Alcohol-related Liver Disease: Causes, Symptoms, And Treatment

Pouring a glass of chilled wine or opening a vintage whisky bottle or consuming alcohol in some other form is a part of celebrations worldwide, among diverse cultures. The alcohol 'kick' makes the people happy, but their liver isn't so happy. The liver, which is the body's filtration plant, is damaged while processing the alcohol; it can recover, given its regenerative power. But danger lurks when people stress out their liver without realizing it and are also unable to read the first signs of alcoholic liver disease.

Most people know that too much alcohol isn't good for health, but they may not know what specific damage alcohol does and how alcohol affects the liver, in particular.

How does alcohol affect the liver?

The damage done to the liver by alcohol comes in 3 stages: fatty liver; hepatitis; and cirrhosis. Once the liver damage reaches the last stage, it's nearly irreversible, though early detection of cirrhosis can halt further decline of liver health. Worse still, heavy drinking over a long period of time increases the risk of liver cancer.

According to an article published on the website of the World Gastroenterology Organisation, alcohol-related liver disease (ARLD) kills a huge number of people every year, and the real number could be much higher than the available number. The article by two Indian doctors from the Institute of Liver and Biliary Sciences, New Delhi, said: "According to the WHO, alcohol consumption accounts for 3.8% of the global mortality... Alcohol is the main cause of liver-related death in Europe with highest mortality rates reported from France and Spain (approximately 30 deaths per 100,000 per year)."

Speaking of the "possibility of underestimation of mortality due to legal issues of documenting alcohol as the primary cause of death", the writers added, "Today, even in Asian countries like India, alcohol is emerging as the commonest cause of chronic liver disease."

More WHO data reveal that alcoholic beverage consumption globally results in 3 million deaths (5.3% of all deaths) annually, and 5.1% of the global disease and injury burden. Alcohol consumption causes death and disability quite early in life, with almost 13.5% of the total deaths in the 20-39 year age group attributable to alcohol.

Some common negative effects of alcohol are:

• Liver diseases characterized by conditions like cirrhosis and hepatitis, which can be life-threatening
• Increased blood pressure
• Heart failure
• Dementia
• Risk of injury due to loss of judgment during driving, etc.

The liver suffers great damage in the form of tissue injury from excessive alcohol consumption, as the liver is the primary site of ethanol metabolism. Consuming alcohol leads to metabolic shifts in the body; too much of this eventually results in the formation of fatty acids and thus a fatty liver.

Alcohol interferes with the body's lipid metabolism taking place in the liver and induces fat deposition in the liver. High alcohol consumption can lead to a wide variety of liver disorders, the most common being a fatty liver, also known as steatosis, followed by hepatitis, and fibrosis or cirrhosis.

Types of alcohol-related liver diseases

There are 3 types of liver diseases related to alcohol consumption:

• Steatosis or fatty liver
• Hepatitis
• Cirrhosis or fibrosis

1. Steatosis

This is the earliest response to high levels of alcohol in the liver, and almost 90% of the drinking population has experienced this. Fatty liver is common in those consuming 4-5 drinks per day for many years. It can also develop through binge drinking, where 4-5 drinks are consumed within 2 hours or less. In this condition, there's the deposition of fat in the hepatocytes or liver cells, usually seen as lipid droplets under the microscope. Steatosis can be reversed if the person stops drinking.

2. Hepatitis

Alcoholic hepatitis is a more severe condition and is characterized by liver inflammation, where the hepatocytes become swollen and eventually die. It occurs in about 30-40% of those with chronic alcohol consumption.

3. Cirrhosis

Hepatic fibrosis, a condition where excessive connective tissue builds up in the liver, which further transforms into its later stage called cirrhosis, involves the accumulation of abnormal amounts of proteins in the liver. It is characterized by scarring of liver tissue. Hepatic fibrosis, just like steatosis, is reversible, provided the drinking stops. However, if the drinking continues, liver inflammation and fibrogenesis continue to progress, eventually leading to cirrhosis, which is almost irreversible, unless detected very early.

Geographical significance in ARLD

Deaths from alcohol-related liver disease (ARLD) are highest in Africa and the Western Pacific (16.9 and 10.8 deaths per 100,000, respectively), while alcohol-related digestive diseases are highest in Europe and the Western Pacific (30.5% and 28.9%, respectively). The socioeconomic status in the different geographies results in differing morbidity and mortality outcomes for these regions.

