ALCOHOL AND ITS EFFECTS
One of the most tragic and scary outcomes for longstanding alcoholism is the development of liver disease. Through repeated bouts of drinking, the caustic effects of alcohol and the stress on the liver can create episodes of inflammation. Our livers are naturally durable and have the capacity to heal and regenerate, but there is a breaking point in which permanent damage occurs. Over time, the cycle of inflammation and healing can become impaired, such that the liver no longer settles into a healthy state. It relaxes into one of scar tissue, and this is what we call cirrhosis.
When someone enters treatment, we will always draw basic lab tests to monitor the liver. We are able to see through these tests if someone is experiencing current inflammation, most likely connected to alcohol use. The liver normally emits chemicals into the bloodstream called ‘transaminases.’ These markers help us know that the liver is continuing to function properly. If these markers are too high, we know that the liver is inflamed. We will give our patient the feedback of this inflammation, and offer our counseling of the medical need to stay sober. Sometimes, people minimize their drinking patterns but are more likely to accept the need for sobriety if given such quantitative data.
It is also very concerning if the transaminase levels are extremely low for a severe alcoholic. This may mean the liver is highly cirrhotic and not capable of doing its job. In these cases, we often refer the patient to receive an ultrasound scan of the liver. This is the most definitive test to confirm a diagnosis of cirrhosis, as we are able to view the actual scar tissue on the liver. Of note, physical exams from a doctor are somewhat useful in screening for liver disease based on the size and feel on an exam. A normal liver is the largest physical organ in the body with a weight of around 1.4 kg and is somewhat tender. An inflamed liver can be highly tender and larger on an exam. A cirrhotic liver can be normal size, larger or smaller based on the extent of scar tissue present.
The liver also carries a vital role in the way our body heals from wounds. Certain clotting factors are synthesized by the liver. One blood test, called the international normalized ratio (INR), helps us determine if the liver is producing enough effective clotting factors. People who have an active liver disease can experience marked bruising to the point of danger. For those with severe deficiencies, a doctor may recommend a blood transfusion, including adding platelets to the body to improve clotting ability.
As a healthy liver is important for filtering toxins from the blood, it makes sense that large volumes of blood pass through the liver tissue each day. When a liver becomes scarred, the blood flow tends to get backed up, causing complications in other parts of the body due to this elevated pressure.
One common finding from patients with liver disease is the swelling of blood vessels in the extremities or the throat. Esophageal varices are bulging blood vessels in the throat which can bleed or severely burst with stress and pressure. Visible blood vessels on the extremities or abdomen are called ‘spider angioma’ and are also a marker of liver disease.
With changes in proteins in the body, specifically the protein albumin, a person can notice shifts of fluid and swelling in different regions. This can include swelling of the feet and ankles or swelling of the abdomen. Abdominal swelling is called ‘ascites’ and can function as a vulnerable space for the body to develop a life-threatening infection called spontaneous bacterial peritonitis, or SBP.
Severe ascites can be very painful and a procedure called paracentesis is sometimes helpful. This is performed in a hospital setting and involves a clinician inserting a needle into the abdominal tissue to drain excess fluid. It can also be used to screen for SBP if a person develops a fever.
Many patients are prescribed blood pressure medications to help alleviate what we call portal hypertension, this phenomenon of liver blood flow back-up. Diuretic medications also are used to help decrease overall swelling and fluid retention.
The only effective cure for cirrhosis of the liver is a liver transplant. This procedure is highly structured and involves collaboration by many physicians, sometimes on a national level. Because a new liver is seen as highly precious, candidates for liver transplantation must be very stable in their lives. This includes a strong recovery if the cause of cirrhosis is alcoholism.
There is some debate in the medical community around the length of time needed to demonstrate such stability. The standard of care has been a 6-month period of sobriety, but there have been liver transplants completed for people with somewhat less sober time.
We use a calculated score to rank potential recipients of a new liver. This is called the “Model for End-Stage Liver Disease” or MELD score and is based on laboratory values of sodium, INR, kidney function and bilirubin. The national database tries to match the most severe cases with the greatest urgency. We track a patient’s MELD score at CeDAR to help monitor the severity of cirrhosis.
After receiving a liver transplant, the recipient will need to take special medications which reduce the body’s immune system. This is necessary to prevent the body from rejecting the foreign tissue of the new liver. Each potential liver recipient is given special education about this process and is also screened for psychiatric issues to ensure that they could effectively and appropriately comply with the medication regimen.
The nursing and medical team of CeDAR is highly competent at working with patients to facilitate quality health outcomes. This includes helping manage those with severe liver disease. As we often discuss the psycho-social and emotional impacts of alcoholism, we must always remember the grave severity of such addictions and their costs on the body. Liver disease is one of the most pronounced medical conditions our patients face, and recovery is necessary for their overall health stability.