What is Alcoholic Liver Disease (Alcohol-related Liver Damage)?
Alcoholic liver disease is a range of conditions that start with fatty liver, can sometimes advance to alcoholic hepatitis, and eventually end up in alcoholic cirrhosis, the most severe and irreversible type of liver damage due to alcohol use.
This disease has three stages:
1. Alcoholic Fatty Liver or Steatosis: During this stage, fat starts to build up in the liver.
2. Alcoholic Hepatitis: This stage involves inflammation of liver cells. The outcome depends on how severe the damage is. Avoiding alcohol, having proper nutrition, treating any infections, and in severe cases, taking a medicine called prednisolone, can help treat alcoholic hepatitis. But, if it gets worse, it can lead to liver failure.
3. Alcoholic Cirrhosis: This is when the liver damage becomes irreversible and can cause complications due to cirrhosis and increased blood pressure in the liver portal system.
What Causes Alcoholic Liver Disease (Alcohol-related Liver Damage)?
Alcoholic liver disease is influenced by a combination of factors. These include your genes, what you eat, your environment, and your immune system.
The liver can usually handle moderate drinking. However, when alcohol consumption increases, it disrupts the liver’s normal functioning. The earliest sign of this is fat building up in the liver cells, a condition often referred to as fatty liver or steatosis. If someone continues to drink excessively beyond this point, they may develop alcoholic hepatitis, an inflammation of the liver. If a person still doesn’t stop drinking, the liver damage can worsen to a stage called alcoholic cirrhosis. This is a serious condition characterized by scarring and lumps in the liver.
The amount and length of time a person has been drinking alcohol are the most significant risk factors for developing liver disease. The kind of alcoholic drink consumed doesn’t significantly impact the risk. Women are generally more at risk than men. Being overweight or eating a fat-rich diet can also increase the likelihood of alcoholic liver disease. Having a hepatitis C infection can make the disease start at an earlier age, cause more severe liver damage, and decrease survival chances. A certain protein, known as Patatin-like phospholipase domain-containing protein 3 (PNPLAP3), is linked to alcoholic liver cirrhosis.
Risk Factors and Frequency for Alcoholic Liver Disease (Alcohol-related Liver Damage)
Alcohol misuse is a widespread problem, both globally and specifically in the United States. It’s the most common cause of liver disease in the U.S., affecting about 61% of the population, with 10-12% of those being heavy drinkers.
According to the Centers for Disease Control and Prevention (CDC), a standard alcoholic drink contains 13.7 grams of pure alcohol. This amount can be found in:
- 12 oz of 5% beer
- 8 oz of 7% malt liquor
- 5 oz of 12% wine
- 1.5 oz of 40% “hard-liquor”
Alcoholic liver disease is prevalent, especially in European countries. Consuming between 30 to 50 grams of alcohol daily over a 5-year period can lead to this condition. Steatosis can develop in 90% of people who drink over 60 grams per day, and cirrhosis in 30% of those who have long-term intake of more than 40 grams per day.
Drinking levels that put individuals at risk include:
- For men: more than 14 drinks per week or over four drinks per occasion
- For women and people over 65: more than seven drinks per week or more than three drinks per occasion
From a liver toxicity viewpoint, significant drinking thresholds are:
- For men: more than 21 drinks per week
- For women: more than 14 drinks per week
This information is essential in differentiating non-alcoholic fatty liver disease (NAFLD) from alcoholic fatty liver disease (AFLD).
Signs and Symptoms of Alcoholic Liver Disease (Alcohol-related Liver Damage)
When assessing a patient’s likelihood for alcoholic hepatitis, it’s important to look at their alcohol consumption habits – how much they drink daily and for how long they have been drinking. There isn’t a single test that can definitively diagnose alcoholic hepatitis, so it’s crucial to rule out any other potential liver problems first.
