Gastroenterologists are modally tasked by both primary care and colleagues in other internal medicine specialties with addressing the bulk of alcohol-related issues from a secondary care perspective. Alcohol can cause both primary illnesses affecting the digestive tract and can precipitate secondary exacerbations of other digestive tract illnesses.

Primary alcohol-related digestive tract illnesses

Alcohol is a chemical irritant to the upper gastrointestinal (GI) tract. In general, this problem manifests with alcoholic beverages of higher alcohol concentration, eg. spirits. However, heroic consumption of non-spirit alcohols may also cause oesophagitis and gastroduodenitis. Primary care doctors may choose to refer symptomatic patients for endoscopy to evaluate these alcohol-engendered dyspeptic symptoms. This can be burdensome, given the existing non-alcohol-related demands for these services. There is evidence linking consumption of alcohol to squamous carcinomas of the head, neck and oesophagus. The incidence of many other solid cancers also increases with alcohol consumption, particularly in females. Cigarette consumption, which often accompanies alcohol, exacerbates this issue. 

Acute hepatitis and acute pancreatitis

Alcohol may cause acute hepatitis and acute pancreatitis. Both entities can be life-threatening and require high-intensity supervision and intervention. Numerous complications can occur and complex and difficult endoscopic interventions may be necessary to deal with these problems. An ill patient with alcoholic hepatitis will require care in a high-dependency or intensive-therapy unit (ITU) setting and necessitates specific expertise. In smaller units with single-handed gastroenterologists, care is compromised by the fact that one person cannot be available 24 hours/seven days a week to optimise management. However, it is very difficult to transfer these patients to larger centres as this is largely predicated upon the presumption that the patient may be a candidate for orthotopic liver transplantation. This is generally precluded unless the patient has demonstrated a certain period of abstinence and insight into the association between his disease and his problem alcohol consumption. This is usually not feasible in the case of an acute presentation with alcohol hepatitis. 

In general, pancreatitis is primarily managed by surgical colleagues. However, there is increasing demand on interventional gastroenterology services for treatment of pseudo-cysts and long-term management of complications such as portal hypertension which may arise due to splenic vein thrombosis.

Chronic alcohol misuse may lead to hepatic fibrosis, cirrhosis and portal hypertension with its attendant complications. End-stage complications of cirrhosis include hepatoma, variceal haemorrhage, ascites, hepatic encephalopathy, bacterial peritonitis, systemic hypotension, peripheral oedema and death. If the patient cannot demonstrate abstinence and insight it can be difficult for specialist hepatology services to be accessed. These patients, like those with acute hepatitis, often require frequent high-intensity intervention and care. Again, this can be overwhelming for a single-handed gastroenterologist.

Chronic pancreatitis is less demanding in terms of the gastroenterologist’s time but still may require intervention for both biliary and pancreatic duct strictures and occasional management of pancreatic colitis. A multidisciplinary approach with endocrinology and pain subspecialty anaesthetists can yield good results for patients. 

Female patients

Female patients present as a special problem in that complications usually occur earlier and with lower cumulative alcohol doses than their male counterparts. Psychosocial factors may result in a lack of willingness among female patients to be sufficiently open about their problem drinking, which may further compound management difficulties.

Secondary effects of alcohol on GI disorders

Alcohol can exacerbate the symptoms of almost any other GI condition, from peptic ulcer disease to inflammatory bowel disease. It is likely that this is mediated through induction of alcohol-related inflammation rather than exacerbating the disease process per se. However, conditions such as viral hepatitis C and haemochromatosis have potent synergies with excessive alcohol consumption. Almost any chronic liver disease has a worse prognosis in patients with type 2 diabetes. In turn, at least one study has shown that the risk of developing type 2 diabetes increases with alcohol consumption.

