Liver and alcohol and obesity

liverAfter finishing my clinic one morning last week, I couldn’t help reflecting on the harm that lifestyle issues had brought to some of the patients I was seeing. I refer of course to alcoholism and obesity and how they can lead to end-stage liver disease, with cirrhosis and liver cancer. Miserable illnesses and a miserable death, totally preventable.

Drinking safely – up to 21 units a week for men and 14 for a woman – has always seemed to me a quite generous allowance in terms of enhancing sociability and gatherings together. Would people really continue to drink to the point of drunkenness if they saw, as I do, all the physical consequences, including trauma to themselves, violence to others and even sudden death from the effect on the heart? Dying from liver disease is particularly unpleasant, even horrifying, with episodes of vomiting blood, abdominal fluid collection requiring frequent tapping, along with failure of brain functions.

There are one and a quarter million admissions to NHS hospitals each year from alcohol-related diseases and this is a terrible reflection on our society. The relentlessly rising mortality rates for chronic liver disease is to be compared with falling rates for other common chronic disorders including strokes and heart disease. Male mortality rates for cirrhosis in the UK now surpass those in France and Italy where notoriously high rates have fallen steadily over a 25 year period. 80% of the hospital admissions are due to alcoholic liver disease and the increase over the past 10 years parallels the rise in overall alcohol consumption. Hospital admissions for alcohol related conditions are projected to rise to two million per annum by 2020. Similarly, obesity, with its consequences on premature death from cardiac disease as well as liver cirrhosis and liver cancer, is an unnecessary evil. There is evidence now too that obesity is a risk factor for developing the common cancers of colon and of the breast.

Approximately 40% of the adult British public are now in the overweight category and 20% are obese and the figures are rising each year, in fact they have trebled in the last 30 years.

Sometimes I now see in my practice adolescents who, because of obesity or starting to drink early, have developed severe consequences in terms of organ damage.

As for the chronically infected Hepatitis B (HBV) and Hepatitis C (HCV) subjects in the country, the numbers are similarly escalating. The pool of chronic HBV infections, estimated at 325,000 persons, has doubled in the past ten years and an additional 7,500 cases are being added each year consequent on immigration from countries with high prevalence rates for HBV. A similar number of HCV positive immigrants are likely to be entering the UK each year and the pool of chronic HCV infections in the country is conservatively estimated at over 200,000 subjects. Less that 20% are thought to have been diagnosed to date for, as with HBV infection, the majority of cases are asymptomatic until the disease is advanced. Because of the long natural history of chronic HCV hepatitis, it is estimated end stage cirrhosis and HCC will peak in 2020. It already constitutes the second major category of end-stage liver disease requiring transplantation in the UK, alcoholic liver disease being the first.

Treatments for these conditions are improving, which is some consolation and with the present pace of medical advance many more new medications will undoubtedly be developed though at the moment they are very expensive. In Hepatitis C, we hope to be shortly introducing new drugs which will completely eradicate the virus infection in 95-100% of cases. Techniques we have established for treatment of liver tumours, namely transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) can give three to five year survivals, even cure. But all this is dependent on early diagnosis. Fortunately diagnostic techniques are also improving.

But how much better to prevent these ills;

by Prof Roger Williams CBE Director Liver Unit at the London Clinic.

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