Alcoholic Liver Disease
Most people drink alcohol to some extent and for most of us, this is not a problem. In fact, alcohol drunk in moderation is actually thought by doctors to be good for our general health. It can help us to relax, unwind, socialise with friends and it can be enjoyable.
However, along with these positive aspects of drinking, there are problems with drinking alcohol for a sizeable minority of people. These problems can be varied and can include the following:
- Drinking too much alcohol in total
- Drinking too much alcohol at any one time (binge drinking)
- Becoming dependant on alcohol
- Drinking at the wrong times and in the wrong places
- Not being able to cope with the side effects of alcohol e.g. aggressive or violent behaviour
- Drinking for the sole purpose of getting as drunk as possible
- Social, domestic, financial, occupational or legal problems which may arise from problem drinking
- Drink driving leading to road traffic accidents.
For a more in depth look at alcohol, safe limits and advice on how to quit problem drinking, please click onto our fact sheet entitled “Managing Alcohol”.
Drinking Alcohol
Alcohol is rapidly absorbed into the bloodstream from the stomach and upper small intestines when drunk. All blood from the stomach and intestines passes through the liver first before being circulated elsewhere around the body. As a result, the highest concentration of alcohol is found within the liver. The liver is responsible for breaking down (metabolising) alcohol and therefore generally, the concentration of alcohol found in other organs is less.
Liver cells (hepatocytes) contain many different enzymes (special types of chemicals which have very specific functions) which break up the molecules of alcohol. These smaller molecules are eventually excreted by the body as water through the kidneys and carbon dioxide through the lungs. But liver cells can only metabolise alcohol at a set maximum rate. So if your alcohol intake exceeds your liver’s capacity to metabolise it, the alcohol level in your bloodstream increases.
The consequences of this are listed in our fact sheet entitled “Managing Alcohol”. But as the liver acts as the “first line” in the defence against the effects of alcohol, it also bears the brunt of alcohol related diseases and problems. Alcoholic liver disease is unfortunately on the increase in many parts of the world.
What is Alcoholic Liver Disease?
Symptoms and signs of alcoholic liver disease are similar to other types of liver disease and are listed here;
None: liver disease may be found incidentally,
- A feeling of being unwell,
- Fatigue,
- Nausea,
- Vomiting,
- Diarrhoea,
- Weight loss,
- Dry eyes and mouth,
- Red or pink, blotchy, mottled patches on the palms of hands (palmer erythema),
- Abnormal small blood vessels on the surface of the skin, mainly on the face, chest and arms (spider naevi),
- Abdominal pain or discomfort,
- Itching of skin,
- Enlargement of the liver (hepatomegaly),
- Jaundice: yellowing of the skin and whites of the eyes,
- Passing dark urine: associated with jaundice,
- Passing pale or clay coloured stools: associated with jaundice,
- Bruising,
- Bleeding from any site e.g. gums, nose, wounds, rectum, vagina,
- Abdominal distension from fluid collecting in the abdomen (ascites),
- Vomiting of blood (haematemesis), from oesophageal varices,
- Confusion and an altered level of consciousness (hepatic encephalopathy),
- Coma,
- Death.
The liver can be affected in a number of ways from the toxic effects of excessive alcohol consumption. Which problems actually occur and when they arise in individuals is impossible to predict and very much depends on;
- An individual’s ability to metabolise alcohol,
- An individual’s genetic predisposition to having alcohol related liver disease,
- The amount of alcohol drunk,
- The length of time of alcohol abuse,
- Gender; females are at greater risk than males for the same level of alcohol intake,
- The presence of obesity. The more obese tend to have greater problems.
The types of changes that can occur in alcoholic liver disease are summarised below. These can occur in combination with each other or may progress from one to the other. These changes are;
1. Fatty Liver
Part or all of the liver may be affected. Liver cells accumulate fat as a result of alcohol intake being high. Usually, fatty liver is reversible and soon resolves if individuals stop drinking alcohol. There are usually no symptoms and most people will be unaware of any changes unless they undergo a routine inspection of their liver, usually for other reasons, with for example, an ultrasound scan. Liver function tests (LFT) which test for liver enzymes by taking a blood sample, are usually normal, suggesting that no damage of liver cells has taken place.
If however, alcohol abuse continues, there is a higher risk of progression of liver changes from fatty liver to the more serious stage of alcoholic hepatitis.
