'˜Silent killer' liver disease striking more and more Scots

Liver disease is the fifth largest cause of death in the UK, with alcohol the biggest factor. On day two of our series examining Scotland's relationship with drink, Kevan Christie investigates what medical experts call the '˜silent killer'
More young women than ever are developing alcoholic liver disease in Scotland with hundreds of patients being diagnosed in their 20s and 30s. 
Picture: Phil Wilkinson
.More young women than ever are developing alcoholic liver disease in Scotland with hundreds of patients being diagnosed in their 20s and 30s. 
Picture: Phil Wilkinson
More young women than ever are developing alcoholic liver disease in Scotland with hundreds of patients being diagnosed in their 20s and 30s. Picture: Phil Wilkinson .

So, the novelty cards and witty T-shirts say, but on day two of Alcohol Awareness Week we shine a light on the scale of abuse this most sturdy of organs endures. A huge dichotomy exists in Scotland between joking about the levels of pain we inflict on our booze-soaked livers and the harsh reality of serious problems slipping under the radar until it’s all too late.

The horror of alcohol-related liver disease, referred to as a ‘silent illness’ by medical experts, is that you can continue a heavy drinking lifestyle with no symptoms but serious damage is happening underneath the surface.

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Often this will only manifest itself with the individual finding out they’ve already got cirrhosis after a catastrophic health complication, like a life-threatening hemorrhage or they find themselves hospitalised with severe jaundice and have turned yellow.

The Scottish statistics for alcohol-related liver disease are predictably alarming – with the average age of death being 59 in contrast to cardiovascular and respiratory disease, where the standard age of death is 80.

This is compounded by the five-fold increase in cirrhosis development in 35-55 year-olds over the past decade, which increases the risk of death.

In Scotland these death rates are also linked to social deprivation with those living in the most deprived areas having an eleven-fold increase in the risk of dying from liver disease in comparison to an individual in the least deprived areas.

Dr Alastair MacGilchrist, consultant liver specialist at the Edinburgh Royal Infirmary says the biggest challenge for medical professionals is to identify early those people who are at risk from drinking too much.

“One of the biggest problems that we have is trying to pick out the advancing disease amongst all the people out there who have for example – slightly abnormal liver tests,” he says.

“It’s often a double, there are the people who are drinking too much and then there are the people who are overweight or diabetic.

“The liver is actually rather similar in terms of both these outcomes and not uncommonly now you see folk who are both overweight and drinking too much so it might be both [factors].

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“The 64 million dollar question for GPs and for hospital specialists is how to most easily identify these people and there’s no perfect solution.

“The standard blood test that a GP does will give you some information about whether there’s a scarred liver or not, and there are some useful ratios you can do on routine blood tests.

“When the GP ticks the liver box when he’s asking for blood tests he gets a certain number of things back but he then has to ask for more specific information to do more detailed analysis.”

Dr MacGilchrist says he has a “prejudice” about people hearing the government talking about safe limits and knowing that they are drinking more than the recommended 14 units per week for both men and women but doing nothing about it because they are feeling fine.

He believes more could be done by medical professionals to identify people who are drinking too much and making a link with liver disease.

He adds: “I think you can put it down to two sentences.

“If somebody is found to be drinking too much you should check their liver function and if somebody is noted to have abnormal liver function you should ask how much they are drinking.

“It’s both a strength and a weakness of the liver that it can soak up a lot of punishment before it actually falls apart. What happens is that over years or decades there will 
be insidious progressive damage.”

Although younger patients and more women with cirrhosis attract the most attention and generate headlines, the vast majority of people with the illness are still men – usually in middle age who are often dependent drinkers relying on cheaper alcohol products.

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Mortality rates vary across the country ranging from 9.1 per 105 population in Dumfries and Galloway to 21.5 per 105 population in Greater Glasgow and Clyde.

Liver disease is the fifth largest cause of death in the UK with 70 per cent of liver cirrhosis a consequence of alcohol.

Dr MacGilchrist says care should be taken not to stigmatise people with alcohol-related liver disease as having behaved in a way that has led them to seriously damage themselves.

He adds: “You have to be slightly careful in using terms like the people have ‘done this to themselves’.

“There’s two different issues which I see. You’ve got alcohol-liver damage and I see that as a liver specialist but you’ve got alcohol addiction or alcohol dependency and that’s not really that person’s fault. They feel great remorse, they feel very guilty because it’s a situation where your heart rules your head – you know what you should do but you just can’t do it.

“I would like to see better public health measures and that’s going to happen.

“I would like to see us being better at picking up earlier disease and that’s in terms of identifying drinkers with abnormal liver function at an early stage before it’s irreversible and when it comes to treatment we’re not as good as we should be at marrying up the liver side of things and the alcohol addiction side of things.

“These people need help and it’s not a very rewarding process because they often don’t see any way of them stopping themselves [drinking].”

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When it comes to a solution Dr MacGilchrist and his fellow medical professionals are in favour of a ‘floor price’ which minimum unit pricing would bring for products like cheap cider and vodka – with the Supreme Court decision due tomorrow.

He believes that it takes generations to change attitudes but believes it can be done and makes comparisons with the moves taken to encourage people to stop smoking, when the Scottish Government brought in a smoking ban and it became unacceptable to 
have a cigarette in a public place. However, he says that ultimately most of the answers lie in the public health arena, not in the hands of doctors and feels that “as a liver specialist I’m picking up the pieces once it’s too late”.

Dr MacGilchrist signs off with a chilling insight into his work on the ward where he literally sees patients change colour in a matter of days due to the onset of severe alcohol-related liver disease.

“I was on ward duty last week and I saw a patient exactly like that. He’d come in with what was thought to be an acute episode of jaundice, perhaps an infection, but when we actually went into it we realised this chap had liver disease for many years unbeknown to him and was drinking more than he should do,” he says.

“You can see patients in their 30s or even younger. I had several ladies in the ward recently in their early 40s with advanced cirrhosis, several of whom will probably not survive.

“One of the sad things I see is often a person’s health is the last thing to go. By the time I see them they’ve lost their family, job, driving licence and then they lose their health.”