Early into the COVID-19 pandemic, Dr. Marina Roytman, Liver Program Director, UCSF Fresno, began to notice a disturbing trend.
Patients were being admitted to Community Medical Centers hospitals with acute alcoholic hepatitis in increasing numbers. Alarmed, Dr. Roytman conducted a study to determine what was going on. Her findings were published in both Central Valley Physicians and The Fresno Bee.
2020 data reveals sharp increase in patient admissions
Alcoholic hepatitis (AH) occurs when someone drinks a lot of alcohol in a short amount of time, leading to severe inflammation of the liver. It differs from cirrhosis in that cirrhosis is scarring of the liver due to extreme alcohol use over the course of many years.
Both are life-threatening.
Dr. Roytman’s study monitored 300 patients for signs of acute alcoholic hepatitis then compared that data to the 2019 numbers. She found that after stay-at-home orders were put into place to slow the spread of COVID-19, the number of patients admitted for AH went up by 69%.
“I noticed that, instead of seeing maybe one or two patients a month with this previously rare condition, suddenly half of my service had acute alcoholic hepatitis,” Dr. Roytman says. “We broke the data down to see, are there any groups that are particularly affected by it? And what we saw was, patients under (age) 40 — their admission rate went up by 100%. Wild numbers.”
She adds, “And, in women, tragically, the admission rate went up by 125%.”
A 40-year partnership between UCSF and Community has helped bring academic physicians such as Dr. Roytman to the Valley. That research helps Valley patients, furthers medical knowledge and often provides access to the newest treatments unavailable elsewhere.
COVID-19 creates “perfect storm”
Dr. Roytman attributes the rise in acute alcoholic hepatitis cases to a number of factors.
First, during the COVID-19 pandemic, levels of stress and anxiety rose, particularly in response to the economic impact of the virus. To cope with job loss, housing insecurity and even food insecurity, some increased their alcohol consumption.
Also, stay-at-home orders removed the daily distractions that kept people busy, such as going to work, running errands, driving kids to appointments and classes, etc. — meaning access to alcohol throughout the day increased.
At the same time, alcohol availability increased as it became easier to order over the internet and through mobile apps. And, daily drinking became normalized through memes and social media.
Access to care became more difficult as doctor’s offices closed and patients stayed away from hospitals for fear of contracting COVID-19. Signs and symptoms that might have been caught earlier went unnoticed.
“And on top of that, when you look specifically at women — on top of everything else that everyone was dealing with — women were suddenly faced with providing 24/7 childcare, (and) being in charge of schooling,” says Dr. Roytman. “So all of this further increased stresses in women, which subsequently translated into the increase in alcohol consumption.”
Alcoholic hepatitis difficult to diagnose
Dr. Roytman says that acute alcoholic hepatitis is a challenge to diagnose unless a physician suspects a patient may have it, and is already looking for it.
Signs and symptoms can include:
Loss of appetite or malnutrition
Nausea and vomiting
Fatigue and weakness
Jaundice, or yellowing of the skin and whites of eyes
Dr. Roytman says it’s crucial for patients to share an accurate history of their drinking with their doctor, though this can sometimes be difficult. Once they start to develop symptoms, many patients stop drinking because they’re not feeling up to it.
“So then they often present to me or to the ER, and if you ask a straightforward question, ‘Are you drinking alcohol?’ they say no, because they stopped drinking 2-3 weeks ago,” she says. “So you really have to be careful in how you take the drinking history and make sure the patient is comfortable telling you the whole story so you can provide the proper diagnosis and treatment for them.”
What is considered “excessive” drinking?
AH results from drinking an excessive amount of alcohol in a short amount of time, but pinpointing what “excessive” means can differ from person to person.
“So, one has to say that there are no safe limits for alcohol consumption that have been established,” says Dr. Roytman. “Drinking alcohol is linked to a number of health problems. We have cardiovascular problems, we have an association with cancers and malignancy, and certainly with liver disease.”
The Dietary Guidelines for Americans, 2020-2025, compiled by the U.S. Department of Agriculture and U.S. Department of Health and Human Services, recommends adults of legal drinking age limit their daily alcohol intake to one drink or less for women and two drinks or less for men.
In the Dietary Guidelines, “one drink” equals:
12 ounces of regular beer (5% alcohol)
5 ounces of wine (12% alcohol)
1.5 ounces 80-proof distilled spirits (40% alcohol)
The guidelines define binge drinking as 5 or more drinks for an adult male, or 4 or more drinks for an adult female, consumed within 2 hours.
Says Dr. Roytman, “Most of the patients I see probably consume what are about 5 to 10 drinks daily. And it does not matter — I cannot emphasize this enough — it doesn’t matter what kind of alcohol you consume. Beer is not any better than hard liquor.”
Treatment for acute alcoholic hepatitis
According to Dr. Roytman, the only way to treat AH is to stop drinking.
“Patients have to stop drinking immediately, completely, and forever,” she says. “Now, this is very challenging because there is a reason for why patients have gotten into these unhealthy drinking habits.”
She suggests patients look into online treatment programs, such as Alcoholics Anonymous, which offers meetings over Zoom.
Other treatment includes a healthy diet with lots of protein to help rebuild the liver. In severe cases, steroids can be used to decrease inflammation. A liver transplant may also be necessary.
More research needed going forward
As COVID-19 restrictions loosen and people are able to get out of the house more often, the opportunity to decrease at-home alcohol consumption is there. But Dr. Roytman worries that for many, harmful drinking patterns have been formed.
“Yes, we’re getting better, but the economy is not back on track — the stressors are still there,” she says. “We’re probably going to go back and look at the data again to see where we are at right now, but realistically, this is something we’re going to be dealing with for years to come.”
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