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Alcoholic liver disease

 

Alcoholic liver disease refers to a range of conditions and associated symptoms that develop when the liver becomes damaged due to alcohol misuse.

Alcoholic liver disease does not usually cause any symptoms until the liver has been extensively damaged. When this happens, alcoholic liver disease can cause:

  • nausea
  • weight loss
  • loss of appetite
  • jaundice (yellowing of the eyes and skin)

The liver

With the exception of the brain, the liver is the most complex organ in the body. It has more than 500 functions, most of which are essential for living.

The functions of the liver include:

  • filtering toxins from the blood
  • producing important chemicals, such as proteins and hormones
  • producing blood-clotting agents that prevent excessive bleeding
  • regulating cholesterol levels in the blood
  • helping to fight infection and disease
  • storing energy for use when the body needs an immediate energy boost

Alcohol and the liver

The liver is a very tough and resilient organ. It can endure a high level of damage that would destroy other organs. It is also capable of regenerating itself. Despite this resilience, prolonged alcohol misuse over many years can damage the liver.

Every time you drink alcohol, your liver filters out the poisonous alcohol from your blood.

Each time your liver filters alcohol, some of the liver cells die. The liver can regenerate new cells, but if you drink heavily for many years, your liver will lose its ability to regenerate new cells, causing serious damage.

Stages in alcoholic liver disease

There are three main stages of alcoholic liver disease, though there is often a considerable overlap between each stage. These stages are explained below.

Alcoholic fatty liver disease

Alcoholic fatty liver disease is the first stage of alcoholic liver disease.

Heavy consumption of alcohol, even for only a few days, can lead to a build-up of fatty acids in the liver.

Fatty liver disease rarely causes any symptoms but it is an important warning sign that you are drinking at a level that is harmful to your health.

Fatty liver disease is reversible. If you stop drinking alcohol for two weeks, your liver should return to normal.

Alcoholic hepatitis

Alcoholic hepatitis is the second more serious stage of alcoholic liver disease.

Prolonged alcohol misuse over many years can cause the tissues of the liver to become inflamed. This is known as alcoholic hepatitis. Less commonly, alcoholic hepatitis can occur if you drink a large amount of alcohol in a short period of time (binge drinking).

Alcoholic hepatitis is usually reversible, though you may need to stop drinking alcohol for several months or years.

Cirrhosis

Cirrhosis is the final stage of alcoholic liver disease. Cirrhosis occurs when prolonged inflammation of the liver has caused scarring of the liver and subsequent loss of function. Loss of liver function can result in death.

The damage caused by cirrhosis is not reversible. In mild to moderate cases, stopping drinking alcohol immediately should prevent further damage and lead to the gradual recovery of liver function. In more severe cases, a liver transplant may be required.

How common is alcoholic liver disease?

Alcoholic liver disease is widespread in Ireland.

It is estimated that:

  • 90-100% of heavy drinkers have alcoholic fatty liver disease
  • one in four drinkers with fatty liver disease will develop alcoholic hepatitis
  • one in five drinkers with fatty liver disease will develop cirrhosis

A heavy drinker is someone who regularly exceeds the recommended weekly limit for alcohol consumption. This is 21 standard drinks per week for men and 14 for women.

Women are more likely to develop alcoholic liver disease, but men are more likely to die from it, possibly because men tend to be heavier drinkers.

In the period 2004-2008 the Health Research Board estimates that there were 700 deaths in Ireland due to alcoholic liver disease. Acohol is one of the most common causes of death, along with smoking and high blood pressure.

Fatty liver disease and hepatitis can develop at any age. Cirrhosis usually develops in people aged 40 or over. However, cases of cirrhosis have been reported in people of all ages, including teenagers.

Outlook

The outlook for alcoholic liver disease largely depends on whether you are willing to stop drinking alcohol, preferably for the rest of your life.

In the early stage of alcoholic liver disease (fatty liver and hepatitis), people who stop drinking have a very good outlook as their liver has the opportunity to repair itself.

Even in cases of cirrhosis, the outlook can be improved dramatically by stopping drinking, not least because you will only be considered for a liver transplant if you do not drink alcohol for at least three months.

Three out of four people with cirrhosis who have a liver transplant will live for at least five years after receiving the transplant, and many will live much longer.

Glossary

Bile

Bile is the fluid produced in the liver and stored in the gall bladder. It helps digest food.

Blood

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Diarrhoea

Diarrhoea is the passing of frequent watery stools when you go to the toilet.

Heart attack

A heart attack happens when there is a blockage in one of the arteries in the heart.

High blood pressure

Hypertension is when the pressure of the blood in your bloodstream is regularly above 140/90mmHG.

Liver

The liver is the largest organ inside the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy. 

Useful Links

What is a standard drink?

