What wrecks the liver? Double Scotches and doctored herbs

Liver disease is on the rise and alcohol is the villain. But there can be other causes. A visit to an old-fashioned bar late in the evening often reveals lonely drinkers with only a glass for company. Neither obviously drunk nor obviously sober, they knock back their drinks twice as quickly as the average customer.

When such a drinker lifts his glass, his hand is likely to have an alcoholic shake — a rapid tremor. Furthermore, his nails will no longer be a healthy pink but slate grey. Often the fingers beneath the base of the nails will be swollen so that in profile they look like a parrot’s bill.

The palms of the hands will be as red as raw liver, their colour emphasised by a clear line between the red palm and the relative pallor of the back of the hand.

The arms will be red and so, too, will the face, the latter as a result of swollen veins; dominant red blobs with spidery legs protruding from them. And the face may be puffed out like a child’s caricature of a chipmunk, for heavy drinkers develop swelling of the parotid glands under and around the ear (these are the glands that swell up with mumps).

If he has been overdoing alcohol for too long he may be losing weight even though his girth is enlarged, with a loose collar but a waistband to rival that of John Bull.

Mercifully, while the drinker is at the bar his chest and abdomen will remain covered — but if they weren’t, an observer might notice his wasted arms and legs and the absence of hair in his armpits. Likewise, the drinker’s other primary and secondary sexual characteristics would have shrivelled — though, paradoxically, whether male or female, the breasts would be enlarged.

Our imagined heavy drinker is showing the obvious signs of advanced liver disease. The incidence of liver failure has risen sevenfold in the 40 years from the beginning of the 1960s to the end of the 1990s, with a 34 per cent rise since 1997. In February this year The Lancet revealed that UK figures for liver failure showed the steepest rise in Western Europe. In the UK and Ireland the worst statistics came from Scotland, followed by Ireland, then Wales and England.

Professor Roger Williams, director of the Institute of Hepatology at University College London, says: “The rise in death rates from cirrhosis of the liver continues. In the UK these statistics show a close relationship to the increase in alcohol consumption and contrast badly with those of other Western European countries.”

There are many causes of cirrhosis but, as Professor Williams emphasises, the most important in this country is excessive alcohol intake. He estimates that of the patients with liver failure whom he sees, more than 70 per cent have the condition for alcohol-related reasons.

Other common causes of cirrhosis are Hepatitis C and B, the metabolic syndrome and obesity (sometimes associated with diabetes) and various autoimmune diseases.

There are other, rarer, causes of liver failure. Few people realise that it can be a feature of anorexia nervosa, as was explained at a recent conference of European liver disease experts in Vienna.

The conference also heard about another occasional cause of the disease. In some parts of the world herbal remedies proffered as treatment for a variety of symptoms are contaminated. Anxious to get a speedy response, herbalists (not usually those working in the UK) may pollute natural remedies with mercury, other drugs and, above all, steroids.

Although any amateur medical sleuth can detect the signs of advanced liver disease in a heavy drinker at the bar, in the earlier stages of the condition — whatever its cause — there may be no symptoms for many years. Its presence and insidious progress is not always revealed by routine blood tests.

The first signs that a patient is likely to notice are an inexplicable weakness and weariness, loss of appetite, weight loss and a general feeling of being unwell.

The signs visible in the bar drinker are the result of changes in the testosterone/oestrogen balance. It is this that gives rise to the red palms, loss of sexual characteristics and female distribution of fat with loss of muscle.

The more dangerous changes are hidden from view. Varicose veins may be forming in the gullet and can cause a torrential bleed at any time. Liver failure may result in kidney and pancreatic malfunction, too — and eventually, because of the liver’s inability to act as the body’s detoxifying centre, unmodified chemicals may cause brain damage.

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