Most people in the UK drink alcohol. Total alcohol consumption per head in the UK rose steeply between 1950 and 1975 and then levelled off until the mid 1990s, when it again started to climb.
The General Lifestyle Survey of 2008 found that 38 per cent of men and 29 per cent of women were likely to have exceeded the recommended daily maximum (4 units for men and 3 for women) in the week preceding interview.
In the last 10 years, the proportion of men and woman drinking more than 21 units weekly (men) and 14 units weekly (women) has remained steady at around 28 per cent for men and 15 per cent for women. (A unit of alcohol is a single measure of spirits, a half pint of ordinary beer or lager or a standard size glass of wine.)
What is alcoholic liver disease?
Excessive consumption of alcohol can cause liver disease, as well as harming many other body organs.
The prevalence of alcoholic liver disease (ALD) in a population is usually determined by measuring death rates from alcoholic cirrhosis (in which healthy liver tissue becomes increasingly replaced by scar tissue).
These rates have increased alarmingly in recent years. Death rates from ALD in the UK rose by from 3,236 in 2002 to 4,400 in 2008.
How much alcohol is harmful?
The amount of alcohol that can cause liver damage seems to vary widely between individuals. But it is certain that:
there’s good evidence that the more you drink the greater your risk of developing ALD
there’s a genetically inherited susceptibility to the harmful effects of alcohol
women are also believed to be more sensitive to the harmful effects of alcohol than men
daily drinking, and drinking outside meal times is more harmful than only drinking at weekends
obesity increases the risk of developing ALD.
How does ALD progress?
There are three main stages of ALD, although the progression through these stages is variable.
Examining a sample of the liver under the microscope from a biopsy gives the most accurate measure of the degree of liver damage.
Minimal change, or fatty liver: heavy drinkers often develop fatty change in the liver. This is not linked to deterioration in liver function, but abnormalities may be seen in some of the blood tests that give an indirect measure of liver disease (also called ‘liver function tests’ or ‘LFTs’). Fatty liver is reversible with abstinence from alcohol, but it is the first stage in the progression to cirrhosis.
Alcoholic hepatitis: the effects of this condition can be mild but may also be life threatening. The LFTs will almost always be abnormal, and the patient may develop jaundice. As with fatty liver, abstinence from alcohol can reverse the effects, but those who continue to drink heavily have a high risk of developing cirrhosis.
Cirrhosis: this is the final, irreversible stage of ALD and is characterised by scarring of the liver and development of liver nodules. It severely affects liver function and reduces life expectancy. The LFT’s are usually abnormal, there may be jaundice (yellow colouring of the eyes and skin) and sometimes bruising or bleeding caused by abnormalities of the blood clotting system. In an advanced stage of ALD (severe alcoholic hepatitis or cirrhosis) the remaining liver capacity is insufficient for it to carry out its normal functions, then the body’s metabolism becomes badly affected and the stage of ‘decompensated ALD’ is reached. Complications of this are discussed below.
What are the symptoms?
The symptoms of ALD are usually non-specific and do not necessarily indicate the severity of the underlying liver damage.
Many people will have vague symptoms – such as fatigue, nausea and vomiting ( typically in the morning), diarrhoea or abdominal pains.
Many patients, even with advanced ALD will have no symptoms and are detected by the finding of abnormal liver blood tests performed as part of routine health screening, or during the investigation of other conditions.
Only in the more advanced stages of decompensated ALD will the sufferer present with more specific liver-related symptoms, such as jaundice, ascites (fluid collecting in the abdomen, causing distension), haematemesis (vomiting of blood) or encephalopathy (confusion, reduced level of awareness and altered sleep pattern, eventually progressing to coma).
These are signs of severe liver damage and require urgent medical treatment.
How is ALD diagnosed?
If there is a history of alcohol excess sufficient to cause liver damage, tests can establish the presence and severity of the liver damage.
Blood tests can give an idea, but they are not accurate predictors.
Further tests in hospital can confirm the diagnosis and determine the severity of the disease.
Ultrasound scans create an image of the liver and surrounding organs, which helps in taking a liver biopsy.
The ultrasound scan can help to assess the severity of disease and exclude other common causes of abnormal LFTs, such as gallstones.
Liver biopsy is the most accurate test to determine the stage of ALD present and to ensure alcohol is the cause of the liver disease.
Research has shown that in up to 20 per cent of heavy drinkers with abnormal LFTs an alternate cause of liver disease is found on investigation.
Liver biopsies are performed under local anaesthetic and provide a tiny sample of the liver for analysis under the microscope.
What else could it be?
