BACKGROUND MEDIA INFORMATION
ALCOHOLIC LIVER DISEASE
What is Alcoholic Liver Disease? (ALD)
Alcoholic liver disease (ALD) is a result of regular and heavy drinking. Alcohol consumption is the
world’s third largest risk factor for disease and disability, but in middle-income countries, it is the
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greatest risk. Four percent of all deaths worldwide are attributable to alcohol and alcohol is the
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world’s leading risk factor for death among males aged 15–59.
The world’s highest alcohol consumption levels are found in the developed world, including
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western and eastern Europe. One in fifteen adults in Europe suffers from serious illness because of
alcohol consumption - making it the third largest cause of early death and illness behind tobacco and
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high blood pressure . From 1970-2000 in England, there was a tenfold increase among women aged
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35-44 dying from cirrhosis.
Harmful Drinking
Europe has the highest rate of alcohol consumption in the world (12.18 litres of pure alcohol
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per adult per year)
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Fifty-five million adults are estimated to drink alcohol to harmful levels in the European Union
One in seven European adults (aged 15 or over) consume more than 40g alcohol/day (men)
or 20g/day (women) on average and over one in five report a heavy drinking episode (50g
1
alcohol on a single occasion) at least once a week
What are the risk factors for ALD?
Alcohol consumption
The amount of alcohol consumed (independent of the form in which it is ingested) is the most
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important risk factor for the development of Alcoholic Liver Disease . The suggested healthy limit of
alcohol intake has long been 21 units (where a unit is defined as the equivalent of 8 g of ethanol) per
4,5,6
week in men and 14 units per week in women.
Above these thresholds, the risk of liver disease becomes significant, and then increases dramatically
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according to a dose dependent pattern. The risk of developing cirrhosis becomes substantial with
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the consumption of 60-80 g/day of alcohol for 10 years or longer in men, and 20 g/day in women.
The suggested healthy limits apply only to persons without pre-existing liver disease. In patients with
chronic liver injury (e.g., carriers of hepatitis B or hepatitis C), the consumption of even small
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quantities of alcohol should be avoided, as they worsen the course of liver disease.
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The definition of safe levels of alcohol intake varies wildly across Europe
United Kingdom: A standard drink is 8g
Austria, France, Ireland, Italy, Poland, and Spain: A standard drink is 10g
Denmark and Italy : A standard drink is 12g
Portugal: A standard drink is 14g
Drinking Patterns
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Drinking outside of meal times increases the risk of ALD 2.7 times as does daily versus weekend
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drinking. Daily drinking carries more than twice the risk of liver damage compared with intermittent
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drinking once or twice per week and binge drinking also dramatically increases the risk of developing
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ALD.
Gender
Women are twice as sensitive as men to alcohol related liver damage and developing more severe
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ALD at lower doses and with shorter durations of alcohol consumption. Higher blood alcohol
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concentrations are found in women than men after consumption of equal amounts of alcohol.
Women also have lower levels of the alcohol metabolising enzyme (gastric alcohol dehydrogenase), a
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higher proportion of body fat and alcohol absorption changes during the menstrual cycle.
Obesity
Obesity is the most significant diet-related risk factor for fibrosis progression and the single most
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important risk factor determining the risk of cirrhosis in heavy drinkers. Heavy drinkers with obesityassociated diabetes have a nine-fold higher risk of developing liver cancer (Hepatocellular
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carcinoma).
Viral Hepatitis
Hepatitis B & C viruses are risk factors for ALD, with disease developing at a younger age, more
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severe symptoms and degenerative effects seen, and a decreased chance of survival. Hepatitis C
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increases the risk of cirrhosis 30-fold in heavy drinkers.
What disease profiles are associated with ALD?
Fatty liver disease
Fatty liver disease, or hepatic steatosis, is the build-up of fat in the liver that usually follows moderate
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intake of alcohol. It rarely causes any symptoms and is therefore hard to detect – for example blood
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tests designed to detect liver damage can often be normal.
Fatty liver disease develops in about 90% of individuals who drink more than 60 g/day of alcohol, but
23,24
may also occur in individuals who drink less.
On its own, fatty liver disease does not cause
significant liver damage and can be reversed if alcohol consumption is stopped for about 4-6 weeks.
However continued alcohol use (40 g/day) increases the risk of progression to cirrhosis to 30%, and
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fibrosis or cirrhosis to 37%.
Alcoholic hepatitis
Alcoholic hepatitis is the second, more serious, stage of alcoholic liver disease and can be caused by
a prolonged high intake of alcohol or a large intake of alcohol in a short period of time (binge
1
drinking).
