Alcohol and liver disease
By Head of Department, dr.med. Ulrik Becker
The Alcohol unit, Hvidovre Hospital
Alcohol consumption in Denmark
Through the 1960s, the Danes’ alcohol consumption has risen to approximately 12 litres of pure alcohol per Dane over the age of 15. Since the 1970s, the consumption has been stable at this level, which means that each adult Dane, drinks on average around 2.2 standard drinks every day (1 standard drink = the contents of one normal pilsner = 12 g of pure alcohol). The consumption is of course spread unevenly – some drink a lot, many drink “normally” and very few don’t drink at all – as a rule of thumb, we say that 20 % of the population consume 75% of the alcohol. Everyone knows the National Board of Health’s drink limitations, which establish the boundaries for alcohol consumption – 14 standard drinks per week for women, and 21 standard drinks per week for men – where anything over equals a higher health risk. Approximately ½ million Danes drink more than the recommended alcohol consumption limits, and around 200.000 Danes are addicted to alcohol, meaning they have developed a pathological addiction to it, the same way that you can get addicted to narcotics and tobacco. Especially Danish youths have an unfortunate European record, when it comes to both consumption amounts, and the age that they start drinking.
Affected blood work/steatohepatitis (fatty liver)
The most frequent effect of a large alcohol consumption is affected “liver enzymes”, meaning the enzymes (ASAT, ALAT, GGT) that are measured in the blood when you’re tested for liver disease. In a randomly chosen segment of the Danish population, approximately every eighth adult has elevated liver enzymes. In many cases this is because of a moderate or large alcohol consumption and elevated liver enzymes without any other symptoms is amongst the most common reasons for referrals to further examination at a liver specialist. In most cases, the reason is the so-called fatty liver, which means an increased accumulation of fat in the liver that is most often caused by alcohol, obesity, diabetes and issues with the metabolism of the liver. Often the diagnosis is based on medical histories and blood work, while it may very rarely be necessary to take a liver biopsy.
Alcohol conditioned fatty liver is in most cases a benign condition that goes away on its own when alcohol consumption is reduced or ceases. In a few cases there may be an increase in connective tissue formation in the liver, especially when there’s also an inflammation in the liver. It is important, however, to correctly expose the reasons for the increased liver enzymes and treat the cause. The sooner an alcohol problem is treated, the higher the chance of successful treatment and positive results.
Alcohol conditioned liver inflammation
Alcoholic hepatitis can be virtually without symptoms, but it can also be an acute disease with signs of liver failure following a period with a very large alcohol consumption. Symptoms are fever, poor general condition, jaundice, enlarged liver and even ascites. Liver enzymes are often very high and a liver biopsy will show inflammation, cell death and increased connective tissue. There’s a high risk of developing cirrhosis and the mortality rate of alcoholic hepatitis is approximately 25% but the prospects are significantly better if the alcohol consumption ceases. Treating the alcohol consumption is therefore incredibly important. Alcoholic hepatitis can be long lasting (months). More specific treatment of the inflammation is still being researched.
Alcohol conditioned Liver Cirrhosis
About a 1000 people die annually due to cirrhosis of the liver – 2/3 men and 1/3 women. Cirrhosis can have many other causes than alcohol, but it is estimated that approximately ¾ of the cases in men and ½ of the cases in women are due to alcohol. Alcohol is therefore the most common reason for cirrhosis of the liver in Denmark. During a case, there have often been one or more episodes with alcoholic hepatitis, prior to the development of cirrhosis.
Cirrhosis is often followed by other complications such as varicose veins in the oesophagus, ascites, oedema and swelling of the legs and a number of symptoms from other organs. 3-5% of cirrhosis patients eventually also develop liver cancer. The mortality rate of cirrhosis is high. If there are complications to the cirrhosis, approximately 50% of patients die within 2 years and if there are no complications, it is 50% within 4 years.
Alcohol is the most significant factor in a given case, since lifespan is more than doubled if alcohol consumption is given up completely. That’s why it is imperative that patients with alcoholic cirrhosis treat their problems with alcohol. Resuming even a modest alcohol consumption would be the same as playing Russian roulette – not because a single unit of alcohol every once in a while is significant, but rather because it often leads to a daily and gradually increasing alcohol consumption, which can be hard to control. That’s why the best advice is lifelong abstinence.
In addition to treating alcoholism, the options for treatment of complications of the liver disease, such as varicose veins, ascites, infections, coma and kidney failure, have improved greatly in the past 10 years. A liver transplant is as accepted as a treatment of patients with alcoholic cirrhosis as it is for other liver diseases – under the condition that any alcohol problem is treated, of course. The results of liver transplants are just as good for patients with alcoholic cirrhosis, as they are for patients with other types of liver disease.
When considering the large amount of people who drink more than the recommended amount of alcohol, you’d think that there was an equally large amount of people with liver disease. That isn’t the case, however. Compared to alcohol consumption, the amount of patients with liver cirrhosis is relatively modest. If you look at a group of alcoholic patients with a very large alcohol consumption, over an extended period, you’ll find that 1-2% develop alcohol cirrhosis per year.
Why is that? There is undoubtedly a genetically conditioned difference in how much an individual can handle. In some, the liver disease develops after a relatively small and short lasting alcohol consumption, while others never develop a liver disease, no matter how much they drink. The problem is that there is no way to know in advance, who has a tolerance to alcohol and who does not. Statistically we know that the risk of liver disease increases, if you drink more than the National Board of Health’s recommendation. We also know that women with a given alcohol consumption, have a higher risk of developing liver disease compared to men and likewise, that metabolizing alcohol in the body is also likely to be significant. A number of factors also have a significance for the risk of developing cirrhosis. If you, while having a large alcohol consumption, also smoke, the risk is increased and likewise if you are either over- or underweight. Having hepatitis C significantly increases the risk of developing alcohol cirrhosis.
There has been a lot of debate on whether or not wine carries less of a risk than other types of alcohol, but there is still no conclusive evidence either way. The problem is, that those who prefer wine over beer or spirits, generally have a healthier lifestyle and that this is why they have an apparent lower risk of contracting a number of health issues.
Alcohol treatment works
It is a common misconception that alcohol treatment doesn’t work anyway. This isn’t true. Many studies show that treatment of patients with alcoholism is effective. Like other chronic illnesses, some experience relapses, but there aren’t more relapses for people with alcoholism, than for example patients with high blood pressure, asthma or diabetes experience. Alcohol treatment has become more structured and in later years, medicine with an effect on alcohol dependency have been developed. In hospitals, it has also been shown, that even shorter treatment sessions are effective, and that increased investment in alcohol treatment means a lower mortality rate due to cirrhosis.