Alcoholic liver disease - the extent of the problem and what you can do about it

Abstract

It takes upwards of ten years for alcohol-related liver disease to progress from fatty liver through fibrosis to cirrhosis to acute on chronic liver failure. This process is silent and symptom free and can easily be missed in primary care, usually presenting with advanced cirrhosis. At this late stage, management consists of expert supportive care, with prompt identification and treatment of bleeding, sepsis and renal problems, as well as support to change behaviour and stop harmful alcohol consumption. There are opportunities to improve care by bringing liver care everywhere up to the standards of the best liver units, as detailed in the Lancet Commission report. We also need a fundamental rethink of the technologies and approaches used in primary care to detect and intervene in liver disease at a much earlier stage. However, the most effective and cost-effective measure would be a proper evidence-based alcohol strategy.

Keywords: Lancet Commission; Liver; alcohol; alcohol policy; cirrhosis; early detection; minimum unit price.

Fig 1.

Standardised UK mortality rate data (age 0–64 years) from the WHO-HFA database normalised to 100% in 1970, and subsequent trends. Adapted with permission.

Fig 2.

Time period between referral to a liver clinic and the first admission with cirrhosis or liver failure. Adapted with permission.

Fig 3.

Diagnostic pathway. AUDIT-C: a three-question test (taken from the ten-question AUDIT) and screening method to identify hazardous alcohol consumption on a scale of 0–12; a score of 4+ indicates hazardous people or are at increasing risk, 7+ indicates harmful drinkers or of higher risk, and 9+ indicates possible alcohol dependency. Red represents when secondary care referral is indicated for probable serious liver disease, acute hepatic injury, severe fibrosis or cirrhosis. Orange represents when secondary care referral is usually indicated for probable progressive liver fibrosis but not cirrhosis. Green represents no evidence of significant liver fibrosis at this stage, risk factors should be addressed and the pathway repeated after an interval if they remain. Blue represents the usual pathway. Grey represents the final decision box. AUDIT C = alcohol use disorders identification test-consumption; ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; DM2 = type 2 diabetes; GGT = γ-glutamyl transpeptidase; HDL = high density lipoprotein; IQR = interquartile range; LFTs = liver function tests; NAFLD = non-alcoholic fatty liver disease; OGD = oesophogastroduodenoscopy. Adapted with permission.

Fig 4.

(A) Mean weekly alcohol consumption, (B) price paid per unit of alcohol and (C) impact of a 50p MUP of alcohol in 404 patients with liver disease, categorised according to their level of alcohol drinking. Adapted with permission. CI = confidence interval; MUP = minimum unit pricing.