Alcoholic hepatitis is characterised by an accumulation of fat in the liver cells as well as inflammation
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of the liver, disrupting its normal function. Mild forms of alcoholic hepatitis may not cause noticeable
symptoms, but as the disease becomes more advanced and the liver more damaged, patients may
experience general malaise, fever, weight loss, tenderness of the abdomen and jaundice – a
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yellowing of the skin.
Alcoholic hepatitis carries a 10-20% risk of death, with many patients developing long-term
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complications. Some patients may recover with total cessation of alcohol consumption but, for
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some, hepatitis persists and leads to cirrhosis.
Cirrhosis
20% of heavy drinkers develop irreversible liver damage, or alcoholic cirrhosis: a serious and
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potentially fatal condition with liver failure and death as the probable end result. Cirrhosis is the final
stage of alcoholic liver disease, when prolonged inflammation of the liver has caused scarring and
loss of function.
The immediate cessation of drinking can prevent further damage in mild to moderate cases, while
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more severe cases will require a liver transplant.
People are often unaware they have cirrhosis - about 30-40% of cirrhosis cases are discovered at
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autopsy. The 5-year survival rate for people with cirrhosis who stop drinking is about 90%,
compared with 70% for those who do not stop drinking. In late-stage cirrhosis the survival rate is only
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60% for those who stop drinking and 35% for those who do not.
What is the long-term prognosis of ALD?
For most people with fatty liver disease and mild alcoholic hepatitis, the liver will recover and heal
itself if alcohol consumption is stopped. Even in the late stages of disease, when cirrhosis is present,
the cessation of drinking will reduce further damage to the liver and increase chances of survival.
However, 3-6% of those who continue to drink alcohol will develop hepatocellular carcinoma, a
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primary liver cancer that could be fatal within months.
How is ALD diagnosed?
Diagnosis of ALD is based on a combination of features:
A history of significant alcohol intake
Clinical evidence of liver disease
Supporting laboratory abnormalities
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However there are a number of issues that make ALD difficult to diagnose:
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Underreporting of alcohol intake is common in patients
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Early forms of ALD are often asymptomatic
Physical exam and laboratory evidence for ALD may be non diagnostic, especially in patients
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with mild ALD or early cirrhosis
Physicians often have to rely on indirect evidence of alcohol abuse, such as questionnaires,
32
information from family members, or laboratory tests to strengthen or confirm a clinical suspicion.
Screening
It is important for physicians to incorporate screening into their general practice.
must be taken which may suggest excessive alcohol consumption. This includes:
o The amount of alcohol consumed
o The pattern of alcohol consumption
o The type of alcohol consumed
o Evidence of social or psychological consequences of alcohol abuse
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A clinical history
Various questionnaires have been used to detect alcohol dependence or abuse, but the gold standard
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is the WHO’s Alcohol Use Disorders Identification Test (AUDIT).
Tests for alcoholic liver damage
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Tests for alcoholic liver damage include:
Blood tests, which among other things measure liver function and damage
Scanning the liver with either an ultrasound, computerised tomography (CT) or magnetic
resonance imaging (MRI) scan
Performing a liver biopsy
Patients with cirrhosis should undergo screening and regular surveillance for hepatocellular
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carcinoma (ultrasound every six months), particularly important for older cirrhotics.
What treatments are available for ALD?
The optimal management of ALD must begin with lifestyle changes, in which abstinence from, or
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dramatic reduction in alcohol use is crucial.
The next step is to eliminate other risk factors that enhance disease progression, such as:
Smoking
Obesity
Inappropriate drug use (e.g. excess acetaminophen/paracetamol)
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Treatment of other liver diseases, such as iron overload or Hepatitis C, is an important step in
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managing ALD progression.
Hospitalisation is recommended to speed up a diagnostic evaluation of patients with jaundice,
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encephalopathy, or ascites of unknown cause.
The assessment of nutritional status and nutritional supplementation should be aggressively
instigated in patients with ALD with more severe disease such as severe alcoholic hepatitis or
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cirrhosis. Nutritional supplementation may enhance liver function and decrease morbidity and
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mortality in some patients.
Drug intervention
Corticosteroids have been the most extensively studied treatment for patients with alcoholic
hepatitis/cirrhosis. They are used in alcoholic hepatitis patients, or patients in a hepatic coma, who do
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not have a significant gastrointestinal bleed or infection.
Pentoxifylline is alternative to corticosteroids in patients who are at risk for hepatorenal syndrome
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(worsening creatinine, infection, hyponatremia).
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At present there are no drugs with documented efficacy available for alcoholic cirrhosis.
Transplantation
Liver transplants are very effective in carefully selected cirrhosis patients who have discontinued
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drinking, but liver transplantation in alcoholic cirrhotics remains a highly controversial and sensitive
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issue.
The seven year survival rate after liver transplant for ALD has been reported as 60%, comparable to
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the rates for primary biliary cirrhosis (76%) and chronic hepatitis C (57%).
References
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