It’s also necessary to consider personal and social factors, as heavy drinking is often associated with depression and other mental health problems. Questions should be asked about the patient’s diet, the amount of alcohol they consume, their food intake, the risk factors for malnutrition, and susceptibility to chronic liver diseases such as viral hepatitis.
Doctors should also check for the following symptoms:
- Nausea and vomiting
- Abdominal pain or discomfort
- Loss of appetite
- Weight changes
- Increased thirst
- Jaundice (yellowing of the eyes)
- Weakness
- Fever (in cases of alcoholic hepatitis)
- Confusion
- Sleep-wake cycle changes
- Mood swings
- Fainting
Alcoholic hepatitis is a type of liver failure. Those who have this condition typically experience symptoms like fever and a tender, swollen liver. It usually affects people between the ages of 40 and 50 who heavily consume alcohol. Patients often have a history of drinking around 30 to 50 grams of alcohol a day, but numbers can be over 100 grams per day. A telltale sign is the rapid onset of jaundice or the yellowing of the skin and eyes. Other symptoms may include fever, fluid buildup in the abdomen, and muscle wasting. In severe cases, alcoholic hepatitis can lead to brain function deterioration, known as encephalopathy. Typically, the patient’s liver is enlarged and tender.
The general physical examination typically shows yellowing of the skin (jaundice), swelling of the liver and spleen, thin spider-like blood vessels visible under the skin, abnormalities in hand function, shrinkage of the testicles, reduced sex drive, enlargement of the parotid and lacrimal glands, whitening of the nails, temporary loss of consciousness, and symptoms of high blood pressure in the veins that carry blood from the intestines and spleen to the liver (such as abdomen fluid buildup, swelling of the lower legs, mental confusion or coma, and bulging veins in the belly).
All patients with newly identified abdomen fluid buildup (ascites) should undergo an abdominal paracentesis in which a needle is inserted into the abdomen to help remove the fluid and analyze it.
Testing for Alcoholic Liver Disease (Alcohol-related Liver Damage)
If you are being checked for cirrhosis, the doctor will order several tests. A complete blood count (CBC) can help identify infection and look for complications associated with cirrhosis such as anemia, low platelet count, or an elevated white blood cell count which can occur in alcoholic hepatitis.
Another test known as liver function tests (LFTs) can help determine the health of your liver. If you have alcoholic liver disease, one enzyme (AST) may be much higher compared to another (ALT). There could also be abnormalities like decreased albumin, increased bilirubin, increased triglycerides, and an increased level of the enzyme GGTP.
The prothrombin time (PT) and INR test helps to check the ability of the blood to clot, which is a process the liver plays a key role in. A higher value could mean more severe liver disease.
Your doctor may also order an abdominal ultrasound. This imaging test will look for problems with the bile ducts and whether there are any tumors in the liver.
A blood test called the basic metabolic profile (BMP) checks for possible kidney failure and electrolyte disturbances which may show up as low levels of potassium, magnesium, and phosphorus. If you have ascites, which is an abnormal buildup of fluid in the abdomen, a test known as the serum-to-ascites albumin gradient (SAAG) can provide clues about what’s causing it. Your doctor may also screen you for other causes of chronic liver disease, including viral hepatitis.
Sometimes, it’s necessary for the doctor to look for varicose veins in your esophagus. This can occur due to the high blood pressure in your liver vessels (known as portal hypertension) in patients with cirrhosis.
If your doctor isn’t certain about the diagnosis or wants to understand the extent of your liver damage, they may perform a liver biopsy. This involves taking a small sample of your liver tissue to examine under a microscope. The procedure carries some risks, including severe bleeding, so it’s usually reserved for instances where the results will strongly impact the treatment plan. In a study, 85% of patients with cirrhosis showed high levels of a protein called CA-125. The sicker the patient (as rated by three common scoring systems), the higher the level of CA-125.
Treatment Options for Alcoholic Liver Disease (Alcohol-related Liver Damage)
The management of alcohol liver disease varies based on how far the disease has progressed.