In Ireland a standard drink has about 10 grams of pure alcohol in it. In the UK a standard drink, also called a unit of alcohol, has about 8 grams of pure alcohol.

Here are some examples of a standard drink.

  • A pub measure of spirits (35.5ml)
  • A small glass of wine (12.5% volume)
  • A half pint of normal beer
  • An alcopop (275ml bottle)

A bottle of wine at 12.5% alcohol contains about seven standard drinks.

What are the low-risk drinking guidelines?

Low risk weekly guidelines for adults are:

  • up to 11 standard drinks in a week for women, and
  • up to 17 standard drinks in a week for men.

Drinks should be spaced out over the week, not consumed in one sitting. Drinking more than the safe levels may cause harm.

 Remember, drinks measures are not always the same. What you get in a pub and what you pour for yourself could be very different.

These weekly limits do not apply to teenagers or to people who are pregnant, ill, run-down or on medication. It is healthier for teenagers not to drink alcohol.

 

Alcoholic fatty liver disease

Alcoholic fatty liver disease does not usually cause any noticeable symptoms unless the build-up of fatty acids in your liver is severe.

If this is the case, symptoms of alcoholic fatty liver disease include:

  • weakness
  • loss of appetite
  • nausea
  • abdominal pain
  • a general sense of feeling unwell

Alcoholic hepatitis

Symptoms of alcoholic hepatitis include:

  • abdominal pain and/or tenderness
  • the appearance of 'spider-like' red blood vessels in your skin
  • loss of appetite
  • nausea
  • high temperature, usually around 38°C (101°F)
  • fatigue
  • yellowing of the skin and eyes (jaundice)

Cirrhosis

The symptoms of cirrhosis usually come in two stages:

  • Early stage symptoms are caused when your liver starts to lose some of its function.
  • End stage symptoms are caused when your liver loses more or all of its function (total loss of liver function is known as liver failure)

Early stage symptoms include:

  • tiredness and weakness
  • loss of appetite
  • weight loss
  • feeling sick
  • very itchy skin
  • tenderness or pain around the liver (located in your abdomen)
  • blotchy red palms
  • problems sleeping

End stage symptoms include:

  • jaundice
  • hair loss
  • oedema (build-up of fluid in the legs, ankles and feet)
  • ascites (build-up of fluid in your abdomen that can make you look heavily pregnant)
  • dark urine
  • black, tarry stools or very pale stools
  • frequent nosebleeds and bleeding gums
  • a tendency to bruise easily
  • vomiting blood
  • muscle cramps
  • right shoulder pain
  • loss of sexual desire
  • dizziness and fatigue
  • breathlessness
  • rapid heartbeat
  • fever and shivering attacks (because you are more prone to infections)
  • memory loss and confusion
  • changes in your personality (due to toxins in the bloodstream affecting your brain)
  • staggering when walking
  • increased sensitivity to alcohol and drugs (because the liver cannot process them)
  • more weight loss from the body and upper arms

When to seek medical advice

Alcoholic liver disease often causes no symptoms until it has reached an advanced level. If you misuse alcohol, you may have liver damage even though you have none of the symptoms above.

It is recommended that you contact your GP and ask for a liver function test (see Diagnosis for more information) if you have a history of regular alcohol misuse.

A good way to assess your history and pattern of drinking is to use a short test known as the CAGE test, which consists of four questions:

  • Have you ever thought you should cut down on your drinking?
  • Have people annoyed you by criticising your drinking?
  • Have you ever felt guilty about your drinking?
  • Have you ever drunk an 'eye-opener', which means, have you ever drunk alcohol first thing in the morning to get over a hangover and steady your nerves?

If you answer yes to one or more of the questions above, you may have an alcohol misuse problem and are advised to see your GP.

Alcoholic liver disease is caused by alcohol misuse. There are two ways that alcohol misuse can cause alcoholic liver disease:

  • Drinking a large amount of alcohol in a short amount of time (known as binge drinking) can cause alcoholic fatty liver disease and, less commonly, alcoholic hepatitis.
  • Drinking more than the recommended limits of alcohol over many years can cause hepatitis and cirrhosis, the more serious types of alcoholic liver disease. 

The more you drink above the recommended limits, the higher the risk of developing alcoholic liver disease.

The highest risk is in:

  • men who drink more than 35 standard drinks of alcohol a week for 10 years or more
  • women who drink more than 28 standard drinks of alcohol a week for 10 years or more

Additional risk factors

Almost all people who misuse alcohol will develop fatty liver disease, around one in four will develop hepatitis and one in five will develop cirrhosis.

However, people who do not develop hepatitis or cirrhosis are still at risk of developing other alcohol-related disorders, such as liver cancer, stroke and heart disease. This suggests that there are additional risk factors that make some people more vulnerable to the effects of alcohol on their liver.