Gender and ARLD

Women tend to consume less alcohol compared to men and are, therefore, at a lower risk of ARLD. However, women are more susceptible to the hepatotoxic effects of alcohol. They progress rapidly to fibrosis and cirrhosis compared with men, and fibrosis persists even after cessation of drinking.

Women have less gastric alcohol dehydrogenase (ADH) activity than men. ADH carries out ethanol oxidation. The reduced gastric alcohol breakdown in women leads to increased bioavailability of alcohol in the bloodstream, which in turn affects hormonal activities.

Risk factors in developing ARLD

Various factors influence the progression of alcohol-related liver disease in people. A few of them are listed below:

1. Drinking pattern

Drinking patterns may be broadly classified into "heavy drinking" and "binge drinking". Heavy drinking usually amounts to 4-5 standard drinks per day over many years. Binge drinking — this is defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), United States, as drinking episodes of 5 or more drinks in men, or 4 or more drinks in women — is on the rise globally, as all types of alcohol become more easily available, and drinking even without any special occasion becomes socially acceptable.

Binge drinking makes you prone to alcohol abuse and dependence, later in life, along with the risk of developing ARLD. Young women who binge drink are particularly susceptible to the grave effects of alcohol.

Epidemiological data suggest that binge drinking is partially responsible for increasing rates of cirrhosis and cirrhosis-related deaths. Several studies and meta-analyses denote 30ml of alcohol daily as the limit, marking a clinically significant and elevated risk of progressing to advanced liver disease if this limit is crossed.

The American Association for the Study of Liver Diseases suggests using less than 21 drinks per week for men and less than 14 drinks per week for women over two years as exclusion criteria for non-alcoholic steatohepatitis clinical trials. Non-alcoholic steatohepatitis (NASH) is a sub-type of Non-Alcoholic Fatty Liver Disease (NAFLD).

2. Obesity

The World Health Organization defines being overweight and obese as having a body mass index (BMI) greater than 25kg/m2 and 30kg/m2, respectively. One of the first stages in the development of ARLD is steatosis, characterized by fat deposition in the liver cells.

Epidemiological data show strong independent associations between alcohol intake and BMI, with the conclusion that individuals who consume more alcohol have higher BMIs. Results from the Third National Health and Nutrition Examination Survey (NHANES III), in the United States, showed that ARLD patients had an obesity prevalence of 44.5% and increased liver-related mortality.

3. Hepatitis C virus (HCV)

Chronic HCV infection is a major cause of chronic liver disease. Alcohol intake negatively modifies the course and outcome of HCV infection. Data show that HCV patients who drink alcohol develop hepatocellular carcinoma (HCC) about 2-3 times more frequently than those who do not drink.

4. Alcohol-related liver disease symptoms

How do you know if alcohol is affecting your liver? Though symptoms of liver damage take time to become obvious, here are some signs you should know about — and take them seriously. If you already know that you're a heavy drinker or a binge drinker, going by the given standards, then these signs, put together with the drinking habits, could point to ARLD.

Symptoms of alcoholic fatty liver disease

People with a build-up of fat inside the liver cells are often asymptomatic or have non-specific symptoms that do not suggest acute liver disease. Some signs are:

• Upper abdominal discomfort on the right side
• Tiredness and weakness
• Unexplained weight loss

Symptoms of alcoholic hepatitis

People in whom ARLD has progressed to the next stage have some more obvious symptoms. The signs are:

• Pain over the liver
• Fever
• Weakness
• Nausea and vomiting
• Appetite loss
• Yellowing of the skin and eyes (jaundice)

Symptoms of alcoholic liver cirrhosis

People in whom alcoholic liver cirrhosis has already begun, especially if previous symptoms were ignored, are likely to have all the symptoms of alcoholic hepatitis and then some more. The signs are:

• Portal hypertension (increased resistance to blood flow through the liver)
• Enlarged spleen
• Poor nutrition
• Bleeding in the intestines
• Ascites (fluid build-up in the belly)
• Kidney failure
• Confusion
• Liver cancer

Note: The symptoms of alcohol-related liver disease may overlap with those of other diseases and should always be confirmed by consulting with a doctor.

Is alcohol-related liver disease fatal?

ARLD can certainly become fatal unless it's detected and reversed at an early stage by giving up alcohol and making other lifestyle changes to promote liver recovery. If left untreated until a later stage, when alcoholic liver cirrhosis has already set in, the chances of survival are diminished, especially if there's liver failure and no possibility of a successful liver transplant.

