Alcohol and drugs

So I’m Andy Holt. I’m one of the transplant hepatologists in the liver unit in Birmingham. So Andy, what is alcohol liver disease and what are the symptoms? So alcoholic liver disease bridges quite a few different diseases. Just by its name you know that it’s something that’s caused by alcohol excess. But what we’re beginning to learn is that– number one– not everyone who drinks excessively develops liver disease, and also some people who– perhaps to you or I– perhaps don’t drink that much seem to develop cirrhosis. So I prefer to call it alcohol-related liver disease, although in many patients alcohol is the dominant injury to the liver. And it usually affects people in young adulthood or middle age.

But it can affect people of any age. And it’s probably the commonest cause of liver disease in the UK. And who can get alcohol liver disease? Pretty much anyone who’s vulnerable to liver disease. So for instance, you might be talking to people about fatty liver disease. Well we know that if you have a tendency to fatty liver disease then the risk threshold is lower. And so anybody who drinks in excess of what their liver can metabolise safely might be at risk of alcoholic liver disease. But clearly if someone in the general public were listening to this they would have in their mind a picture of someone who lives under a railway arch and drinks all day.

But not everyone with alcohol-related liver disease is like that. In fact that’s a minority of the patients we see here. And a lot of the patients that we see here with alcohol-related liver diseases would look very normal to someone outside the clinic. Do we know how alcohol damages the liver? Yeah we’re getting better at that. I mean we haven’t fully understood the mechanisms. But one of the strongest predictors for alcohol-related liver disease is actually genetics. And we’re beginning to unpick some of those genetic patterns that will predict these things.

And in fact we’re finding that a lot of the risk factors that lead to alcohol-related liver disease are similar to the genetic risk factors that might be to fatty liver disease. So some people have a kind of genetic vulnerability and the alcohol just adds on to that and, if you like, it amplifies or accentuates the injury. Also we know that certain other liver diseases will give you a vulnerability. So it’s quite common actually for someone to be referred with alcohol cirrhosis and for us to find that, yeah, there’s alcohol damage but they also might have too much iron in their liver. Or they might have a problem with some proteins that are stored in the liver.

So there might be more than one process that’s damaging the liver. And can the liver also be damaged by drugs? Yes it can. And it can be damaged by drugs that doctors prescribe. And it can be damaged by drugs that people take themselves and perhaps the doctor doesn’t know about it. So we know, for instance, that if you take cannabis then that might accelerate fibrosis for a variety of reasons. We know that some drugs that we might give for skin diseases can sometimes cause fibrosis in patients.

And actually sometimes drugs that are given for all sorts of different things in the wrong person can react in a bad way with the liver and can damage the liver so badly that it stops working. Do we know what are the current treatment options for alcoholic liver disease? Yeah it’s difficult to treat. And that’s because you have to deal with the addiction, if the person’s drinking too much, and you have to deal with the effects of the liver damage. So you can’t take the two apart. They’re all part of the same thing. Presumably it’s the same for drugs as well? Exactly, yeah.

So in many cases people have drunk harmfully for well over a decade and it’s part of their life. And in some cases, in truth, it’s a part of their life they’re not willing to give up. It’s who they are. It’s how they are. It’s where their friends are, in the pub. And so they find it very difficult to make those changes. So you have to work with the psychology. You have to work with the addiction psychiatry elements of these things. And at the same time we try to do our best to manage the problems of the cirrhosis as well. So it’s a multi-disciplinary issue.

It involves a lot of different experts bringing in a lot of different skills in order to manage the patient successfully.