Alcoholic Liver Disease

Alcoholic liver disease develops after years of heavy drinking and can progress through several stages, from fatty liver to life-threatening cirrhosis. While early stages may cause no symptoms, the condition is one of the most common causes of chronic liver disease and can be reversed or slowed by stopping alcohol use.

Table of contents

• What is alcoholic liver disease?
• Stages of the disease
• Causes and risk factors
• Symptoms
• Diagnosis
• Treatment
• Outlook and prognosis

Alcohol-associated liver disease, Alcohol-related liver disease, ALD, ARLD

• Liver

What is alcoholic liver disease?

Alcoholic liver disease is a condition where the liver (the large organ in your abdomen that helps process what you eat and drink) becomes damaged from drinking too much alcohol over time. Healthcare providers now often call this condition alcohol-associated or alcohol-related liver disease, because it develops from heavy alcohol use whether or not someone has an alcohol dependency^[1].

The name change happened to make clear that the disease comes from the amount of alcohol consumed, not from alcohol dependency or what used to be called “alcoholism”^[1]. This is an important distinction because anyone who drinks heavily over a long period can develop this condition, regardless of whether they are dependent on alcohol.

Alcoholic liver disease is one of the most common causes of chronic liver disease. In the United Kingdom, alcohol consumption is the most common cause of liver disease, accounting for 6 in 10 cases^[4]. The condition can progress through several stages and, in its most advanced form, can lead to cirrhosis (severe scarring of the liver) and liver failure^[1].

Stages of the disease

Alcoholic liver disease progresses through distinct stages, each representing increasing damage to the liver. Understanding these stages is important because earlier stages can often be reversed if alcohol use stops.

Fatty liver disease (Steatosis)

The earliest stage is called steatosis or fatty liver disease. At this stage, excess fat builds up inside liver cells. This happens when you regularly consume more alcohol than your liver can process^[1]. Research shows that about 90% of people who drink heavily develop this first stage of liver disease^[1].

Fatty liver can develop after drinking a large amount of alcohol, even for just a few days. It rarely causes symptoms, but it serves as an important warning sign that you’re drinking at harmful levels^[2]. The good news is that fatty liver disease is reversible. If you stop drinking alcohol for a period of time that could be months or years, your liver should return to normal^[2].

Alcoholic hepatitis

The second stage is alcoholic hepatitis, which involves inflammation (swelling and irritation) of the liver. This happens when the excess fat in your liver causes inflammation. Long-lasting inflammation eventually starts to damage liver tissues^[1].

Alcoholic hepatitis is a potentially serious condition that can be caused by alcohol misuse over a longer period. It can also occur if you drink a large amount of alcohol in a short period of time, known as binge drinking^[2]. When this develops, it may be the first time a person realizes they’re damaging their liver through alcohol.

The liver damage from mild alcoholic hepatitis is usually reversible if you stop drinking permanently. However, severe alcoholic hepatitis is a serious and life-threatening illness. Many people die from this condition each year, and some people only discover they have liver damage when their condition reaches this advanced stage^[2].

Cirrhosis

Cirrhosis is the most advanced stage of alcoholic liver disease. This is when long-lasting inflammation has caused permanent damage, and scar tissue has replaced much of the healthy liver tissue^[1]. About 30% of people with alcoholic liver disease reach this stage^[1].

At the cirrhosis stage, the liver has become significantly scarred. Even at this point, there may not be obvious symptoms^[2]. Cirrhosis is generally not reversible, but stopping drinking alcohol immediately can prevent further damage and significantly increase your life expectancy^[2]. When too much liver tissue is damaged, your liver functions start to fail, a condition known as liver failure^[1].

Causes and risk factors

Alcoholic liver disease develops when you drink so much alcohol that it affects how your liver works. Alcohol is a toxin, and it’s your liver’s job to process it. When the liver has too much alcohol to process, it affects the liver’s other jobs, such as processing fats. This causes fat to start building up in the liver^[1].

Most people who develop alcoholic liver disease do so after five to 10 years of heavy alcohol use^[1]. The definition of heavy alcohol use differs depending on sex. For males, heavy drinking means three or more drinks per day or 21 or more drinks per week. For females, heavy drinking is two or more drinks per day or 14 or more drinks per week^[1].

