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Depiction of alcohol-related liver disease in the EASL International Liver Congress

  • Richard H. Goodheart
    Affiliations
    Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, WA, Australia
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  • Oyekoya T. Ayonrinde
    Correspondence
    Corresponding author. Address: Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, WA 6150, Australia. Tel.: +61861522827.
    Affiliations
    Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, WA, Australia

    Medical School, The University of Western Australia, Nedlands, WA, Australia

    Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
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Published:August 18, 2022DOI:https://doi.org/10.1016/j.jhep.2022.08.012

      Linked Article

      • The stigma of alcohol-related liver disease and its impact on healthcare
        Journal of HepatologyVol. 77Issue 2
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          People with alcohol-related liver disease (ALD) experience stigma and discrimination. This review summarises the evidence on stigma in healthcare and its implications for people with ALD, drawing from the literature on the stigma associated with mental illness and, specifically, alcohol use disorder (AUD). Public stigma, self-stigma and structural stigma all contribute to failure to seek help or delays in seeking help, inferior healthcare, and negative health outcomes, which increase the overall burden of ALD.
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      • Reply to: “Depiction of alcohol-related liver disease in the EASL International Liver Congress”
        Journal of HepatologyVol. 78Issue 1
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          We thank Dr Goodheart and Dr Ayonrinde for their assessment of the implementation rate of the new nomenclature for alcohol-related liver disease proposed by EASL in the Clinical Practice Guideline from 2018,1,2 as part of the alcohol-related presentations at the EASL 2022 International Liver Congress in London. They showed that the new terminology has not yet been fully adopted in the community and that the former nomenclature continues to be used even at EASL events. Further, the proposed changes have not been adopted by the WHO and not implemented in the International Classification of Diseases (ICD)-11 2022 update.
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      To the Editor:
      In some clinical or social interactions, the term “alcoholic” is a pejorative or stigmatising label applied to people with an alcohol use disorder (AUD).
      • Shi H.D.
      • McKee S.A.
      • Cosgrove K.P.
      Why language matters in alcohol research: reducing stigma.
      When alcohol is consumed in quantities considered excessive or potentially harmful, it risks precipitating or perpetuating adverse physical and mental health outcomes. However, labelling individuals with patterns of excessive alcohol intake as “alcoholic” fails to reflect the complexities of the genetic and biopsychosocial factors that lead to addiction, while defining people by their illness. In a recent edition of Journal of Hepatology, Schomerus and colleagues reviewed the stigma of alcohol-related liver disease.
      • Schomerus G.
      • Leonhard A.
      • Manthey J.
      • Morris J.
      • Neufeld M.
      • Kilian C.
      • et al.
      The stigma of alcohol-related liver disease and its impact on healthcare.
      They noted that concerns about stigma related to disclosure of alcohol use not only discourages and delays health-seeking behaviour by individuals with harmful alcohol use, but also risks provision of sub-standard healthcare and potentially worse health outcomes for an already underserved population who are sometimes regarded as undeserving of equal health and healthcare compared with their peers.
      • Schomerus G.
      • Leonhard A.
      • Manthey J.
      • Morris J.
      • Neufeld M.
      • Kilian C.
      • et al.
      The stigma of alcohol-related liver disease and its impact on healthcare.
      While the role of alcohol in development and progression of fatty liver and liver-related outcomes had been detailed as far back as the early nineteenth century,
      • Ayonrinde O.T.
      Historical narrative from fatty liver in the nineteenth century to contemporary NAFLD - reconciling the present with the past.
      alcohol and other lifestyle factors at that time were described in somewhat disparaging terms. The European Association for the Study of the Liver (EASL) Clinical Practice Guidelines published in 2018 tackled the nosology of alcohol-related liver disease, and encouraged more progressive and less stigmatising diagnostic labels that avoid the term “alcoholic” that was felt to undermine patient self-esteem and dignity.
      European Association for the Study of the Liver
      EASL clinical Practice guidelines: management of alcohol-related liver disease.
      Importantly, the term “alcohol-related liver disease” was preferred over “alcoholic liver disease”, as it recognises alcohol as a contributing factor in liver disease and hopefully reduces anchoring bias. Surprisingly, the EASL guidelines retained the term “alcoholic hepatitis” for now. The American Association for the Study of Liver Diseases (AASLD) Practice Guidance similarly recommends a change from use of “alcoholic” to “alcohol-associated” liver diseases.
      • Crabb D.W.
      • Im G.Y.
      • Szabo G.
      • Mellinger J.L.
      • Lucey M.R.
      Diagnosis and treatment of alcohol-associated liver diseases: 2019 Practice guidance from the American association for the Study of liver diseases.
      In light of the progress in understanding of addictions, socio-demographic factors related to AUD, and stigma directed towards alcohol-related liver disease,
      • Schomerus G.
      • Leonhard A.
      • Manthey J.
      • Morris J.
      • Neufeld M.
      • Kilian C.
      • et al.
      The stigma of alcohol-related liver disease and its impact on healthcare.
      we examined the depiction of alcohol-related liver disease in abstracts and session names at the recently concluded EASL International Liver Congress 2022. We found “alcoholic liver disease” was a subcategory for abstract presentations, comprising forty-seven abstracts.

