The festive season is behind us and many people’s thoughts are now turning to the new year and New Year’s resolutions, which for many may include an aim to cut back on the amount of alcohol they drink.
NICE recently released a draft consultation on liver disease. As a society, we have an awkward relationship with liver disease and alcohol. Indeed, most people think that cirrhosis and alcoholic liver disease are the same thing. In the late 1990s UK licensing laws were relaxed in line with our European cousins. The intention was to stop the stampede to “last” orders, towards a more enlightened approach to drinking, preferably while discussing issues of politics and philosophy. Of course, this was an illusion because the rates of alcoholic liver disease were higher in continental Europe.
The result of this (although admittedly not the only factor) has been a significant rise in the rates of cirrhosis observed within the UK. [2] Factors including greater availability of alcohol, a reduction in cost in real terms, and the pernicious impact of advertising and marketing have added to the rise. Of course alcohol is only one of the three unholy trinities of liver disease, the others being viral hepatitis (chronic hepatitis B and C) and non-alcoholic fatty liver disease.
NICE’s preliminary draft must be framed within this context. There are quality statements in it that touch on non-alcoholic fatty liver disease; ultrasound screening for hepatocellular carcinoma; the treatment of oesophageal varices endoscopically; and, finally, offering non-invasive testing for patients deemed to be at risk of cirrhosis i.e. screening. Now in theory this sounds like a good idea, but only in theory. The classic criteria for successful screening include that: the condition is an important health problem, there is an accepted treatment, there are facilities for diagnosis and treatment, and there is a suitable and acceptable test. [3] The nub of screening is this—either the disease is detected at an early stage so that the life threatening form of disease can be prevented, or curative treatment can be offered.
Economically, it is not an entirely altruistic exercise. Those implementing screening want to be sure that the cost is met, not purely on an individual level (as shown by prolonged survival), but also in reducing the cost to the state in the long term. A problem for all screening programmes is identifying “at risk” populations and getting them to participate.
The document highlights the “at risk” groups who should be focused on, but patients with viral hepatitis may not engage with conventional models of healthcare (or may not know they have it), overweight patients may not consider themselves at risk of liver disease, and patients drinking in excess of 35-50 units of alcohol per week may consider themselves social drinkers only—surely they couldn’t get cirrhosis. Patients should be identified from general practice, liver and gastroenterology clinics, and metabolic clinics. A public health campaign to highlight the dangers of liver disease to encourage patients to self-refer may be useful. This could also highlight the dangers of obesity (diabetes, cancer, and cardiovascular disease); the impact of alcohol on other aspects of life; and the risk factors for developing and consequences of having viral hepatitis.
Then there is the test. A principle of screening is that this should not be the diagnostic test. So disease aetiology has become the screen, which could mean a lot of tests given UK obesity rates and drinking habits. [2 & 4]
Acoustic radiation force impulse imaging (ARFI) is performed as part of a liver ultrasound and takes time (10-15 minutes). It requires a radiologist or trained ultrasonographer. There are already mutterings of discontent over the narrower question of ultrasound screening for hepatoma, so one could imagine an uprising of our sunlight shunning colleagues outside the buildings of the Royal College of Radiologists, if surveillance for cirrhosis using an imaging technique is to be broadened. [5] A fibroscan is an ultrasound based test that estimates the degree of liver scarring (fibrosis) and thus can be used to estimate the risk of cirrhosis. It is a quick test (i.e. it takes five minutes to perform) and can be done by anyone trained to do it, but it has a failure rate of 5-10%, particularly in obese patients.
Once the test is available, hubs for the cirrhosis testing should be created. These could operate in primary or secondary care centres, perhaps as “walk in clinics.” A diagnosis of cirrhosis would mandate a comprehensive explanation of its implications and a referral to a “specialist.” How this service will be financed and run is, unsurprisingly, not outlined. So this draft is a wish list. The carcass needs meat. Anyone for politics and philosophy?
Tim Cross qualified from St Bartholomew’s hospital medical school in 1996 and trained in gastroenterology and hepatology in Cambridge, London, and Plymouth. He works as a consultant hepatologist at the Royal Liverpool Hospital, Liverpool, UK.
Conflicts of interest: Tim Cross has received research and travel funding from BMS, Gilead, Bayer, and Sirtex.
References:
- Leon DA, McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. 2006 Jan 7;367(9504):52-6
- Wilson JMG, Jungner G. Principles and practice of screening for disease. Public Health Papers 34. World Health Organization. 1968
- http://content.digital.nhs.uk/catalogue/pub16988/obes-phys-acti-diet-eng-2015.pdf