Several factors can increase your risk of developing alcoholic liver disease beyond just the amount you drink. The quantity and duration of alcohol intake are the most important risk factors. However, other factors also play a role^[1].

Women are more susceptible to developing alcoholic liver disease than men, even when consuming the same amount of alcohol^[3]. Younger age can be a risk factor, as can genetic susceptibility. Having a higher body mass index and eating a high-fat diet also increase the risk^[3].

Having another liver disease at the same time makes alcoholic liver disease more likely to develop and progress. Concurrent hepatitis C infection, for example, is associated with younger age of onset, more advanced damage to liver tissue, and decreased survival^[3].

Symptoms

One of the challenges with alcoholic liver disease is that it often doesn’t cause symptoms until the liver has been severely damaged^[2]. You can have liver disease without knowing it. This means the condition is frequently diagnosed during tests for other health problems, or at a stage when liver damage is already advanced^[2].

When symptoms do appear, fatigue is often the first one people notice^[1]. As the disease progresses, additional symptoms may develop.

Later symptoms can include^[1][2]:

• Feeling sick or nauseous
• Weight loss
• Loss of appetite
• Yellowing of the whites of the eyes or skin, called jaundice
• Swelling in the ankles and abdomen
• Fever
• Fluid buildup in your belly, known as ascites, or in your ankles, called edema
• Vomiting blood or passing blood in stools
• Confusion or drowsiness

The most common symptom of alcoholic hepatitis specifically is jaundice, which happens when a substance called bilirubin (a yellow-colored waste product) builds up in the body^[6].

Diagnosis

Diagnosing alcoholic liver disease typically starts with a physical examination and a conversation with your doctor about how much alcohol you drink. It’s important to be honest about your alcohol use, both current and past, so your doctor can make an accurate diagnosis. Sometimes healthcare providers might ask to talk to family members about a loved one’s drinking habits^[1].

The diagnosis is primarily based on clinical findings. For alcoholic hepatitis specifically, doctors use a consensus definition that includes acute-onset jaundice, specific laboratory abnormalities, and a characteristic history of alcohol use^[13].

Several tests may be used to diagnose alcoholic liver disease and determine how damaged the liver is^[1]:

Blood tests, particularly liver function tests, are especially important. These show how well your liver is working and reveal signs of liver inflammation and damage. In alcoholic hepatitis, typical results may include elevated liver enzymes, particularly a ratio of aspartate aminotransferase to alanine aminotransferase greater than 2 to 1. High bilirubin levels indicate jaundice, and abnormal clotting tests suggest the liver isn’t making enough proteins needed for blood clotting^[12].

Imaging tests can help visualize the liver. Ultrasound uses high-frequency sound waves to create pictures of your liver. CT scans use X-rays to produce detailed images, while MRI uses magnetic fields and radio waves to create comprehensive pictures^[1].

A liver biopsy involves removing small tissue samples from the liver with a needle, then examining them under a microscope. This procedure is necessary only if the diagnosis is unclear and an accurate diagnosis would change how the condition is managed^[13].

Doctors also use laboratory-based scoring systems to determine disease severity and treatment options. These include the Maddrey Discriminant Function, the Model for End-Stage Liver Disease, and the Lille score^[13].

Treatment

Stopping alcohol use

The most important part of treating alcoholic liver disease is to stop drinking alcohol. There is currently no specific medical treatment that can reverse the damage caused by alcohol to the liver. The main treatment is to stop drinking, preferably for the rest of your life^[2].

If you have fatty liver disease, the damage may be reversed if you stop drinking for a period of time that could be months or years. After recovery, your doctor might advise whether it’s safe to start drinking again, though this should be discussed carefully^[2][14].

If you have a more serious form of alcoholic liver disease, such as alcoholic hepatitis or cirrhosis, lifelong stopping of alcohol use is recommended. This is because stopping drinking is the only way to prevent liver damage from getting worse and potentially stop you from dying of liver disease^[2][14].

