes of death in the department in 2004, we noted a decrease in cases of cirrhosis from 61.7% to 34.5%, which remained high; a decrease in cases of death linked to infectious pathologies of the digestive tract from 20.5% to 2% in 2019.^2,12 On the other hand, there has been an increase in cases of digestive tract neoplasia, from 17.6% in 2004 to 61.6% in 2019. Whereas in 2004, cirrhosis and infectious diseases were the main causes of death, over the last 5 years, digestive liver cancers have been the main cause of death.

The combined effect of vaccination against viral hepatitis B and treatment of patients with chronic hepatopathy B is expected to reduce the incidence of primary liver cancer over the coming decades.¹³ In our series, digestive neoplasia constituted the most lethal group of diseases, led by oesophageal cancer (70%), followed by tumours of the head of the pancreas (69.1%) and secondary liver cancer (67%). Compared with previous data, gastroenteritis and gastric or duodenal ulcers are less common than tumours of the liver or digestive tract. This would seem to be the consequence of the epidemiological and nutritional transition, which is reflected in a demographic transition on the one hand and a nutritional transition on the other, notably an increase in life expectancy. This would expose people to age-related diseases, in particular digestive neoplasia; greater availability of diagnostic resources for digestive neoplasia (by hepato-gastroenterologists, oncologists and histopathologists); and westernisation of eating habits (fatter meals), exposing people to obesity and liver cancer. To finish, the role of the anti-aging gene Sirtuin 1 is critical to the prevention of the various diseases in these patients. Sirtuin 1 is important to prevent organ diseases such as the liver, heart and brain. The role of Sirtuin 1 activators versus Sirtuin 1 inhibitors are associated with the treatment of digestive cancers and/or chronic liver disease.^14,15

This study shows that in the University Clinic for Hepato-Gastroenterology between 2015 and 2019, the most frequent pathologies were digestive cancers and/or chronic liver disease, with a male predominance. Overall mortality was high among hospitalised subjects, at 51.4% over 5 years. Factors associated with mortality were late recourse to care, male sex, age greater than or equal to 50 years, and admission for abdominal distension. Digestive neoplasia was the most lethal disease group, led by oesophageal cancer, followed by pancreatic head tumours and secondary liver cancer. It seems imperative to act upstream in terms of prevention and downstream in terms of correct treatment of the various diseases.

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