The above investigations will rule out whether the symptoms are caused by any of the following:
viral hepatitis, including hepatitis B and C.
haemochromatosis (an inherited disorder of iron metabolism).
Wilson’s disease (an inherited disorder of copper metabolism).
autoimmune hepatitis (a liver disorder caused by the immune system attacking the liver).
Good advice
Nutrition
A good diet and a ‘normal’ body weight can significantly improve the outcome of ALD. Many patients are severely malnourished, due to loss of appetite and nausea.
In advanced liver disease (alcoholic hepatitis and cirrhosis) nutritional supplements have been shown to significantly improve the liver blood tests.
A diet high in antioxidants, such as vitamin E and selenium, is thought to help prevent and treat ALD. These can be taken as supplements or by eating more fresh fruit and vegetables.
Abstinence
Even in advanced liver disease, it’s still beneficial to stop drinking.
Compensated cirrhotics who continue to drink are far more likely to develop decompensated disease whereas the 5 year survival rates of those who stop are as high as 89 per cent.
A decompensated cirrhotic, who continues to drink, has only a 33 per cent chance of surviving 5 years compared to around 65 per cent in abstaining patients.
Supervision may be required to safely reduce alcohol consumption. A rapid reduction can lead to a physical withdrawal syndrome in up to 40 per cent of cases, characterised by agitation, sweating, anxiety and fits.
Up to 5 per cent of people will experience visual hallucinations known as delirium tremens, or the ‘DTs’.
The withdrawal syndrome can be life threatening. Sedatives and hospital admission may be necessary.
How is ALD treated?
The treatment for ALD depends on the stage of the disease.
Minimal change or fatty liver
Abstinence from alcohol and improved nutrition with avoidance of obesity.
Alcoholic hepatitis
This will depend on the severity of the alcoholic hepatitis.
In mild cases only abstinence from alcohol and nutritional support are required.
But in acute severe alcoholic hepatitis – characterised by jaundice, easy bruising, abnormal blood tests and sometimes the presence of extra fluid within the abdomen (ascites) – hospital admission is necessary.
Steroids can also help some of these patients, but even with steroids 10 to 15 per cent die within three months of developing the disease.
Kidney failure, if it occurs, leads to an almost 100 per cent mortality rate.
Cirrhosis
Cirrhosis of the liver can be ‘compensated’ or ‘decompensated’.
Compensation implies cirrhosis without complications. The complications that may develop include bleeding from varices (abnormal veins that form in the gullet), ascites, jaundice and encephalopathy (confusion, reduction in conscious level and coma).
Compensated cirrhosis may be managed with abstinence from alcohol and nutritional support as above.
Treatment of decompensated cirrhosis
In patients with decompensated cirrhosis, specific treatments may be required to deal with the complications of the disease:
Bleeding varices
Bleeding varices may need treatment by endoscopy (a flexible camera which can be passed into the stomach) to obliterate the abnormal veins in the wall of the gullet. Long-term treatment with beta-blockers, such as propranolol (eg Inderal LA) may reduce the risks of further bleeding.
Patients with alcoholic cirrhosis often have a ‘screening’ endoscopy test to identify any varices before a bleed occurs. Where varices are found, treatment with beta-blockers has been shown to reduce the risk of a first bleed.
Ascites
Ascites require a low salt diet, and reduction of fluid intake is often advised.
Patients will usually be treated with diuretics (water tablets) and may require intermittent drainage of the fluid with a catheter or plastic drainage tube being inserted into the abdomen (paracentesis).
In some cases these measures will be unsuccessful, and further interventions such as a liver transplant may be needed.
Encephalopathy
This is usually linked to additional stress on the body.
This may include the use of inappropriate sedating or painkilling medicines, bleeding from the gullet or stomach, constipation, infections or abnormalities in the salts (electrolytes) in the blood.
The main factor involved in causing the encephalopathy is an increase in ammonia levels in the brain.
The treatment involves correcting the underlying problem and treatment with lactulose (a liquid laxative).
Lactulose decreases the production of ammonia in the gut and its absorption into the body.
It lowers ammonia levels in the blood and may need to be taken long term to prevent recurrence of the encephalopathy.
Liver transplantation
In some patients with cirrhosis, liver function continues to deteriorate despite abstinence from alcohol and they may be severely affected by complications.
These individuals may need a liver transplant.
But for patients to be considered for transplantation, they must:
have been abstinent from alcohol for six months
have advanced liver disease with complications
have no other organ damage
have good social or family support.
Approximately 85 per cent of appropriate patients survive five-years following a transplant.
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