Medical treatment often involves measures like abstaining from alcohol, joining detoxification programs, and getting nutritional support. It’s also crucial for individuals with this disease to have regular screenings for liver cancer every six months and check-ups for esophageal varices if they have cirrhosis. Because people who drink alcohol regularly are more likely to damage their liver with acetaminophen, they should not exceed more than 2000mg per day, even though the average person can safely take up to 4000mg daily. Also, treating other liver diseases like Hepatitis B and C is important.
Surgical treatment becomes necessary when the liver damage cannot be reversed. The definitive treatment is a liver transplant in those who have demonstrated continued abstinence from alcohol.
In the case of alcoholic hepatitis, abstaining from alcohol and getting the right nutritional support are foundational to managing the condition. An addiction specialist can help provide and enlist the support needed to abstain from alcohol successfully. Without treatment, 10% to 20% of patients with alcoholic hepatitis are likely to develop cirrhosis each year, but with abstinence, 10% can be expected to see a reduction in liver injury.
Additionally, doctors further categorize patients with alcoholic hepatitis as mild-moderate or severe, determined through specific calculations (discriminant function and MELD score). Patients with severe alcoholic hepatitis are often treated with prednisolone, an anti-inflammatory medication, or, for those who can’t take it orally, methylprednisolone administered intravenously. If patients don’t respond to this treatment within a week, the medication should be discontinued, but those who respond favourably should continue the treatment for another three weeks.
However, there are a few situations in which prednisolone should not be used, such as active gastrointestinal bleeding, pancreatic inflammation, uncontrolled diabetes, infection, or kidney failure. Instead, these patients may receive pentoxifylline, another anti-inflammatory medication. Patients with bacterial infection should only be treated with corticosteroids after the infection is under control using antibiotics.
Presently, studies show that while the use of steroids like prednisolone can improve short-term survival rates, there is no significant improvement for 6-month or 1-year survival rates, and no benefits are observed from the use of pentoxifylline.
Patients with alcoholic hepatitis often have an increased risk of infection, especially when on steroids. They are also liable to experience alcohol withdrawal. To manage this, lorazepam and oxazepam are recommended for prevention and treatment. It is also crucial for these patients to monitor their daily calorie intake, and nutritional supplementation may be needed if daily oral intake falls below 1200 calories.
Lastly, in severe cases where patients do not respond to steroids and have a high MELD score (greater than 26), liver transplantation may be considered. However, this is not a universally accepted practice due to concerns about patients relapsing into alcohol use, the scarcity of organs for transplantation, and other social and ethical considerations. Yet, the survival rate was found to be comparable to patients with similar MELD scores who had liver transplants for other reasons, and the recidivism rate (relapsing into drinking alcohol) was also similar.
What else can Alcoholic Liver Disease (Alcohol-related Liver Damage) be?
Alcoholic hepatitis can sometimes be mistaken for other types of liver inflammation such as hepatitis caused by viruses, certain medications, or the body’s immune system targeting the liver. It’s important to take into account the patient’s history, symptoms, and the results of blood tests to differentiate between these conditions.
One common condition that can be mistaken for alcoholic hepatitis is Non-alcoholic fatty liver disease (NASH). This is because both diseases can progress through similar stages: the buildup of fat in the liver, inflammation, and cirrhosis (severe liver damage).
On top of NASH, there are several other conditions that can seem similar to alcoholic hepatitis, which include:
- Reye’s syndrome
- Unexplained liver disease
- Wilson’s disease that has quickly turned severe
- Emphysema
- Alpha-1 antitrypsin deficiency, which affects the liver and lungs
- Bile duct infection that spreads upwards
- Liver failure associated with liver cancer
To make an accurate diagnosis, physicians need to uniquely identify these possible conditions.
