Alcohol Related Liver Disease

The NHS advice on recommended daily alcohol intake is no more than 2-3 units for women and 3-4 units for men on a regular basis.

Hazardous drinking means excess alcohol intake above these limits, which leads to an increased risk of health problems directly related to alcohol. Harmful drinking indicates the presence of physical or psychological harm.

When alcohol dependence occurs, this is associated with a compulsion to drink, overriding other normal activities. Tolerance to alcohol develops, leading to increasing intake. Severely dependent drinkers might experience withdrawal symptoms like anxiety and tremor, addressed by more alcohol intake.

Diagnosis of Alcohol Misuse

Alcohol misuse may be diagnosed using Alcohol Use Disorders Identification Test (AUDIT) consisting of 10 questions or the simpler Fast Alcohol Screening Test (FAST) with 4 questions

Common Presentations:

1. Incidental Abnormal Blood Tests, No Symptom

Alcohol is one of the commonest causes of abnormal liver function tests (LFTs). Unless there is an alternative explanation for abnormal LFTs, it would be reasonable to advise a period (about 2 months) of significant reduced alcohol intake or abstinence and then repeat the LFTs.

Alcohol related liver disease (ARLD) does not show symptoms until the most advanced stages. Liver damage begins with fatty liver, progresses through fibrosis and eventually cirrhosis occurs. Normal LFTs don’t equate to a normal liver.

Even if the LFTs improve or normalise, patients should be referred for assessment if there is suspicion of chronic liver disease with clinical signs or abnormal blood tests (reduced albumin, abnormal clotting, or low platelet count).

2. Psychological

People with alcohol problems are more likely (than those without alcohol problems) to have a psychiatric or personality disorder. Conversely, a significant number of people with a psychiatric disorder suffer from alcohol dependence. The psychological effects of alcohol include depression, anxiety, and personality change.

It may be difficult to work out whether alcohol or psychological/ psychiatric problems came first. They should be addressed with a holistic approach by a multi-disciplinary alcohol care team.

Traditionally, people offering short-term help in the voluntary sector tended to call themselves counsellors, while people who had trained on a psychotherapy course would call themselves psychotherapists. People with primarily psychological problem may contact the local Improving Access to Psychological Therapies (IAPT) service. In the presence of any physical alcohol related problems, it would be more appropriate to see a psychiatrist who is medically qualified, as he/she can prescribe medication if necessary.

3. Psychological and Physical

For hazardous and harmful drinking, early identification & brief advice (IBA) and brief interventions (counselling sessions) in hospital and primary care are effective in reducing alcohol consumption. This may be available through the local Community Alcohol Team/ Service.

Community detoxification for alcohol dependence may be possible under supervision with or without medication to help ease withdrawal symptoms. A tranquiliser called Chlordiazepoxide is commonly used.

In more severe alcohol dependency, residential or inpatient detoxification involving an admission to a hospital is recommended due to the risk of more severe withdrawal symptoms, such as seizures and hallucinations.

The detoxification is followed by a recovery program. For the people who have successfully achieved abstinence from alcohol, Acamprosate (Campral) and Disulfiram (Antabuse) help prevent relapse.

4. Physical

a. Alcoholic Hepatitis
This is a type of acute hepatitis (liver inflammation) when patients typically present with jaundice. Patients don’t necessarily have developed cirrhosis. If a liver biopsy is done, there are specific histological features to diagnose alcoholic hepatitis.

The severity and prognosis can be assessed by modified Maddrey discrimination function (mDF) and Glasgow alcoholic hepatitis score (GAHS). A mDF score greater than 32 indicates severe alcoholic hepatitis with poor prognosis.

Severe alcoholic hepatitis requires hospitalisation and consideration of treatment with steroids.

b. Complications of Cirrhosis and Portal Hypertension
In the presence of chronic liver disease or established cirrhosis, portal hypertension and liver failure (decompensation) may ensue. The presentations include jaundice, ascites, hepatic encephalopathy or upper gastrointestinal tract bleeding from varices.

The mortality rate increases when there are associated complications of spontaneous bacterial peritonitis (SBP), hepato-renal syndrome (HRS), sepsis and malnourishment. Patients presenting with the above have grave prognosis even when they survive a hospital admission, especially if they do not maintain abstinence from alcohol following discharge.

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