Alcoholic Liver Disease
Alcohol and Liver Damage
The liver serves many essential functions in our bodies such as aiding in digestion and helping to metabolize and clear toxins from the blood. The liver is also where alcohol and many medications are broken down so they can clear our bodies.11
Chronic alcohol use can contribute to the development of alcohol-related liver disease (ALD). ALD follows a progression of conditions that starts with alcoholic fatty liver disease. Fatty liver disease is caused by a buildup of fat in the liver and is typically classified as caused by alcohol or if the cause is non-alcohol-related—such as obesity or diabetes. It is possible to stop or reverse alcoholic fatty liver disease by stopping alcohol use.11
With the continued use of alcohol, however, ALD will progress to alcoholic hepatitis, a state of inflammation that begins to damage cells in the liver. Continued consumption of alcohol further damages the liver and progresses to the final stage of ALD. End-stage ALD is called cirrhosis of the liver, and is characterized by irreversible scarring, a decline in liver function, and will eventually lead to liver failure and death.
Types of Alcohol-related Liver Disease
Alcohol use is directly responsible for approximately half of the incidents of liver disease worldwide.1 Liver disease often follows a progression of conditions from fatty liver to alcoholic hepatitis to cirrhosis of the liver, if drinking continues. Below is a detailed description of each stage: 1,4,5
- Fatty Liver. Alcoholic fatty liver disease is caused by a buildup of fat in the liver. Relatively mild fatty liver (or hepatic steatosis) may be asymptomatic and can develop even with moderate patterns of alcohol consumption, though heavy drinking increases the likelihood. It is possible to stop or reverse this condition with continued abstinence from alcohol.
- Alcoholic hepatitis. Continued drinking can lead to chronic liver inflammation, known as alcoholic hepatitis. Symptomatic hepatitis may include some jaundice and an enlarged liver. More advanced disease may include anemia and coagulation problems. Attempts to manage alcoholic hepatitis may include alcohol abstinence, nutritional support, and in some cases, corticosteroid therapy. If drinking continues, the condition may become progressively severe, with chronic inflammation eventually leading to extensive, irreversible necrosis of liver tissue.
- Cirrhosis of the liver. Cirrhosis of the liver occurs when hepatic fibrosis and scar tissue become extensive, potentially resulting in portal hypertension and a shrunken, non-functioning liver. Cirrhosis of the liver is irreversible. However, quitting alcohol can stop it from getting worse.
Symptoms of Alcohol-related Liver Disease
Symptoms commonly appear only after severe liver damage has already occurred, although some people do show nonspecific symptoms in earlier stages of the disease.5,8 At its various stages of progression, some signs and symptoms of ALD can include:2,5,8
- Yellow tint to the skin and/or to the white of the eyes.
- Loss of appetite (anorexia).
- Weight loss.
- Liver enlargement (early ARLD).
- Abdominal pain/discomfort.
- Skin that is intensely itchy.
- GI bleeding.
- Easy bruising.
- Swollen or distended abdomen (ascites).
- Edema of lower legs and feet.
- Blotchy red discoloration on the palms of the hands.
- Small or shrunken liver (later stage ARLD)
- Characteristic changes on blood tests (serum transaminases).
- Portal hypertension caused by high blood pressure in the liver.
- Esophageal varices, which means that veins in the esophagus are enlarged.
- Variceal rupture and hemorrhage
- Hepatic encephalopathy, which may include confusion and marked changes in behavior.
- Imaging evidence (CT, MRI, ultrasound) of characteristic changes such as liver nodularity and enlarged spleen.
Risk Factors for Alcohol-related Liver Disease
ALD is associated with chronic and heavy alcohol use. However, even occasional binge drinking—consuming between 4 and 5 alcoholic drinks within a 2-hour period—can lead to a buildup of fat in the liver and increase the risk of developing alcoholic steatosis as the first stage of alcoholic liver disease.1,5
Other factors that may influence an individual’s risk of alcoholic liver disease include:1,6,7,8
- Drinking Patterns. Drinking 40 to 80 grams ethanol/day by males (roughly 3 to 6 standard drinks) and 20 to 40 grams/day (1.5 to 3 standard drinks) by females for 10 to 12 years has been a predictor of more severe cases of ALD in past studies.1
- Weight. Obesity can contribute to fatty liver disease and may be correlated with alcohol-related liver damage.
- Concurrent health issues. Medical comorbidities such as hepatitis B and C can make alcohol-related liver disease progress faster.
- Genetics. Studies suggest that there may be a genetic component to alcohol-related liver disease. Genetic vulnerability may explain why a relative minority of heavy drinkers develop liver problems.
- Age. Older adults may be more likely to show signs of liver damage.
- Gender. Women are at increased risk of developing alcohol-related liver disease than men are due to potential metabolic and body composition differences that result in higher average blood alcohol concentrations from comparable amounts of alcohol being consumed.
- Smoking. Cigarettes have been linked to an increased risk of developing alcoholic cirrhosis and can impair liver functioning.
- Other substances. If you take prescription medications, over-the-counter drugs, or even supplements, this can affect your liver. Additionally, these can also interact with each other, alcohol, or other drugs to further damage your liver.
Diagnosing Alcohol-related Liver Disease
It is important to be honest with your doctor about your use of alcohol and other substances, as it can have a major impact on your health. Since alcohol-related liver disease can be tough to detect in some cases, your doctor may want to conduct some testing in order to confirm their suspicion based on your symptoms and history of alcohol use, or rule it out as a potential diagnosis.2 In order to diagnose alcohol-related liver disease, your doctor may do the following:2,4,5,8
- Exam. The doctor will talk to you about your symptoms, your drinking, your eating habits, and conduct a physical examination, paying attention to your abdomen and your extremities. This is to identify any causes that can cause or contribute to your symptoms, and determine which part of your body is affected.