Possible additional risk factors include:

  • obesity
  • being female (women appear to be more vulnerable than men to the harmful affects of alcohol)
  • eating a high-fat diet
  • having a pre-existing liver condition, such as hepatitis C (a chronic viral infection of the liver)

Alcoholic liver disease is often first suspected when tests for other medical conditions show that the liver has been damaged.

For example, blood tests can detect enzymes in your blood that are normally only present if your liver has been damaged.

Blood tests can also detect if you have low levels of certain substances, such as a protein called serum albumin which is made by the liver. This would suggest that your liver is not functioning properly.

Blood tests used to assess liver function are known as liver function tests.

If tests or your symptoms suggest that there is damage to your liver, your GP will ask you about your alcohol consumption.

It is important to be totally honest about how much and how often you drink alcohol.

If you say you drink less alcohol than you do or deny drinking any alcohol, you may be referred for further unnecessary testing. This could lead to a delay in the treatment you need.

If your symptoms or liver function test suggest that you may have alcoholic hepatitis or cirrhosis, further examination is sometimes required to assess the state of your liver.

Tests include:

  • imaging studies, such as ultrasound, CT or MRI scans
  • a biopsy, where a fine needle is inserted into your body (usually between your ribs) and a small sample of liver cells is taken and sent to a laboratory to be examined under a microscope

 

Glossary

Abdomen

The abdomen is the part of the body between the chest and the hips.

Anaesthetic

Anaesthetic is a drug used to either numb a part of the body (local) or to put a patient to sleep (general) during surgery.

Biopsy

A biopsy is a test that involves taking a small sample of tissue from the body so that it can be examined. 

MRI

MRI stands for magnetic resonance imaging. It is the use of magnets and radio waves to take detailed pictures of inside the body.

Ultrasound

Ultrasound scans are a way of producing pictures of inside the body using sound waves.

X-ray

An X-ray is a painless way of producing pictures of inside the body using radiation.

Treatment for alcoholic liver disease involves stopping drinking alcohol. This is known as abstinence.

If you have alcoholic fatty liver disease, you may be able to resume moderate drinking after two weeks of abstinence.

In the case of alcoholic hepatitis, life-long abstinence from alcohol is recommended.

For cirrhosis, life-long abstinence is essential to prevent you from dying of liver failure.

An estimated 70% of people with alcoholic liver disease have an alcohol dependency problem. These people need additional support and advice to help them stop drinking.

People with a dependence on alcohol can find attending self-help groups useful. The best-known one is Alcoholics Anonymous.

Medication is available to help people abstain from alcohol. Disulfiram (sold under the brand name Antabuse) can be used if you are trying to abstain but are concerned that you may relapse, or have relapsed in the past.

Disulfiram causes you to have extremely unpleasant physical reactions if you drink any alcohol, including:

  • nausea
  • chest pain
  • vomiting
  • dizziness

These reactions should deter you from drinking any more alcohol.

For more information and advice on abstaining from alcohol, see the section on Treatment for alcohol misuse.

Nutritional therapy

Nutritional therapy is another important part of treatment for alcoholic liver disease.

This is because most people with alcoholic liver disease are also malnourished, due to a combination of factors:

  • people who drink heavily usually have poor diets
  • many people with alcoholic liver disease experience a loss of appetite
  • loss of normal liver function can interfere with the production of bile, a fluid produced in the liver that digests many important nutrients

Research has also found that being malnourished makes the liver more vulnerable to the harmful effects of alcohol.

A high-calorie diet that contains plenty of protein and carbohydrates is usually recommended for people with alcoholic liver disease. You may also be told to take mineral and vitamin supplements.

Your GP can advise you on a suitable diet or, in some cases, refer you to a dietitian.

In the most serious cases of malnutrition, nutrients may need to be provided through a feeding tube that is inserted directly into your stomach.

Medication

The use of medication in the treatment of alcoholic liver disease is controversial. Many experts have argued that there is limited evidence of its effectiveness.

With severe alcoholic hepatitis, corticosteroid medications may be used to reduce inflammation of the liver.

A number of medications have been used to treat cirrhosis, including:

  • anabolic steroids (a more powerful type of steroid medication)
  • propylthiouracil (a type of medicine originally designed to treat overactive thyroid glands)
  • colchicine (a medication originally designed to treat gout)

There is a lack of good-quality evidence that these medications are effective in treating alcoholic liver disease.

Liver transplants

In the most serious cases of cirrhosis, the liver loses its ability to function and liver failure occurs. Once liver failure has occurred, it is usually possible to sustain life for several years using medication. However, a liver transplant is currently the only way to cure liver failure.

Most transplant centres expect you to commit to not drinking alcohol for the rest of your life. You usually have to abstain from drinking alcohol for at least three months before you are considered suitable for a transplant.

Glossary

Abdomen

The abdomen is the part of the body between the chest and the hips.