Possible areas for improvement

There is clear evidence that increasing the price of alcohol in certain societies is associated with the concomitant reduction in alcohol consumption and its attendant medical problems. However, this may not be a successful strategy in the 26 counties of Ireland because of our geographic proximity with a lower alcohol tax regime. In the first year of the current economic austerity programme, excise duty and value-added tax was increased but this resulted in a decrease in revenue to the Irish Exchequer without decreases in consumption. It is clear that, if this approach is to be successful, a co-ordinated approach with the Northern Ireland authorities will be needed and is currently under discussion.

Prohibition of alcohol also results in a decline in alcohol consumption and medical complications of same. However, this is unlikely to be an approach which would gain the necessary popular support for its implementation in a ‘supposedly democratic’ Western society. Prohibiting products deemed to specifically target young consumers would be another matter and is worthy of consideration. Increasing the minimum age for purchase of alcohol and/or rigorously policing would be a potentially fruitful measure. 

Finally, instituting a ban on advertising in various media, analogous to that which applies to cigarettes or which was applied in France (in respect of alcohol), would also seem to be a useful measure. In particular, disestablishing the link which appears to exist between sport and alcohol would seem advisable. Competitive sports flourished long before alcohol advertising became widespread and it is more than likely that they would survive in its absence.

Unfortunately, as there is a considerable ‘lag-time’ between the onset of problem drinking and the development of most medical complications, it may be 10-20 years before reductions in consumption are matched by reductions in associated medical complications.

Reform and reconfiguring services

In conjunction with these measures it would be more than prudent to reform and reconfigure the medical services available for the treatment of alcohol-related complications. Approximately E1 billion is collected by Revenue in respect of excise duty and VAT on alcohol. It has been extrapolated that E1.4 billion is spent by the health services on alcohol; this is mainly based on two studies from the UK, which showed extraordinarily high levels of alcohol-related medical admission (25-40%.)* It is difficult to know for certain because there are no ‘hard’ figures for alcohol-specific health expenditure either within individual hospitals or in the health service in general. 

The best way to reduce costs, until such time as other measures designed to reduce consumption bear fruit, would be to optimise and expedite medical management and tackle recidivism, thus reducing repeat admissions. This will require investment in the short and medium term to achieve long-term savings.

I would propose that a small proportion of total alcohol revenues be ring-fenced and dedicated to secondary care services for alcohol. Total numbers of gastroenterologists should be increased to at least the figures envisaged in the ‘so-called’ Hanly report and the practice of appointing single-handed gastroenterologists should be abandoned not only for alcohol-related issues but also general issues of quality and safety in GI diseases and quality and governance in endoscopy.

In addition, regional hepatological units should be established in level 4 and strategically located level 3 hospitals with defined, written protocols for accepting ill patients with alcohol-related liver illness. Healthcare professionals trained in ‘brief interventions’ should be available seven days a week in all acute medical facilities. Some studies associate such measures with a 20% reduction in problem alcohol consumption and are particularly useful in individuals in whom dependence is not yet well established. 

Dedicated centres for standardised residential multidisciplinary treatment of alcohol dependence should also be established on a regional basis. These entities should be distinct from existing psychiatric hospitals and attractive propositions for patients on the basis of geography, accommodation and other social factors. There may be potential for converting unwanted post-Celtic Tiger property developments. This is a lot more realistic than suggesting such buildings could be converted into acute hospitals because hospital grade infrastructure and services would not be required. Liaison psychiatric services should be established between such centres and the acute hospitals. These centres should be led by psychiatrists specialising in alcohol dependence with the use of any proven pharmacotherapy not to be precluded.

These improvements may require restricting the overall number of acute medical facilities providing care to patients with alcohol-related medical issues, however any ensuing inconvenience would be outweighed by better outcomes and reduced recidivism. 

I would estimate that 10% of current alcohol-related revenue could achieve all of these aims and dramatically improve circumstances. In the long-term one would hope that the need for these facilities will recede, however the strategy of matching funding with alcohol-related tax revenue will ensure that these treatment programmes will be adequately resourced.

*This would not reflect the reality of the author’s acute medical practice.

References available on request.