The Epidemiology of Alcoholic Liver Disease
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The Epidemiology of Alcoholic Liver Disease Robert E. Mann, Ph.D., Reginald G. Smart, Ph.D., and Richard Govoni, Ph.D. This article describes the various forms of alcoholic liver disease (ALD), with particular emphasis on cirrhosis, the form of liver disease that often is most associated with alcohol abuse and about which the most information is available. Epidemiological research has evaluated the prevalence of ALD and the factors that often contribute to the disease. Although the most potent factor in ALD is the excessive consumption of alcoholic beverages, gender and ethnic differences also account for some important variations in rates of liver disease. Mortality rates from cirrhosis have declined in the United States and some other countries since the 1970s. A number of factors may have contributed to this decline, including increased participation in treatment for alcohol problems and Alcoholics Anonymous membership, decreases in alcohol consumption, and changes in the consumption of certain types of alcoholic beverages. KEY WORDS: alcoholic liver cirrhosis; epidemiological indicators; gender differences; ethnic differences; AODR (alcohol and other drug related) mortality; morbidity; AOD (alcohol and other drug) use pattern; risk factors; trend; aggregate AOD consumption; beneficial vs adverse drug effect; Alcoholics Anonymous; United States; survey of research ne of the most enduring insights Alcohol consumption increased into the effects of alcohol has substantially in many countries after ROBERT E. MANN, PH.D., is a senior Obeen the assertion that heavy World War II, which spurred greater scientist in the Department of Social, alcohol consumption increases mortality interest in the effects of alcohol con- Prevention and Health Policy Research rates, especially those from cirrhosis of sumption on cirrhosis and other forms at the Centre for Addiction and Mental the liver and other forms of liver disease of alcoholic liver disease (ALD). One Health and an associate professor in the (see the sidebar, p. 211). The scientific of the most influential efforts to sum- Department of Public Health Sciences study of alcohol-related mortality marize research in this area was under- at the University of Toronto, both in began in the 1920s with Pearl’s studies taken in 1975 by an international Toronto, Canada. (1926) of death rates among various group of scientists sponsored by the REGINALD G. SMART, PH.D., is a principal types of drinkers. He and others found World Health Organization (WHO). and senior scientist in the Department of that heavy drinkers had higher rates of The resulting book, Alcohol Control Social, Prevention and Health Policy overall mortality and of mortality from Policies in Public Health Perspective (Bruun et al. 1975), reviewed studies of clinical Research at the Centre for Addiction and cirrhosis than did lighter drinkers or and nonclinical populations of heavy Mental Health in Toronto, Canada. abstainers. Since then, mortality studies drinkers. All studies found that a greater have continued to demonstrate that proportion of heavy drinkers died of RICHARD GOVONI, PH.D., is a research heavy drinkers and alcoholics die from cirrhosis than would be expected based fellow in the Department of Public Health cirrhosis at a much higher rate than the on rates of cirrhosis deaths in the Sciences at the University of Toronto and general population (Mann et al. 1993; general population (i.e., liver cirrhosis an assistant professor in the Department Pell and D’Alonzo 1973; Schmidt and deaths among heavy drinkers ranged of Psychology at the University of Windsor de Lint 1972; Thun et al. 1997). In from 2 to 23 times higher than the in Windsor, Canada. addition, laboratory studies conducted rate that would be expected in the gen- in the 1930s established that feeding eral population). The preparation of this work was supported large amounts of alcohol to rats and This research established a firm in part by a fellowship to R. Govoni other animals caused liver disease connection between heavy alcohol con- from the Ontario Problem Gambling (Lelbach 1974). sumption and liver disease. Investigators Research Centre. Vol. 27, No. 3, 2003 209 Ode to the Liver measuring and transferring or its mortar wastes away, Modest, in your hidden the eyes of the rose are gone, organized alchemical the teeth of the carnation wilted friend, chamber. and the maiden silent in the river. underground Yellow Austere portion worker, is the matrix or the whole let me give you of your red hydraulic flow, of myself, the wing of my song, diver grandfather the thrust of the most perilous of the heart, of the air, depths of man, generator the soaring there forever hidden, of energy: of my ode: everlasting, I sing to you it is born in the factory, and I fear you of your invisible noiseless. as though you were judge, machinery, And every feeling meter, it flies or