Stopping drinking is not easy, especially since an estimated 70% of people with alcoholic liver disease have an alcohol dependency problem^[2][14]. Support, advice, and medical treatment are available through local alcohol addiction support services. Many people find it useful to attend self-help groups such as Alcoholics Anonymous^[2][14].

Medicines may be prescribed to help you stop drinking alcohol, including acamprosate, disulfiram, and naltrexone^[14]. Psychological therapy, such as cognitive behavioral therapy, can also help^[2][14].

When you stop drinking, you may experience withdrawal symptoms. These are typically worst during the first 48 hours but should improve as your body adjusts to being without alcohol, usually within 3 to 7 days. In some cases, you may be offered medicine called a benzodiazepine to help manage withdrawal. Some people need to stay in a hospital or specialist rehabilitation clinic during the initial withdrawal phase so their progress can be closely monitored^[2][14].

Nutritional support

Malnutrition is common in people with alcoholic liver disease, so it’s important to eat a balanced diet to ensure you get all the nutrients you need^[14]. Nutritional support is an important part of treatment and should provide daily energy intake of 35 to 40 kilocalories per kilogram of body weight and daily protein intake of 1.2 to 1.5 grams per kilogram of body weight^[13].

Avoiding salty foods and not adding salt to your meals can reduce your risk of developing swelling in your legs, feet, and abdomen caused by fluid buildup. The damage to your liver can mean it’s unable to store glycogen, a carbohydrate that provides short-term energy. When this happens, the body uses muscle tissue for energy between meals, leading to muscle wasting and weakness. This means you may need extra energy and protein in your diet^[14].

Healthy snacking between meals can help increase your calories and protein. It may be helpful to eat 3 or 4 small meals a day rather than 1 or 2 large meals. Your doctor can advise you on a suitable diet or refer you to a dietitian. In the most serious cases of malnutrition, nutrients may need to be provided through a feeding tube inserted through the nose into the stomach^[14].

Medications for severe disease

For people with severe alcoholic hepatitis, treatment in a hospital may be necessary. Corticosteroids are recommended for severe alcoholic hepatitis without active infection^[13]. Specific treatment with corticosteroids may reduce inflammation of the liver in some people with this condition^[14].

The response to corticosteroid therapy should be evaluated using the Lille score at day 7 of treatment. This helps doctors determine whether the medication is working and whether to continue treatment^[13].

Liver transplantation

In the most serious cases of alcoholic liver disease, where the liver has stopped functioning and does not improve when you stop drinking alcohol, a liver transplant may be required^[2][14].

You will only be considered for a liver transplant if you have developed complications of cirrhosis despite having stopped drinking. All liver transplant units require people with alcoholic liver disease to not drink alcohol while awaiting the transplant and for the rest of their life^[2][14].

Outlook and prognosis

The outlook for people with alcoholic liver disease depends largely on the stage of the disease and whether they stop drinking alcohol. Death rates linked to alcoholic liver disease have risen considerably over recent decades. Alcohol misuse is now one of the most common causes of death in the United Kingdom, along with smoking and high blood pressure^[2].

For severe alcoholic hepatitis, overall and in-hospital death rates are high, with a 28-day mortality rate of 16% to 30% and a one-year mortality rate of 56%^[13]. The presence of underlying cirrhosis and continued alcohol use negatively impact long-term outlook^[13].

However, the beneficial effects of stopping alcohol begin immediately. If you have simple fatty liver and stop drinking, the liver can heal and return to normal. If you have alcohol-induced cirrhosis and stop drinking, damage to the liver will stop and the liver will improve, although liver scar tissue will remain. In some patients, the scarring seems to lessen over time^[11].

For alcoholic hepatitis, stopping alcohol is necessary and will lead to improvements in most patients^[11]. Stopping drinking immediately can prevent further damage and significantly increase life expectancy even for those with cirrhosis^[2].

Life-threatening complications of alcoholic liver disease that can occur in advanced stages include internal bleeding, buildup of toxins in the brain, fluid accumulation in the abdomen with associated kidney failure, liver cancer, and increased vulnerability to infection^[2].

The most effective way to prevent alcoholic liver disease is to stop drinking alcohol or stick to recommended limits. If you regularly drink alcohol to excess, tell your doctor so they can check if your liver is damaged^[2].