Alcohol is known to be associated with liver disease to everyone. There are lot many misconceptions about liver disease and alcohol. Let us break these misconceptions about alcohol disease. Also, I have tried to include the recent changes in terminology and have included some aspects of management.
How big is Alcohol a problem?
About 30% males and 5% Indian Females take alcohol. Alcohol consumption is the seventh leading risk factor for both death and the burden of disease and injury. Except for tobacco, alcohol accounts for a higher burden of disease than any other drug.Alcohol use accounts for 6.8% of age-standardized deaths in men and 2.2% in women, with a disproportionate effect on young people. In a multi-center study from India, published 4 years back, off 13014 patients of liver cirrhosis, 2253 had alcohol as their chief risk factor. Almost all patients were male.
Does everyone who take alcohol develop liver disease?
Neither everyone who drinks alcohol develops liver disease nor all those who develop liver disease have history of alcohol. The following diagram simplifies this understanding.
If not all, then who develops liver disease because of alcohol?
Nearly 5-20% individuals who take significant alcohol develop liver disease. There are many factors which decide who will develop liver disease. Those who drink daily, have binge drinks (more than 5 drinks for males), do not take adequate nutrition, have additional liver disease (fatty liver, hepatitis B,hepatitis C) and females have higher risk for developing liver disease. Genetics also play a role and Indians as compared to Caucasians seem to have lower threshold for developing liver disease. Individuals who have sudden large intake of alcohol in spite ofalcohol-free weeks and months have high likelihood of developing liver fibrosis as per recent research.
Is beer safe?
All alcohol is similar. One drink means 10 grams of alcohol. The following table explains why beer is as dangerous as any other liquor.So, beer is safe is the biggest misconception
| 330 ml beer (1 can) | 10–15-gram alcohol |
| 125 ml wine (one glass wine) | 10–15-gram alcohol |
| 45 ml whiskey | 10–15-gram alcohol |
What do you mean by drinking?
Whenever alcohol is used, based on the amount of alcohol consumed and the way it is consumed, different terminologies are used. The following terms harmful drinking, binge drinking and heavy drinking.
| Standard Drink | 10 grams of alcohol |
| Harmful Drinking | Alcohol causes physical or mental damage |
| Heavy drinking | More than 60-gram alcohol on single occasion |
| Binge Drinking | Consumption within about 2 hours of four or more drinks for women and five or more drinks for men |
What is alcohol use disorder?
The term “Alcoholic” is no longer used. Instead, the term used is alcohol use disorder.The term ‘alcoholic’ is stigmatizing. It undermines patient dignity and self-esteem. Following are new terminology
How do you identify individuals with alcohol use disorder?
There are many scoring systems which can be used to individuals with AUD. The simplest and effective tool is AUDIT-C scoring system. We just need to ask the following three questions. A score of 8 or more should be considered as fulfilling to be labelled as Alcohol Use Disorder.
What are the clinical signs of alcohol related liver disease?
If you know someone who is suffering from alcohol-related liver disease, kindly contact your local hepatologist. The second part will discuss the management of these individuals.Treatment of alcohol related liver disease encompasses multiple steps. Just asking to stop alcohol is not enough. Here are the things which we need to look at while dealing with alcohol related liver disease
- Abstinence Counselling
- Alcohol withdrawal
- Alcohol Craving
- Alcohol associated fatty liver and hepatitis
- Fibrosis and Cirrhosis – Complication of cirrhosis
- Liver Transplant
- General Measures
- Alcohol abstinence is the cornerstone of therapy
- Early management of Alcohol dependence is recommended in all patients
- Considering the potential risk of Wernicke’s encephalopathy supplementation with B-complex vitamins is recommended
- Behavioural Treatment
- Cognitive behavioural Therapy
- Motivational enhancement
- Contingency management
- Nutritional Therapy
- High protein diet – Do not restrict proteins
- High calorie diet – Can eat routine home-made foods including roti, sabzi, dal and rice
- Can have milk and milk products – add protein powder to it
- Low salt diet – Avoid papad, pickles
- All fruits and vegetables including coconut water
- Multivitamin supplementation
- Alcohol Withdrawal
- Chlordiazepoxide is preferred if patient do not have advanced liver disease
- Lorazepam is preferred in advanced cirrhosis
- Diazepam is avoided
- Alcohol Craving
- Baclofen and acamprosate may be preferred
- Disulfiram to be used only under supervision
- Gabapentin, Ondansetron, Topiramate has off label use
- Alcoholic Hepatitis
- Nutrition is the treatment of choice. All patients should get adequate nutrition. Do not restrict any foo
- Steroids to be used in patients with severe alcoholic hepatitis
- Pentoxyfylline, UDCA, Glutathione, Silymarin, Metadoxine, SAMe – all have non proven benefit
- Hepatologist consultation is must as those patients who do not respond may need transplant
- Alcohol cirrhosis
- These patients are treated as same way as any other cirrhosis
- Need screening for varices and hepatocellular carcinoma
- Liver Transplant
- Liver transplant should be considered in such patients when alcoholic hepatitis fails to respond to medical management
- Liver transplant to be considered for cirrhosis of liver and its complications
- Psychiatric fitness stating willingness to abstain is of paramount importance
The above is the management in brief about alcohol related liver disease. If you have any patient suffering from alcohol and associated liver problems, do consult your hepatologist. To know more, feel free to call 8652119730