barcelona . spain - European Association for the Study of the Liver

BARCELONA . SPAIN
164 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 165
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
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ILLEGALLY PRODUCED SPIRITS IN EASTERN EUROPE: TO WHAT
EXTENT AND AT WHAT RISK
Dirk W. Lachenmeier
Karlruhe, Germany
E-Mail: Lachenmeier@web.de
KEY POINTS
• Unrecorded alcohol comprises homemade, illegally produced, or smuggled alcohol products
as well as surrogate alcohol that is not officially intended for human consumption (e.g.,
mouthwash, perfumes and eau-de-colognes).
• Unrecorded alcohol consumption is highest in Eastern Europe.
• Illegally produced spirits are often sold at higher alcoholic strength (>45% vol) but for half
the price of legal beverages, potentially leading to more detrimental patterns of drinking and
overproportional rates of liver cirrhosis.
• There is currently a lack of data to demonstrate causality between the quality of illicit spirits
(e.g., higher levels of certain contaminants in home-produced products) and liver toxicity on a
population scale.
• Polyhexamethyleneguanidine (PHMG) contained in surrogate alcohol (antiseptic liquids) from
Russia was associated with an outbreak of acute cholestatic liver injury, histologically different
from conventional alcoholic liver disease.
INTRODUCTION
In Central and Eastern Europe, large discrepancies can be found between recorded alcoholic beverage
consumption and alcohol-related mortality (1). One example is Hungary, where mortality from liver disease
is approximately fourfold that of countries with similar per capita consumption of alcohol (e.g. (2, 3)). One
reason for this might be the particularly high unrecorded consumption (2).
Despite the high levels of unrecorded consumption in some countries (up to 40% of total consumption),
there are almost no data on long-term consequences, such as chronic diseases, which may stem specifically
from unrecorded consumption. This is partially due to the fact that few people consume only unrecorded
alcohol over time (4). Consider the example of a person who died of alcoholic liver cirrhosis in Russia, and
had been mainly consuming unrecorded alcohol products in his final years. Typically, he would have been
drinking only recorded alcohol for some time before switching to surrogate alcohol for economic reasons
when drinking became increasingly heavily (5). With this switch and subsequent exposure to ‘other’ forms
of alcohol, there are three potential impacts (4):
• The alcoholic liver cirrhosis would have taken exactly the same course
• The alcoholic liver cirrhosis would have taken a different course, for example, later onset, longer duration,
or no fatal outcome, if this person had consumed recorded alcohol only.
• The alcoholic liver cirrhosis would not have occurred with consumption of recorded alcohol.
It is extremely difficult to determine whether unrecorded consumption or mainly unrecorded consumption
is causal in the onset of a chronic disease; i.e., whether the components which differ between recorded
and unrecorded alcohol cause certain health consequences (6). As a result, few studies have investigated
whether unrecorded consumption causes health consequences over and above those of recorded
consumption. Notably, such a study was conducted in India (7), wherein the authors concluded that
unrecorded consumption (country liquor) was associated with a general risk of alcoholic liver disease,
particularly alcoholic liver cirrhosis, despite having relatively low alcohol concentrations compared with the
local recorded type. However, this study was not well controlled, and therefore confounding by social status
and other factors cannot be excluded (4).