Alcohol related liver disease

George AboudaGastroenterology 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

SteatosisSteatosis

SteatohepatitisSteatohepatitis

CirrhosisCirrhosis

Hepatocellular carcinoma

Hepatocellular carcinoma

Liver diseaseSpectrum of Hepatic Pathology

Liver diseaseSpectrum of Hepatic Pathology

12-20%

0-12%

12-20%25%Diehl AM 2006 www.bsg.org.ukDay C. Clinical Medicine 2005; 6: 19-25

30%

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

0

50

100

150

200

250

Jan Mar May Jul Sep Nov

Alcohol admissions in AAU Jan-Dec 2009

0

10

20

30

40

50

60

Jan Mar May Jul Sep Nov

ARD ALD

Number of patients

34 18

Bed/days occupancy

287 405

Admission episodes

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 ToolOne question in A&E (ASQ)

Alcohol liaison workerJunior doctors

AUDIT questionnaireAlcohol specialist nurse

< 8….discharge8 .. AUD20 … SADQ

Brief intervention

Continue care in community e.g ADSAdmit …AAU/speciality-Rx of Alcohol withdrawal( care pathway ) -start detox. .community-full detox community/inpatient

Alcohol specialist nursepsychiatry/medical(PLN/LNP)

Specialist consultant led outpatient and inpatient careFor high risk ALD and serious co-morbidities

Alcohol De-addiction pathway-Hull & East Yorkshire Hospitals

* 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)

Admit the Patient

Screening Tool/ SASQ/AUDIT* Questionnaire

Discharge with Community support

Assess severity by SADQ**

DO NOT START FULL DETOX UNTIL PATIENT AGREES FOR IT & IS MOTIVATED

Pt with suspected Alcohol abuse seen in A& E/ AAU

Score >20 Score <20

Prescribe Pabrinex & Chlordiazepoxide as per regime

Brief intervention by specialist nurses in A&E/AAU

Symptoms of liver disease

• 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 .

• 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

In the clinic

• Alcohol abstinence is crucial to allow liver to pick up

In the hospital ward

• 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