There's been a huge increase in the number of people in the North-East suffering from end-stage liver disease and sufferers are gettng younger. But back-up services in the area are poor. Barry Nelson reports.

MIKE Bramble is worried. After 20 years working with people with drink problems he has never experienced such high levels of alcohol-related illness.

"I have seen a large increase in the last ten years in the number of people, particularly young men, coming in with end-stage alcoholic liver disease and people who have established cirrhosis and alcohol-related hepatitis," says Prof Bramble, who runs a specialist ward for patients with liver disease at James Cook University Hospital in Middlesbrough.

More and more young men, some in their 20s and 30s, are being admitted with seriously damaged livers. Some are so ill that their behaviour is violent and unpredictable and many ultimately die of liver failure if they are unable to stop drinking.

"These patients are quite ill and confused and pose problems on the ward. You can deal with one alcoholic patient going off the rails, but when you have got four or five of them it creates pandemonium," says Prof Bramble, who has seen a 50 per cent rise in admissions due to alcohol-related liver disease in the past decade.

"We give them drugs to reduce symptoms such as hallucinations but we still end up with some patients being very violent towards our nursing staff, who face danger almost every week," he says.

Research published last week showed that in the West Midlands deaths from liver disease increased from six per 100,000 in 1993 to 12.7 per 100,000 in 2000. The doctors responsible for the studysaid the increase was almost exclusively the result of alcohol liver diseases, which almost trebled from 2.8 per 100,000 to eight per 100,000 during the seven year period.

What baffles the specialists from Wolverhampton University is what is causing the increase in drink-related fatal illness. Available evidence does not show any significant increase in UK alcohol consumption in the past decade, nor in the numbers of people drinking heavily.

The doctors speculate that the type of alcoholic drink consumed may be one of the reasons for the increase in deaths, along with possible genetic or unidentified environmental factors. The relative reduction in the cost of alcohol has not helped.

"If it is cheap and easy to get hold of, people will drink it," Prof Bramble says. He also blames changing attitudes to heavy drinking. "The culture is that you go out and get plastered."

The recommended safe limit for men is 20 units a week and 14 for women (a unit is half a glass of ordinary lager or a small glass of wine or single measure of spirits) but Prof Bramble says it is clear that many people are drinking to "dangerous" levels.

While not all patients on ward four have drink-related liver problems, those who are in hospital because of abusing alcohol fall into two broad categories: those who are able to give up drinking and those who find it almost impossible.

"Not all our drink-related patients are unable to give up drinking but there are a lot in that category. The drinkers who get liver damage and can't stop get cirrhosis and die with liver failure," he says.

Like former Manchester United legend George Best, who recently underwent a liver transplant, patients with severely damaged livers who want to be placed on the waiting list for a transplant have to show they have been completely sober for a long period. Keeping reformed alcoholics away from drink once they are away from the hospital environment is no easy task. Unfortunately, Prof Bramble believes the North-East is poorly served in the kind of back-up services for ex-drinkers which may help them stay on the wagon. "Many are really addicted to alcohol so they find it very difficult to give up. The support services in the region are very poor, I'm afraid. There really isn't a good network to give these folk the support they need when they go out into the world."

Without support in the community, many alcoholics with liver disease hit the bottle again and it is not unusual for them to end up back at ward four, sometimes six or seven times.

This is one of the pressing reasons why the South Tees trust has funded the unit's first alcohol liaison nurse whose task is to help drinkers stay dry once they are back in the real world.

Since Jill Emmerson was appointed in January she has had "some success" in keeping people off the demon drink, says Prof Bramble.

Jill is a very experienced nurse who has no illusions about the task facing her. But she is inspired by knowing that she can help people back from the brink.

She tries to visit new patients within 24 hours of admission and works hand-in-hand with the hospital staff to try to wean them off booze.

Often they are in very poor shape, suffering from the effects of a massive daily intake of alcohol and then the devastating effects of withdrawal. "Many of our patients are brought in suffering from fits after suddenly stopping drinking," says Jill.

Often they are suffering from long-term nutritional deficiencies, because they have been too busy drinking to eat properly. This contributes to memory problems that many patients have, although this usually improves during treatment.

Once the patients are making progress, Jill works with them to help them realise that their future lies in their own hands. "I am not there to tell them to stop drinking. I am there to support their decision. If somebody has been told that if they carry on drinking they are going to die, I will do my utmost to motivate them to stop," she says.

Patients are encouraged to fill in balance sheets listing the good and bad things about drink and sobriety and given dietary supplements designed to boost their livers. After they are discharged, they come back to the ward at regular intervals and work with Jill on their abstinence programme.

"We look at life-style changes, education, basic things. Sometimes they don't even know where their liver is," says Jill. "We look at how alcohol affects the liver and the need for healthy eating."

In the case of patients with severe liver damage, their intake of substances such as fatty food and salt has to be strictly limited to try to protect their remaining liver function.

Jill holds one-to-one clinics three times a week on the ward, but in a cosy room fitted out with comfortable home-like sofas.

She has no illusions that some patients will be economical with the truth about their drinking, but most people usually own up eventually. "On the way to their goal there may be hiccups but the important thing is that they come and tell me about it," says Jill.

She sees up to five patients a day and as the 30-bed ward is usually pretty full, she is kept busy all the time.

Initially, Jill sees the patient two or three times a week, although this is gradually stepped down over time. On average, it takes about three months before the patient is ready to strike out on their own, though Jill is always there at the end of a phone line.

"I can't say everyone will stay sober. Some people seem to walk it but for the majority it is a real struggle," she says.

While she is not anti-drink personally she is alarmed at the changing profile of her patients. "They are getting younger. I've seen people who are 23 and 24, for instance. People used to go out drinking on Friday and Saturday nights but now it seems that it's seven days a week."

A shortage of liver donors means that a transplant is by no means guaranteed if someone with liver disease manages to kick the booze.

But at least Jill knows that she will have helped patients to improve their quality of life.

"It's very satisfying," she says. "I wouldn't do it if it wasn't."