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Alcoholic liver disease
Written by Dr Matthew Warren, specialist registrar in liver medicine and Professor Christopher P Day, professor of liver medicine
Good advice
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 is still beneficial to stop drinking. Compensated cirrhotics who continue to drink are far more likely to develop decompensated disease whereas the survival rates of those who stop are as high as 89 per cent. But a decompensated cirrhotic who continues to drink only has a 33 per cent chance of survival.
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:
Alcoholic hepatitis
Steroids can also help some of these patients, but even with steroids 90 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
Treatment of decompensated cirrhosis
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
Encephalopathy
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
Approximately 85 per cent of appropriate patients reach the five-year survival rates following a transplant.
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.
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.
In patients with decompensated cirrhosis, specific treatments may be required to deal with the complications of the disease:
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.
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.
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:
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