impulse implacable indicator, from your tireless grew in your machinery, and if I can not confined mill, received some drop surrender myself in shackles to austerity, delicate of your tireless if the surfeit of powerful elaboration, delicacies, entrail, to love you added or the hereditary wine of my country ever alive and dark. fire or melancholy, dared While let one tiny cell to disturb my health the heart resounds and attracts be in error or the equilibrium of my poetry, the music of the mandolin, or one fiber be worn from you, there, inside, in your labor dark monarch, you filter and the pilot flies into the wrong sky, giver of syrups and of poisons, and apportion, the tenor collapses in a wheeze, regulator of salts, you separate the astronomer loses a planet. from you I hope for justice: and divide, Up above, how I love life: Do not betray me! Work on! you multiply the bewitching eyes of the rose Do not arrest my song. and lubricate, and the lips you raise of the matinal carnation and gather sparkle! the threads and the grams How the maiden Pablo Neruda, 1904–1973 of life, the final in the river laughs! Nobel Laureate in Literature, 1971 distillate, And down below, Translation by Oriana Josseau Kalant the intimate essences. the filter and the balance, “Oda al Higado,” by Pablo Neruda, Submerged the delicate chemistry viscus, translated by Oriana Josseau of the liver, Kalant, as published in Alcohol measurer the storehouse Liver Pathology (J.M. Khana, of the blood, of the subtle changes: Y. Israel, and H. Kalant, editors) you live no one © 1975. Reprinted with permis full of hands sees or celebrates it, sion of the Centre for Addiction and full of eyes, but, when it ages and Mental Health, Toronto. 210 Alcohol Research & Health The Epidemiology of Alcoholic Liver Disease also have observed that the price of availability and includes recommenda Drinking Patterns and alcohol is a significant determinant tions to control cirrhosis and other Alcoholic Liver Disease of alcohol consumption and thus of alcohol-related problems through tax cirrhosis mortality rates (Bruun et al. ation (Chaloupka et al. 2002; Cook Many studies show that the amount 1975; Edwards et al. 1994; Seeley and Tauchen 1982). The validity of of alcohol consumed and the dura 1960). These findings have laid the this availability-control approach has tion of that consumption are closely foundation for an influential public been widely supported (e.g., Edwards associated with cirrhosis.1 One of the health approach to controlling liver et al. 1994), and investigations of the best demonstrations of this associa disease and other alcohol problems that epidemiology of ALD have continued tion was presented by Lelbach emphasizes the control of alcohol’s to be central to it (e.g., Ramstedt 2001). (1974), who studied 319 patients in Types of Alcoholic Liver Disease The most prevalent types of alcoholic liver disease are changes; white nails; thickening and widening of the fatty liver, alcoholic hepatitis, and cirrhosis. Often, as fingers and nails (clubbing); liver enlargement or people continue to drink heavily, they progress from inflammation; and abnormal accumulation of fat fatty liver to hepatitis to cirrhosis. The disorders can in normal liver cells (fatty infiltration). Diagnosis of also occur together, however, and liver biopsies can show cirrhosis must be made with biopsies, although labo signs of all three in some people (Kirsh et al. 1995). ratory tests can be helpful as well. About 10 percent to 15 percent of people with alco Alcoholic Fatty Liver holism develop cirrhosis, but many survive it. Many are unaware that they have it, and about 30 percent to 40 percent About 20 percent of alcoholics and heavy drinkers of cirrhosis cases are discovered at autopsy (Anand 1999). develop fatty liver, or steatosis. In many cases there The 5-year survival rate for people with cirrhosis who stop are no clinical symptoms except for an enlarged liver drinking is about 90 percent, compared with 70 percent (hepatomegaly). Fatty liver can be reversed if alcohol of those who do not stop drinking. However, for late-stage consumption is stopped or significantly reduced, but cirrhosis—that is, when jaundice, accumulation of fluid the condition can lead to death if alcohol consump in the abdomen (ascites), or gastrointestinal bleeding have tion is not reduced or stopped. Some biopsies from occurred—the survival rate is only 60 percent for those people with fatty liver show inflammatory changes, who stop drinking and 35 percent for those who do not. an early sign of more serious liver disease. Other Forms of Liver Disease Affected by Alcohol Alcoholic Hepatitis Alcohol can be a factor in other forms of liver disease Alcoholic hepatitis usually is diagnosed when a liver not specifically attributed to it, and alcohol may interact biopsy indicates inflammatory changes, liver degener with risk factors for other forms of liver disease. For ation, fibrosis, and other changes to liver cells.