What to expect with Alcoholic Liver Disease (Alcohol-related Liver Damage)
The outlook for people diagnosed with early-stage liver disease can be pretty good as the conditions of fatty liver and inflammation of the liver may improve after stopping alcohol intake. However, it’s important to note that up to 20% of these patients could still develop cirrhosis, which is a severe scarring of the liver. This stage is irreversible and often leads to a poor prognosis. Regular checks for liver cancer are essential at this stage. The presence of fluid in the abdomen, bleeding from enlarged veins in the esophagus or stomach, severe confusion due to liver damage, and kidney failure due to severe liver disease also suggest a poor outlook.
The Model for End-Stage Liver Disease (MELD) is a scoring system used to rank patients for liver transplants based on how urgently they need it, and it’s used to predict the chances of survival over the next 90 days. In 2016, they added sodium levels to the MELD score for patients older than 12 with a MELD score above 11. The 90-day survival rates based on the MELD score range from 1.9% for a score less than 10 to as high as 71.3% for a score of 40.
Another useful tool for predicting survival rates in patients with severe inflammation of the liver caused by alcohol is the DF score. Patients with alcoholic hepatitis and a DF score above 32 have over a 50% chance of not surviving the next 30 days.
Possible Complications When Diagnosed with Alcoholic Liver Disease (Alcohol-related Liver Damage)
Alcoholic liver disease can lead to a variety of significant complications. Here are some of the key ones:
- Variceal Hemorrhage: Indicators of this condition include vomiting blood or passing dark, tarry stools. Physicians often treat this with a range of procedures like endoscopic band ligation, sclerotherapy, and the placement of a special type of stunt known as TIPS. However, TIPS can increase the risk of hepatic encephalopathy.
- Ascites: Ascites is the most common complication, which is characterized by an accumulation of fluid in the abdomen. It often presents itself with symptoms including a swollen belly and swollen feet. Management options for this condition include sodium restriction, diuretics, fluid removal from the abdomen, and TIPS.
- Spontaneous Bacterial Peritonitis (SBP): This is an infection of the fluid in the abdomen without any other evident source of infection. Diagnosis is confirmed by lab tests showing an increase in certain white blood cells in this fluid. It’s usually treated with antibiotics.
- Hepatorenal syndrome: This complication leads to kidney failure due to advancement of the alcoholic liver disease. Symptoms include an increase in a certain kidney function test, decreased output of urine, and the absence of protein in urine. This condition is divided into two types based on its severity. Critically ill patients are typically treated with a combination of a drug that helps to improve blood vessel function, and protein through IV. Noncritically ill patients are treated with drugs and protein. In severe cases, a liver transplant may be required.
- Hepatic hydrothorax: This is when there is a buildup of fluid in the space between the lungs and the chest wall. Treatment includes diuretics, fluid removal from the chest, and TIPS.
- Hepatopulmonary syndrome: This condition affects the lungs, usually presenting itself with breathlessness and low blood oxygen levels. The only treatment option is a liver transplant.
- Hepatic encephalopathy: This is a condition where liver disease affects brain function, leading to changes in mental state. Treatment options include medications and addressing any triggering factors such as infections or internal bleeding.
There are also other less common complications such as cirrhotic cardiomyopathy, liver cancer, gastropathy related to the portal vein, high blood pressure in the vein supplying the liver, and blood clots in the portal vein.
Preventing Alcoholic Liver Disease (Alcohol-related Liver Damage)
For people with alcoholic liver disease, understanding their condition is just as important as medical treatment. The most important part of managing this disease is complete avoidance of alcohol. This is vital to prevent the disease from getting worse and leading to other health problems. However, quitting alcohol can be tough without the help of specialized rehabilitation programs.
Addressing the root causes of the alcohol addiction often requires mental health support, and family involvement can be crucial. It’s essential to encourage those suffering from alcoholic liver disease to join support groups and counseling programs.
Educating patients also includes stressing the importance of regular check-ups. This is particularly important for those with severe liver damage, as they need to be monitored for a specific type of liver cancer known as hepatocellular carcinoma.
