1. Alcohol related liver disease George Abouda Gastroenterology and Hepatology consultant Alcohol awareness day September 2013

2. Liver disease is the 5th 'big killer' in England and Wales, after heart, cancer, stroke and respiratory disease but unlike the others, no clear national service framework. Of the big five liver disease is the only major cause of death increasing year on year Liver disease deaths have increased by 12% in just three years, since 2005, totalling 46,244 lives lost. If these rates continue, deaths from liver disease are predicted to double in 20 years

3. Between 1999 and 2005 and in the last 30 years, mortality has risen over 450% in the UK

6. The process of alcohol liver disease is silent, but when liver disease has developed it presents as an acute illness with a 25-50% immediate mortality There was a 41% increase in the number of deaths from alcoholic liver disease Hospital admissions for alcohol-related disease, including alcoholic liver disease, have more than doubled since 1995/6 and between 2002/3 and 2006/7 there was a 71% increase. There was over 1.1 million hospital admissions directly related and attributable to alcohol in 2011 Liver disease is preventable disease

7. Alcohol and the liver disease The cost to the NHS of alcohol misuse has been estimated at £2.7 billion each year In 2011, there were 10,732 alcohol-related deaths in men and 5,992 in women In 2007 4,580 people died in England and Wales from alcoholic liver disease 2012 NICE recommendation for ARD http://www.statistics.gov.uk/cci/nugget.asp?id=1091

8. Steatosis Steatohepatitis Cirrhosis Hepatocellular carcinoma Liver disease Spectrum of Hepatic Pathology Liver disease Spectrum of Hepatic Pathology 12-20% 0-12% 12-20% 25% Diehl AM 2006 www.bsg.org.uk Day C. Clinical Medicine 2005; 6: 19-25 30%

9. Alcohol problem in Hull Hull is the 11 th most deprived local authority area out of 352 in England Hull experiences well over the national average of alcohol consumption 40,000 people in Hull are hazardous or harmful drinkers 8000 are alcohol dependent 2/3 of alcohol related hospital admissions are dependent drinkers 1289/100,000 are admitted with ARD

10. Alcohol is a real burden in the acute trust Method: Retrospective analysis of attendances and admissions with Alcohol related medical problems. Patients from Jan-Dec 2009 analysed on a monthly basis. Total of 2055 attendances to A & E Average 516 admissions via AAU per year (43/month). Bed Occupancy in Ward 7 over 8 weeks.

11. Alcohol in A & E -Jan-Dec 2009

12. Alcohol admissions in AAU Jan-Dec 2009

13. ARDALD Number of patients 3418 Bed/days occupancy 287405 Admission episodes 3722

14. Bed occupancy –ward 7 1 st Feb to 21 st March 2010 173 total admissions 34 with Alcohol dependence required 1 week detox (approx 20%)- 1 direct admission. 5.8% recurrent admissions ( 2-3 times) Average length of stay for ALD pts = 18.4 range b/w 4-62 days Total number of bed days occupied = 405

15. The Need Multidisciplinary Alcohol Care Team led by a consultant with dedicated sessions. This team will collaborate with Public health, Psychiatry specialists, PCT, patients groups and stakeholders to develop and implement a comprehensive alcohol strategy

17. Avoid alcohol three days a week Meeting the challenge of improved quality of care and better use of resources

18. Secondary care is a pivotal key player in alcohol service for Hull and East Yorkshire. We have the core setup to build a coherent alcohol service team Consultant with interest in alcohol related disease Excellent links with Humber mental NHS Efficient and experienced community services

19. Meetings with commissioners and planning department. Agreement to fund 3 posts of alcohol liaison nurses in acute trust Alcohol liver nurse Referral form with screening tool Assessment of alcohol intake as part of new AAU clerking sheet. Protocol for management of patients with alcohol related withdrawal symptoms on the intranet Regular Alcohol OPC

20. Education

21. Screening Tool One question in A&E (ASQ) Alcohol liaison worker Junior doctors AUDIT questionnaire Alcohol specialist nurse < 8….discharge  8.. AUD  20 … SADQ Brief intervention Continue care in community e.g ADS Admit …AAU/speciality -Rx of Alcohol withdrawal ( care pathway ) -start detox..community -full detox community/inpatient Alcohol specialist nurse psychiatry/medical(PLN/LNP) Specialist consultant led outpatient and inpatient care For high risk ALD and serious co-morbidities

23. Symptoms of liver disease Most of the time non specific Fatigue Jaundice Itching Easy bruising Leg/abdomen swelling Confusion

24. How do we manage liver disease All patients who have risk factors for developing liver disease should be tested by their GPs/health centres ( alcohol excess, obesity, viral infection,..) Liver disease can be diagnosed by blood tests or scans We use non invasive novel tests in Hull to diagnose liver disease early. We offer one stop liver clinics where patients are reviewed by consultant, assessed, scans done and results given at end of consultation.

25. Healthy diet not weight reduction Gentle exercise without muscle building Reduce alcohol even if it is minimum Set targets and time of review Treat the obvious Control other metabolic risk factors In the clinic

26. Alcohol abstinence is crucial to allow liver to pick up

27. In the hospital ward IV vitamins IV fluids Diuretics Anti coma measures Antibiotics Staging the disease Endoscopy Liver transplant Nurse assessment Patient views and understanding Alcohol liaison nurse review Family support Social support Palliative care

28. Alcohol related liver disease is preventable