1. ARLD diagnosis

To diagnose whether you're suffering from alcohol-related liver disease, a doctor will perform a complete physical examination and study your medical history.

Tests used to diagnose ARLD include the following:

• Blood tests: This includes liver function tests, which show whether the liver is working properly or not.
• Liver biopsy: This involves removing small tissue samples from the liver with a needle or during surgery. These samples are studied using a microscope to find out the type of liver disease.
• Ultrasound: This test uses high-frequency sound waves to create a picture of the organs.
• CT scan: This imaging test uses X-rays and a computer to produce images (often called "slices") of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
• MRI: The Magnetic Resonance Imaging test uses a magnetic field, radiofrequency pulses, and a computer to make detailed pictures of internal body structures. Sometimes injecting dye into a vein is used to produce images of body parts. The dye helps show the liver and other organs in the abdomen.

2. ARLD treatment

The obvious first step to help you with alcohol-related liver disease is the cessation of drinking, also called abstinence from drinking.

Treatment for ARLD includes:

• Alcohol withdrawal treatment
• Nutritional support
• Liver transplant
• Treating complications of ARLD
• Medicines

3. Alcohol withdrawal treatment

Since the body has been too dependent on alcohol, withdrawal generally has painful symptoms, including:

• Anxiety
• Fatigue
• Mood swings
• Clammy skin or sweating
• Dilated pupils
• Headache
• Nausea and vomiting
• Severe agitation or confusion

You may need hospitalization and the healthcare providers will monitor your blood pressure, temperature, and heart rate. You will receive intravenous (IV) fluids and medication, and possibly a sedative until withdrawal is complete.

4. Nutritional support

In ARLD, chances are that the patient is malnourished due to loss of appetite, and nausea. Providing sufficient calories with nutritional supplements is very crucial to the recovery and healing of liver inflammation. In severe situations, the doctor may give enteral therapy, where a simple feeding tube is inserted into the stomach, to provide all the necessary nutrients.

5. Liver transplant

In severe cases, the patient's condition may deteriorate further and he/she may develop liver failure. At that point, liver transplantation is the only cure.

6. Treating complications of ARLD

Chronic liver disease results in cirrhosis and often leaves scarred, non-functional tissue on the liver. Although there's no cure for cirrhosis, the doctor will work to manage its symptoms, and prevent it from progressing, by asking you to do the following:

• Take medications
• Stop drinking alcohol
• Lose weight if you are overweight
• Eat a low-sodium diet

7. Treating portal hypertensive bleeding

Since the liver develops scarred tissue in ARLD, the blood does not circulate properly in the body, leading to the formation of varicose veins in the stomach or esophagus, due to high blood pressure in the portal vein. Internal bleeding from these varicose veins may be fatal.

Common treatment options for this include:

• Medication to lower the blood pressure
• Variceal ligation using rubber bands on the varices
• Intrahepatic shunt, where the shunt prevents the vein from opening and bleeding

8. Medicines

FDA-approved medications like disulfiram and naltrexone are used with limitations due to their inherent hepatotoxic properties. Corticosteroids, N-acetylcysteine, and Pentoxifylline are used to treat and manage liver disease.

Dos and Don'ts to prevent ARLD, or to stop its progress

1. Dos

• Do keep track of your drinking and eating habits, to control the damage well in
• Do follow a healthy exercise routine to keep yourself fit in the long run.
• Do visit a doctor even at the earliest signs and symptoms of liver damage like pain, swelling, fever, and when experiencing weight loss, fatigue, and yellowing of the skin and eyes.
• Do get yourself physically examined regularly by your doctor to understand if you're at risk of alcohol-related liver disease.

2. Don'ts

• Don't self-assess for ARLD, and don't self-medicate.
• Don't continue to keep drinking once diagnosed with ARLD, unless allowed by your doctor.
• Don't neglect your general diet and lifestyle, as poor choices can put additional stress on the liver, on top of the alcohol-related stress.

Conclusion

Alcohol-related liver disease can constitute various pathological conditions, ranging from a fatty liver and hepatitis to more severe cirrhosis. When diagnosed well in time, ARLD can be effectively managed and reversed with medication and other treatments.

Apart from treatment, a few simple steps such as diet and lifestyle modifications go a long way in undoing the damage caused by ARLD. The first step to preventing ARLD is to analyze your habits and see if you're at risk of the disease. From there, you can start making the right decisions.

Keep reading for credible information about similar health conditions, and how you can maintain good liver health.