Minuk report are clearly influenced by the design of their study. Accordingly, several points require amplification and comment. In the public perception, liver disease has long been associ-
The first issue worthy of scrutiny is the set of criteria used ated with alcohol abuse. This perception stigmatized not only to establish a diagnosis. These criteria did not require a bipatients, but the entire field of hepatology. It has, at times, opsy for confirmation. As a result, although the criteria used hindered the allocation of both public funding and private may have been sufficient for the diagnosis of some diseases philanthropy for liver diseases research, and has given such as hepatitis B, other diagnoses, including alcoholic liver ground only grudgingly, if at all, in the face of major educadisease, could have been missed. Reliance on a patient's retional efforts by both professional groups and such lay organiporting of alcohol intake may be notoriously unreliable, and zations as the American Liver Foundation. At the most permay result in an inappropriate diagnosis. In particular, sonal level, the public's sentiments about alcoholic liver chronic hepatitis C and alcoholic liver disease not infredisease are not infrequently expressed by the families of poquently coexist. While the former is readily established by tential liver donors, some of whom seek to stipulate that the serological studies, the latter diagnosis is likely to be underdonated organ not be used for an alcoholic recipient.
reported when diagnoses are not biopsy-proven. The reasons The bases for the public's distaste for alcoholic liver disease for this coexistence are many, but include a tendency of subare complex, and undoubtedly include an appreciable moralstance abusers to abuse more than one substance at various istic component. Similar factors undoubtedly color the opintimes. Today's alcoholic may have been an intravenous drug ions of many physicians. However, their views may well be user in the past, or vice versa. In any event, a considerable amplified by the impression that treating alcoholic liver disbody of data indicates that the cause of abnormal liver chemease consists far too often of a futile effort to stem fatal variistries is most accurately determined when the history, physiceal hemorrhage by passage of a Blakemore tube in the midcal examination, and laboratory data are supplemented with dle of the night in a dingy and ill lit treatment room of a a liver biopsy. 2-4 decrepit municipal hospital. While therapy for the recalci-A second noteworthy aspect of the report is the ethnic trant, actively drinking alcoholic remains largely unremake-up of the study's catchment area, which may have warding, prospects for the seemingly growing number of alcoskewed the results. The ethnic background of 30% of the holics who are successfully withdrawn from their addiction referrals studied were Southeast Asians and aboriginals (Naare steadily improving. Despite considerable early skeptitive Americans). That may account for the disproportionate cism, liver transplantation in the abstinent alcoholic is assonumber of patients with hepatitis. The low incidence of diagciated with only a modest rate of recidivism and excellent nosed alcoholic liver disease may have further been skewed long-term results. After all, unlike the various viral hepatitiby the low incidence of alcoholism reported in the Asian popudes, alcoholic liver disease does not recur in the transplanted lation. 5 liver, at least in the large majority of patients who remain
The report describes the patients sent to a particular speabstinent. As a result, many now abstinent alcoholics, rescialist referral practice. It considers briefly but does not fully cued by a transplant, have returned to highly functional and address the various selection biases which may mitigate productive lives. Moreover, in the hands of a skilled hepatoloagainst poorer patients suffering from alcoholism being so gist, adept at modern pharmacological and interventional referred. Thus, it may not accurately reflect the prevalence therapy, the abstinent alcoholic can anticipate an improved of various forms of liver disease in the community at large. prognosis even without transplantation. The emotional re-For comparative purposes, diagnostic information was acwards of caring for such individuals can be substantial. cumulated for 1,000 patients seen during 1995 by members While alcohol undeniably remains a major cause of liver of Liver Diseases Associates, the faculty liver disease practice disease in the United States, alcoholic liver disease is no at the Mount Sinai Hospital in New York City, NY. The objeclonger the mainstay of many contemporary hepatology practive of this exercise was simply to estimate the prevalence of tices. This point is highlighted in the article by Byron and various liver disease diagnoses seen in another urban, hospi-Minuk in this issue of HEPATOLOGY, in which the patient tal-based referral practice. In our sample, hepatitis C acprofile of an urban, hospital-based referral practice, the liver counted for the greatest number of referrals (45%), followed disease unit at the University of Manitoba, is analyzed. 1 The by primary biliary cirrhosis (22%), miscellaneous diseases authors present a retrospective study examining the ages, which included many cases of hemochromatosis (9%), hepatidiagnoses, and referral patterns of their patients. A variety tis B (7%), autoimmune chronic hepatitis (4%), nonalcoholic of liver diseases were encountered, with acute and chronic fatty liver disease (4%), alcoholic liver disease (3%), and viral hepatitis being the most prevalent diagnoses. Alcoholic liver disease accounted for only 5% of their patients. The cryptogenic cirrhosis (3%). Our disease profile confirmed the authors conclude that ''contrary to popular belief . . . the low number of referrals for alcoholic liver disease but was majority of liver disease patients seen in an urban, hospitalotherwise rather different from that reported by Byron and based practice are not middle-aged alcoholics.'' As noted be-Minuk. 1 Our findings reflect the prevalence of hepatitis C in low, that general conclusion is borne out by other experiences. the New York area, as well as the research interests in our group.
The emergence of acute, and more particularly chronic vi-