      Abstracts of The International Liver CongressTM 2022 22–26 June 2022, London, United Kingdom. Journal of Hepatology. Volume 77, Supplement 1, Pages S1–S1080.

      After excluding six abstracts about “alcoholic hepatitis”, twelve of the remainder (29.3%) referred to “alcoholic liver disease”, “alcoholic steatohepatitis” or “alcoholism” rather than the recommended nomenclature outlined by the EASL Clinical Practice Guideline. Amongst twenty-one abstracts referring to alcohol-related hepatitis, 13 (61.9%) referred to the condition as “alcoholic hepatitis”. This demonstrates that over one-third of clinicians/scientists who submitted abstracts regarding “alcoholic hepatitis” took the initiative of calling it alcohol-related hepatitis.
      Whilst it may be argued that simple terminology will have a minor impact on patient outcomes, it could reflect an easily overcome barrier to better healthcare in an already vulnerable population. Fear that admission of heavy alcohol use would result in stigma from clinicians, and attempts by non-drinkers to distance the aetiology of their liver disease from perceptions of an alcohol aetiology, hence “alcoholic”, may result in defensiveness, shame, guilt and avoidance of discussions around alcohol intake.
      • Mellinger J.L.
      • Scott Winder G.
      • DeJonckheere M.
      • Fontana R.J.
      • Volk M.L.
      • Lok A.S.F.
      • et al.
      Misconceptions, preferences and barriers to alcohol use disorder treatment in alcohol-related cirrhosis.
      ,
      • Heyes C.M.
      • Schofield T.
      • Gribble R.
      • Day C.A.
      • Haber P.S.
      Reluctance to accept alcohol treatment by alcoholic liver disease transplant patients: a qualitative Study.
      The fear of being labelled as an “alcoholic” has been linked to patients avoiding appropriate treatment.
      • Heyes C.M.
      • Schofield T.
      • Gribble R.
      • Day C.A.
      • Haber P.S.
      Reluctance to accept alcohol treatment by alcoholic liver disease transplant patients: a qualitative Study.
      Additionally, the use of stigmatising language leads to reduced problem recognition, and the perception of being labelled an “alcoholic” shames patients into understating the severity of their alcohol intake.
      • Schomerus G.
      • Leonhard A.
      • Manthey J.
      • Morris J.
      • Neufeld M.
      • Kilian C.
      • et al.
      The stigma of alcohol-related liver disease and its impact on healthcare.
      Potentially, people may then remain in the pre-contemplative stage of harm reduction and avoid making meaningful improvements to their lifestyle. It is well understood that the best way to improve health outcomes within alcohol-related diseases is to focus on harm reduction, such as a decreased intake, or controlled progression to abstinence; any small changes may help.
      Although the International Classification of Diseases 11th Revision (ICD-11)
      World Health Organization
      ICD-11: International classification of diseases (11th revision).
      is yet to update the diagnostic label “alcoholic”, there is a push for a change in nomenclature in ICD-12 liver disease coding that would recognise the contribution of alcohol to the burden of liver disease but remove stigmatising terms, such as “alcoholic”.
      • Karlsen T.H.
      • Sheron N.
      • Zelber-Sagi S.
      • Carrieri P.
      • Dusheiko G.
      • Bugianesi E.
      • et al.
      The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality.
      This would encourage widespread adoption of contemporary descriptors amongst clinicians and researchers.
      In conclusion, despite the EASL and AASLD recommendations for updating terminology in alcohol-related liver disease, the 2022 International Liver Congress abstracts have shown that uptake of progressive nomenclature is limited amongst the hepatology community. It is concerning to see that over one-quarter of abstracts still used the historical stigmatising terminology. Conferences with world-leading hepatologists have a global reach, and therefore the opportunity to accelerate global change. Changing the section title to alcohol-related or alcohol-associated liver disease in future conferences, plus encouraging abstract submissions to use these would provide leadership in this subject. If EASL leads, the world will follow.

      Financial support

      The authors received no financial support to produce this manuscript.

      Conflict of interest

      The authors have no potential conflict of interest to declare that are relevant to this manuscript.
      Please refer to the accompanying ICMJE disclosure forms for further details.

      Authors’ contributions

      The authors contributed equally to the drafting and revision of the manuscript and both approved the final manuscript.

      Supplementary data

      The following are the supplementary data to this article:

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