2. Alcoholic Hepatitis
Hepatitis means “inflammation of the liver”. LFT’s can be abnormal with elevated liver enzymes. The higher these levels, the more damage has taken place. This therefore represents a more serious stage than simple fatty change. The degree of inflammation can vary from mild to severe.
- Mild hepatitis: this may cause no symptoms and may simply be diagnosed by a routine blood test, perhaps taken for other reasons. Liver damage may be reversible at this stage providing alcohol consumption is stopped. However, in some people, the hepatitis becomes chronic (longer standing), if alcohol intake continues unabated. These people risk development of liver cirrhosis.
- Moderate hepatitis: this occurs as liver enzymes levels continue to climb as more liver damage occurs. Patients often have symptoms at this stage with complaints such as nausea, lethargy, a feeling of being unwell, upper abdominal discomfort and jaundice. This is when individuals develop a yellowish skin and eye colour due to raised levels of bilirubin.
- Severe hepatitis: this is a serious condition causing several worrying symptoms and may result in death. Symptoms are caused by liver failure. Patients may become deeply jaundiced, have bleeding from almost any site such as gums, wounds, rectum or vagina, may be confused, fall into a coma and sometimes this condition may be fatal. Rapid assessment is required in hospital. The only solution for many may be a liver transplant if other treatments don’t work.
3. Alcoholic Cirrhosis
Cirrhosis means “scarring of the liver”. Normal liver cells are replaced with scar tissue and nodules by a process called fibrosis. Although this process occurs gradually, it is a serious condition as liver cells die. The scarring of the liver affects the normal structure of the liver, its function and its ability to regrow and regenerate. Slowly, the liver starts to fail and its ability to carry out its several hundred functions wanes until eventually, other body organs and systems begin to succumb to the build up of toxins that the liver can no longer process. The scar tissue also affects the normal blood flow through the liver. This creates a back pressure effect on the hepatic portal vein. In turn, this can cause other serious complications such as severe and sometimes fatal bleeding from varicose veins (varices) which develop in the foodpipe (oesophagus).
Cirrhosis may occur for many other reasons. These are summarised on the page entitled “Cirrhosis of the Liver”. Cirrhosis is not reversible. Once scarring has taken place, those liver cells which die and are replaced by fibrous scar tissue cannot regenerate. But, the advancement of scar tissue formation may be slowed or even halted if alcohol intake is stopped.
How Can Alcoholic Liver Disease Be Treated?
Clearly, for those with any alcohol related illness, complete abstinence from alcohol must be strongly advised – patients must stop drinking alcohol completely. Poor dietary intake is a common problem amongst heavy drinkers. Therefore, this needs to be addressed also, perhaps by a dietician. Supplements may be required also with vitamin B complex, vitamin E and selenium.
These steps alone may be enough for those with mild hepatitis. More intensive hospital treatment will be needed for those with severe hepatitis. In those with cirrhosis diagnosed early and if alcohol intake is stopped, further liver damage may be avoided and the patient can remain stable as enough normal liver remains to carry out the vital roles required. If cirrhosis is too severe or if patients continue to drink, then further liver damage will continue until liver failure ensues. At this stage, liver transplantation may be the only option. But even this may only be considered if the specialist liver doctor (hepatologist) or transplant team can be convinced that the patient will stop drinking alcohol.
Compensated and Decompensated Cirrhosis
Cirrhotic liver patients can be divided into 2 groups; those with compensated cirrhosis and those with decompensated cirrhosis. Compensated cirrhotics have no complications and so are easier to treat and tend to have a good prognosis providing they stop drinking alcohol. Liver disease does not progress in this instance.
Those with decompensated cirrhosis have serious complications and are much more challenging to manage. The problems which may arise include;
Bleeding Oesophageal Varices
As cirrhosis develops, the blood circulation through the liver is disrupted. As a result, back pressure in the vessels that supply liver with blood is created. This back pressure leads to the protrusion of varices (varicose vein like vessels) in the gullet (oesophagus). These may bleed heavily and this bleeding can be very difficult to control. Patients must be rushed into hospital for an endoscopy to be carried out. This enables the vessels to be isolated and the bleeding stopped. But, despite this, many patients lose too much blood and die of shock. In those that survive, medicines such as beta-blockers (propranolol) are given which reduce the risk of further bleeding.
