Liver Disease – Public Health Challenge
Liver disease is a major public health challenge. Anyone involved in acute medicine will fully appreciate the emerging epidemic of liver disease. In contrast to the progress made in improving outcomes in heart disease and stroke, mortality from liver disease has risen dramatically over the past 20 years. Alcohol-related liver disease continues to account for the vast majority of liver related hospital admissions– between 2001 and 2022 alcohol-related liver disease hospital discharges increased by 42%. Patients with alcohol-related liver disease stay in hospital on average three times longer than patients hospitalised for non-alcohol related problems. Alcohol related liver disease accounted for over 45000 hospital bed days in 2022 in Ireland. Epidemiological data on the economic impact of alcohol related liver disease in Ireland is limited. In Northern Ireland, Alcohol related liver disease is now the second highest contributor to years of working life lost. The mean age of death from alcohol related liver disease is just 57 years.
Addressing the burden of alcohol-related liver disease requires a multifaceted approach. Firstly, policy change is required to reduce alcohol related harm at a societal level. The implementation of the public health alcohol bill is a positive first step. This has the potential to address the principle modifiable drivers of alcohol related harm – price and availability. The benefits of such an approach have been seen in Scotland where minimum unit pricing (MUP) was introduced in 2018. Although it is too early to appreciate to the full effects of MUP, alcohol-specific death rates have risen more slowly in Scotland compared the rest of the UK since MUP was introduced.
Secondly, there is a pressing need to collect better epidemiological and geographic data on liver disease related hospital admissions, mortality and access to specialist care. This data is needed for healthcare planning to identify gaps in care to improve outcomes for patients with liver disease. Networks and referral pathways to specialist care can be developed to align with newly established regional hospital groups. For example, Comprehensive multidisciplinary specialist cirrhosis care clinics have been shown to have a big impact on survival in patients with cirrhosis (53% relative risk reduction in 1 year mortality). There is also an opportunity to provide better integrated care to bridge the gap between primary and secondary care for patients with liver disease as part of the slaintecare strategy. We have good examples of where such a data driven approach has worked. The reconfiguration of stroke care and the resultant stepwise improvement in patient outcomes following stroke was catalysed by data from the first national stroke audit (2005-2008). Quality improvement initiatives for patients with liver disease can learn from this model of data driven quality improvement.
Mortality from end stage liver disease is high, and a fundamental change in approach at an individual patient level is also required to improve outcomes. This requires embracing simple methods for early identification of liver fibrosis coupled with disease prevention strategies. Liver disease is just one of the clinical manifestations of harmful alcohol use. Patients with harmful levels of alcohol use have frequent contact with healthcare professionals before liver disease becomes clinically apparent. Obtaining a screening alcohol history in every acute medical admission provides an opportunity to deliver brief alcohol interventions. The AUDIT (alcohol use disorder inventory tool) questionnaire remains the gold standard as a screening instrument. However, it is impractical to use it in all patients admitted through the emergency department. One proposed “pre-screening” technique is to use question 3 of the AUDIT questionnaire (“how often do you have 5 or more drinks on one occasion?”) followed by the full questionnaire if this is positive. Pharmacotherapy is underutilised in the management of patients with alcohol use disorder, and many patients would potentially benefit from its more widespread use. Drugs such as acamprosate, naltrexone and baclofen are effective as an adjunct to psychosocial therapy to maintain alcohol abstinence. Low dose baclofen can also be used to patients with cirrhosis and hepatic impairment.
Liver transplant remains a lifesaving option in a selected group patients with advanced liver disease who can a transplant survival benefit. Patients with complications of decompensated cirrhosis (i.e. recurrent ascites, hepatic encephalopathy, or variceal bleeding) have high mortality in the absence of an aetiological treatment for the underlying liver disease. Median survival in this group is less than 2 years in the absence of liver transplant. Early discussion with a liver transplant unit is advised before patient’s physical function deteriorates as their liver disease progresses. Organ donation rates have declined across the world following the COVID pandemic and Ireland is not immune to this trend. There is a pressing need to increase organ donation awareness as well as expanding the donor organ pool by using more extended criteria donors and donors after circulatory death. Noval technology such normothermic machine perfusion for donor organs to assess organ viability has revolutionised transplantation.
Finally, as a society we need to address the stigma around alcohol related disease. One small step is to avoid stigmatising terms such as “alcoholic”. Stigma results in discrimination, a reduction in health seeking behaviour and reduced alcohol of resources. A consensus statement from the four largest global liver societies have strongly advocated for a change in medical terminology replacing the term “alcoholic” with “alcohol-related” or “alcohol associated” (i.e. alcohol related hepatitis or alcohol related cirrhosis).
Written by Dr Omar Elsherif, Consultant Hepatologist, St Vincent’s University Hospital
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