- Bloodwork. Certain blood markers can be analyzed to assess how well your liver is functioning. If liver disease is already present, it can give your doctor an indication of the severity or progression of the disease. Blood tests can also check for viral diseases that could additionally complicate issues, such as hepatitis.
- Imaging. This can be used to rule out other issues, such as obstructions in the bile ducts or tumors, which can cause similar issues, and it can give your doctor a better idea of what kind of liver disease you have, if any. Imaging that is commonly used can include ultrasound, a CT scan, an MRI scan, and/or abdominal ultrasonography, which are able to gather images of your liver.
- Liver biopsy. If your doctor reasonably suspects that you have alcoholic cirrhosis, but can’t confirm it any other way, they may conduct a biopsy, where a thin needle is inserted into your liver and some cells are removed to be looked at under a microscope. This can help your doctor understand how severe the disease is, and allow them to understand how best to treat you.
- Procedures. If your stomach has become very swollen (ascites), the doctor may draw out some of the fluid to examine it, evaluate what it is from, and relieve the pressure you may be feeling because of it. When portal hypertension, enlarged esophageal blood vessels, and the potential for upper gastrointestinal tract bleeds are an issue, endoscopic examination may be necessary.
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Treating Liver Disease and Alcoholism
If you have been diagnosed with ALD it is recommended to stop drinking.11 Abstinence is the only way of possibly reversing liver damage, in the early stages, or in more advanced cases, preventing it from becoming worse.11 It is important to discuss treatment options with your healthcare provider; these can include counseling, medications, and a treatment program. If you are physically addicted to alcohol, a medically supervised detox is recommended for a safe withdrawal. It can be dangerous to stop drinking on your own. A rapid reduction in alcohol can lead to withdrawal symptoms including anxiety, agitation, hallucinations and seizures. Your doctor can recommend a program that best meets your needs. This may include:11
Nutrition therapy: Nutritional deficiencies are very common in people with ALD. Your doctor may recommend a special diet, as well as vitamin and nutritional supplements, to combat the effects of malnutrition and help you gain weight if needed. You may be referred to a nutritionist who can assist you with meal 9 Alcohol-Related Liver Disease planning. If you have trouble eating enough to get the vitamins and nutrients you need, your doctor may recommend giving you a special nutrient-rich liquid intravenously or via tube feeding.
Medications: Depending on the severity of your disease, your doctor may recommend medications to help reduce liver inflammation. These drugs have shown some short-term benefit in increasing survival. Steroid treatment with prednisolone is usually the first-line medication, followed by pentoxifylline, if steroid therapy doesn’t work. No alternative medicine treatments have been found to cure alcohol-related hepatitis.
Liver transplant: For people with advanced alcohol-related cirrhosis, the only treatment option may be a liver transplant. However, active alcoholics do not usually qualify as suitable organ recipients. For transplant to be an option, you’d need to find a transplant center that would consider you and then meet the requirements of the program, including abstaining from alcohol for six months prior to transplant and agreeing not to resume drinking afterward.
Research has shown that treatment can be very effective in helping individuals maintain a life of sobriety, no matter how grave the problem may seem.12
The type of treatment that will be most suitable may be determined by several individual factors such:
- Previous attempts to quit.
- The amount of current alcohol use and corresponding level of physical dependence.
- Co-occurring medical and/or mental health conditions.
- Additional substance use.
Within a comprehensive treatment plan, individuals may experience private and group therapy, family counseling, behavioral therapies, support group meetings, wellness activities, and medication treatments.13 Behavioral therapies can help individuals focus on identifying and changing the behaviors that led to addiction in the first place.12
- Osna, N.A., Donohue, T.M., & Kharbanda, K.K. (2017). Alcoholic liver disease: Pathogenesis and current management. Alcohol research: Current reviews, 38(2), 147-161.
- Torruellas, C., French, S.W., & Medici, V. (2014). Diagnosis of alcoholic liver disease. World journal of gastroenterology, 20(33), 11684-11699.
- National Institute on Alcohol Abuse and Alcoholism. (2021, April). Understanding alcohol use disorder.
- Patel, R., & Mueller, M. (2021). Alcoholic liver disease. Treasure Island, FL: StatPearls Publishing.
- National Health Service. (2018, August 10). Alcohol-related liver disease.
- Schuppan, D., & Afdhal, N.H. (2008). Liver cirrhosis. Lancet, 371(9615), 838-851.
- Roerecke, M., Vafaei, A., Hasan, O.S.M., Chrystoja, B.R., Cruz, M., Lee, M., … Rehm, J. (2019). Alcohol consumption and risk of liver cirrhosis: A systematic review and meta-analysis. American journal of gastroenterology, 114(10), 1574-1586.
- Jackson, W. (2021, May). Alcohol-related liver disease.
- American Liver Foundation. (n.d.) Nonalcoholic fatty liver disease (NAFLD).
- Saberi, B., Dadabhai, A. S., Jang, Y. Y., Gurakar, A., & Mezey, E. (2016). Current management of alcoholic hepatitis and future therapies. Journal of clinical and translational hepatology, 4(2), 113–122.
- American Liver Foundation. (2017). Alcohol-Related Liver Disease
- . National Institute on Alcohol Abuse and Alcoholism. (2014). Treatment for Alcohol Problems: Finding and Getting Help.