Anaesthetic

Anaesthetic is a drug used to either numb a part of the body (local), or to put a patient to sleep (general) during surgery.

Blood

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Bowels

The bowels are the part of the digestive system between the stomach and the anus that digest and absorb food and liquid.

Brain

The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.

Gall bladder

The gall bladder is a pear-shaped organ that stores bile until the body needs it for digestion. It is located under the liver.

Heart

The heart is a muscular organ that pumps blood around the body.

Inflammation

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Jaundice

Jaundice is a condition that causes yellowing of the skin and the whites of the eyes. It is brought on by liver problems.

Liver

The liver is the largest organ in the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Vein

Veins are blood vessels that carry blood from the rest of the body back to the heart.

Vomit

Vomiting is when you bring up the contents of your stomach through your mouth.  

Drinking alcohol if you have liver disease from other causes

Advice on drinking alcohol will vary from person to person. Some people can drink within normal recommended limits, while others should not drink at all. People with any liver condition should be very cautious about drinking because there is strong evidence that it increases damage. Ask your doctor for advice. 

Portal hypertension and varices

Portal hypertension is a common complication of cirrhosis and, less commonly, alcoholic hepatitis.

Portal hypertension occurs when the blood pressure inside your liver has risen to a potentially serious level.

When the liver becomes very scarred, it is harder for blood to move through it. This leads to an increase in blood pressure.

The blood must also find a new way to return to your heart. It does this by opening up new blood vessels, usually along the lining of your stomach. These new blood vessels are known as varices.

If the blood pressure rises to a certain level, it can become too high for the varices to cope with, causing the varices' walls to split and bleed.

This could cause moderate but long-term bleeding, which can lead to anaemia (a condition where the body does not have enough oxygen-carrying red blood cells).

Symptoms of anaemia include:

  • fatigue
  • breathlessness (dyspnoea)
  • pale skin
  • irregular heartbeat

Alternatively, the bleeding can be rapid and massive, causing you to:

  • vomit blood, and/or
  • pass stools that are very dark or tar-like

Split varices can be treated by using a gastroscope(a 'camera-tube' designed to be passed down into the stomach) to locate the varices. A tiny rubber band is then used to seal the base of the varices.

Hepatic encephalopathy

One of the most important functions of the liver is to remove toxins from your blood. If your liver is unable to do this due to hepatitis or cirrhosis, the levels of toxins in your blood increase. A high level of toxins in the blood due to liver damage is known as hepatic encephalopathy.

Symptoms of hepatic encephalopathy include:

  • agitation
  • confusion
  • disorientation
  • muscle stiffness
  • muscle tremors
  • difficulty speaking, and, in very serious cases
  • coma

Hepatic encephalopathy usually requires admission to hospital. The function of the body is supported while medication is given to remove toxins from the blood.

The most effective way to prevent alcoholic liver disease is to stop drinking alcohol, or at least stick to the recommended weekly limits.

The recommended weekly limits of alcohol consumption are seventeen standard drinks of alcohol for men, and fourteen for women. A standard drink of alcohol is equal to about half a pint of beer, a small glass of wine or a pub measure of spirits.

Even if you have been a heavy drinker for many years, reducing or stopping your alcohol intake will have important short- and long-term benefits to your liver and your overall health.

If you have cirrhosis, stop drinking immediately. Alcohol increases the rate at which the condition progresses, regardless of the cause.

Talk to your GP or pharmacist if you are taking over-the-counter or prescription medications, because the liver processes some medications.

One of the symptoms of end-stage liver disease is an abnormal accumulation of fluid in the abdomen, called ascites. If you have ascites, reduce the amount of sodium (salt) in your diet to 1,000mg a day (500mg if possible). This will help reduce the amount of fluid in your body.

Eat a well-balanced diet. You may need extra energy and protein. Liver disease can cause the liver to stop working properly, so it may be unable to store glycogen, the carbohydrate that provides short-term energy. When this happens, the body uses its own muscle tissue to provide energy between meals, which leads to muscle wasting and weakness.

Healthy snacking between meals can top up your calories and protein, which helps preserve muscles and keeps them strong. Improved nourishment will make you feel better, so try to eat regularly, about every two to three hours.

Limit your caffeine intake. Caffeine is processed through the liver and eliminated from the body by the kidneys. This process is drastically affected by the presence of cirrhosis, and can result in a higher concentration of caffeine in the blood, causing headaches, fatigue, insomnia and anxiety. Avoid drinks that contain caffeine such as coffee, tea and some soft drinks.

Glossary

Abdomen

The abdomen is the part of the body between the chest and the hips.

Blood

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Kidney

Kidneys are a pair of bean-shaped organs located at the back of the abdomen, which remove waste and extra fluid from the blood and pass them out of the body as urine.

Liver

The liver is the largest organ inside the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Tissue

Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.   


Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.