Alcohol related liver disease
George Abouda
Gastroenterology and Hepatology consultant
Alcohol awareness day
September 2013
• Liver disease is the 5th 'big killer' in England and Wales,
after heart, cancer, stroke and respiratory disease but
unlike the others, no clear national service framework .
• Of the big five liver disease is the only major cause of
death increasing year on year
• Liver disease deaths have increased by 12% in just
three years, since 2005, totalling 46,244 lives lost. If
these rates continue, deaths from liver disease are
predicted to double in 20 years
•Between 1999 and 2005 and in the last 30 years, mortality has risen over 450% in the UK
• The process of alcohol liver disease is silent, but when
liver disease has developed it presents as an acute
illness with a 25-50% immediate mortality
•
There was a 41% increase in the number of deaths from
alcoholic liver disease
• Hospital admissions for alcohol-related disease,
including alcoholic liver disease, have more than
doubled since 1995/6 and between 2002/3 and 2006/7
there was a 71% increase .
• There was over 1.1 million hospital admissions directly
related and attributable to alcohol in 2011
• Liver disease is preventable disease
Alcohol and the liver disease
• The cost to the NHS of alcohol misuse has been estimated at £2.7
billion each year
• In 2011, there were 10,732 alcohol-related deaths in men and 5,992
in women
• In 2007 4,580 people died in England and Wales from alcoholic liver
disease
• 2012 NICE recommendation for ARD
http://www.statistics.gov.uk/cci/nugget.asp?id=1091
Liver disease
Spectrum of Hepatic Pathology
Steatohepatitis
30%
12-20%
Steatosis
Cirrhosis
Hepatocellular
carcinoma
Diehl AM 2006 www.bsg.org.uk
Day C. Clinical Medicine 2005; 6: 19-25
Alcohol problem in Hull
• Hull is the 11th most deprived local authority area out of
352 in England
• Hull experiences well over the national average of
alcohol consumption
• 40,000 people in Hull are hazardous or harmful drinkers
• 8000 are alcohol dependent
• 2/3 of alcohol related hospital admissions are dependent
drinkers
• 1289/100,000 are admitted with ARD
Alcohol is a real burden in the
acute trust
• Method: Retrospective analysis of attendances and
admissions with Alcohol related medical problems.
• Patients from Jan-Dec 2009 analysed on a monthly
basis.
• Total of 2055 attendances to A & E
• Average 516 admissions via AAU per year (43/month).
• Bed Occupancy in Ward 7 over 8 weeks.
Alcohol in A & E -Jan-Dec 2009
250
200
150
100
50
0
Jan
Mar
May
Jul
Sep
Nov
Alcohol admissions in AAU
Jan-Dec 2009
60
50
40
30
20
10
0
Jan
Mar
May
Jul
Sep
Nov
Number of
patients
Bed/days
occupancy
Admission
episodes
ARD
ALD
34
18
287
405
37
22
Bed occupancy –ward 7
• 1st Feb to 21st March 2010
• 173 total admissions
• 34 with Alcohol dependence required 1 week detox
(approx 20%)- 1 direct admission.
• 5.8% recurrent admissions ( 2-3 times)
• Average length of stay for ALD pts = 18.4
range b/w 4-62 days
• Total number of bed days occupied = 405
The Need
Multidisciplinary Alcohol Care Team led by a consultant
with dedicated sessions. This team will collaborate with
Public health , Psychiatry specialists, PCT, patients
groups and stakeholders to develop and implement a
comprehensive alcohol strategy
Avoid alcohol three days a week
Meeting the challenge of improved quality of care and
better use of resources
• Secondary care is a pivotal key player in alcohol
service for Hull and East Yorkshire.
• We have the core setup to build a coherent
alcohol service team
Consultant with interest in alcohol related disease
Excellent links with Humber mental NHS
Efficient and experienced community services
• Meetings with commissioners and planning department .
• Agreement to fund 3 posts of alcohol liaison nurses in
acute trust
• Alcohol liver nurse
• Referral form with screening tool
• Assessment of alcohol intake as part of new AAU
clerking sheet .
• Protocol for management of patients with alcohol related
withdrawal symptoms on the intranet
• Regular Alcohol OPC
Education
Screening Tool
One question in A&E (ASQ)
Alcohol liaison worker
Junior doctors
Alcohol specialist nurse
AUDIT questionnaire
Brief intervention
Continue care in community e.g ADS
Alcohol specialist nurse
psychiatry/medical(PLN/LNP)
< 8….discharge
8 .. AUD
20 … SADQ
Admit …AAU/speciality
-Rx of Alcohol withdrawal
( care pathway )
-start detox. .community
-full detox community/inpatient
Specialist consultant led outpatient and inpatient care
For high risk ALD and serious co-morbidities
Alcohol De-addiction pathway-Hull & East Yorkshire Hospitals
Pt with suspected Alcohol
abuse seen in A& E/ AAU
Screening Tool/
SASQ/AUDIT* Questionnaire
Score >20
Admit the Patient
Brief intervention by
specialist nurses in
A&E/AAU
Score <20
Discharge with
Community support
Assess severity
by SADQ**
Prescribe Pabrinex
& Chlordiazepoxide
as per regime
DO NOT START FULL DETOX UNTIL PATIENT AGREES FOR IT & IS MOTIVATED
* SASQ/AUDIT score: 8-16= hazardous drinking, >16= Dangerous drinking, >20=
dependency
**SADQ score <15= mild dependency, 15-29= Moderate, >30 Severe dependency
*** Initial dose depends on the patient’s SADQ score (Ex, 20 mgs QDS on day 1 if
SADQ score is 20)
Symptoms of liver disease
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Most of the time non specific
Fatigue
Jaundice
Itching
Easy bruising
Leg/abdomen swelling
Confusion
How do we manage liver disease
• All patients who have risk factors for developing liver
disease should be tested by their GPs/health centres
( alcohol excess, obesity , viral infection ,..)
• Liver disease can be diagnosed by blood tests or scans
• We use non invasive novel tests in Hull to diagnose liver
disease early .
• We offer one stop liver clinics where patients are
reviewed by consultant , assessed , scans done and
results given at end of consultation .
In the clinic
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Healthy diet not weight reduction
Gentle exercise without muscle building
Reduce alcohol even if it is minimum
Set targets and time of review
Treat the obvious
Control other metabolic risk factors
• Alcohol abstinence is crucial to allow liver to pick up
In the hospital ward
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IV vitamins
IV fluids
Diuretics
Anti coma measures
Antibiotics
Staging the disease
Endoscopy
Liver transplant
• Nurse assessment
• Patient views and
understanding
• Alcohol liaison nurse
review
• Family support
• Social support
• Palliative care
Alcohol related liver disease is preventable