Liver disease patients found to have hospital discrimination

A report into patient deaths across England, Wales and Northern Ireland, has concluded that the NHS has been guilty of showing a dismissive, negative and discriminative attitude towards people who are suffering with alcohol-related liver disease.

The findings are part of a new report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which state there are poor levels of care in the health service, not enough specialist doctors, as well as shortcomings in regards to screening, managing patient’s drinking habits and caring for acutely ill patients.

NCEPOD assessed almost 200 hospitals and thoroughly examined the cases of 385 patients who had died from alcohol-related liver disease.

The research found that as many as 32 of the deaths – one in 12 of those examined – could have been prevented if the patients had received better quality care, and shockingly, under half of the patients reviewed were deemed to have received what could classed as ‘good’ care.

It was found that despite three-quarters of the patients being admitted into hospital more than once; a third had never been referred to alcohol support services for help in stopping their drinking.

In addition, a quarter of the patients whilst in hospital had never been given the chance to see a specialist in diagnosing and treating liver disease – a gastroenterologist or hepatologist. In fact, the presence of consultant hepatologists were only discovered at 28% of the 191 hospitals studied in the report.
The NCEPOD strongly argue that every patient who attends hospital should be screened for alcohol misuse and any patient with worrying drinking behaviour should be given alcohol support services. The report also says that anybody suffering with urgent alcohol-related liver disease should never have to wait more than 24 hours before being seen by a specialist such as a gastroenterologist or hepatologist.

Report author Dr Mark Juniper, NCEPOD clinical co-ordinator and consultant physician at the Great Western Hospitals Foundation trust, said: “Many people with alcohol-related liver disease have multiple admissions with this condition. This gives clinicians an ideal opportunity to offer appropriate treatment and advice to patients to help them stop drinking and improve their future health. Unfortunately, this isn’t happening and in over a third of patients reviewed in this study, referral for support to stop drinking was not made, despite most hospitals reporting to have alcohol liaison services. This is partly because the services are not available at all times that they are needed.”
Dr Juniper, a consultant physician the Great Western hospitals NHS foundation trust, Swindon, continued: “Similarly, patients were not always seen by a specialist in liver disease, and when they were, this was often not for several days after admission. We know that abstinence works, and that when simple advice is offered to patients, one in eight will reduce their harmful drinking levels – that’s better than the results from ‘stop smoking’ support services. There are misunderstandings. It is quite difficult to predict the patients who will do well and who will do badly once they get into hospital and are very sick…there are patients who are being denied intensive care and aggressive treatment who do have the potential to survive.”

Liver disease, also known as ‘hepatic disease’, is where the liver is damaged or develops a disease. Alcoholic liver disease is just one of many varying types of liver disease and covers numerous conditions and associated symptoms that emerge after the liver becomes damaged because of alcohol misuse.

Unfortunately, symptoms of alcoholic liver disease do not often appear until the liver is severely damaged so it is important to monitor drinking levels before it is too late.

Alcohol misuse can lead to alcoholic fatty liver disease, alcoholic hepatitis and cirrhosis of the liver. All have a number of symptoms but common signs are loss of appetite, nausea, weakness and abdominal pain. However, when cirrhosis reaches its more serious second stage, the person will experience total loss of liver function, known as liver failure, and other symptoms can include: personality changes (as a result of toxins in the bloodstream interfering with the brain), vomiting blood, rapid heartbeat, staggering when trying to walk, dark urine, jaundice, hair loss, muscle cramps and more weight loss.

If you are misusing alcohol, you could still have liver damage even though you are displaying none of the above symptoms. Medical Specialists Pharmacy recommend that if you are drinking too much alcohol, contact your GP as soon as possible and request a liver function test in addition to a blood test to detect enzymes that are usually only present in the blood due to liver damage.

Traffic light test could provide early diagnosis of liver disease

A new traffic light test could help doctors diagnose liver disease earlier in high risk populations. The Southampton Traffic Light (STL) test, developed by Dr Nick Sheron and colleagues, at the University of Southampton and University Hospital Southampton NHS Foundation Trust, combines several different tests and clinical markers.

It is estimated one in five adults inEngland, some 10 million people regularly exceed Government advice on safe drinking. However because liver disease develops without symptoms, many people have no idea they have liver failure until it is too late.

The Department of Health states, “Men should not drink more than three to four units of alcohol a day and women should not regularly drink more than two to three units a day.”

The Royal College of Physicians also advises no more than 21 units per week for men and 14 units per week for women. An average pint of beer or lager contains roughly two units of alcohol. A small 125ml glass of ordinary strength wine has one and a half units, while a 25ml shot of a 40 per cent spirit has one unit.

The Southampton Traffic Light test combines different tests and indicators, to give a score showing the likelihood of a patient developing a problem. The researchers said, “The test can diagnose liver disease much earlier, enabling those at risk to change their drinking habits, which could save their lives.”

They also went on to say, “That while it should not be a substitute for clinical judgment or other tests, it could help GP’s determine the potential severity of liver disease, in high risk patients such as heavy drinkers, those with type 2 diabetes or the obese.”

Dr Nick Sheron, a consultant at Southampton General Hospital who led the study, and who published his work in the British Journal of General Practice, hopes the test will save lives. He said, “We are reliant on general practitioners detecting liver disease in the community, so they can intervene to prevent serious liver problems developing, but so far we haven’t been able to give them the tools they need to do this.”

Nurses could take blood from those doctors recommend to be tested one week, for them to return for the results the next. Like traffic lights, the scores are given in three colours. Red will mean the patient already has liver fibrosis and may have cirrhosis. Amber means there is at least a 50:50 chance of scarring, with a significant possibility of death within five years. In such cases patients should be advised to stop drinking, to reduce their chance of developing further diseases, whilst green means there is no cirrhosis.

It was given to more than 1,000 patients, and their progress carefully followed, in some cases over several years, to assess the ability of the test to predict the onset of liver fibrosis or cirrhosis.

After proving accurate in severe liver disease, it is hoped the test could help GPs accurately assess the potential severity, of liver disease in high risk patients, including heavy drinkers, those with type 2 diabetes, or  people. Dr Sheron said, “It is a powerful tool and a message for people. We find that for most patients this is a pretty good stimulus to stop drinking or at least to cut down to safe levels.”

Professor Sir Ian Gilmore, chair of the Alcohol Health Alliance, said, “One of the challenges of liver disease, which is rising dramatically in this country, is the silent nature of the condition, which is that it is often too late to reverse the damage. This large study from Dr Sheron and colleagues in Southampton may prove really useful for guiding the right patients towards specialist care in a timely way.”