Alcohol-Related Liver Disease

Alcohol-related liver disease (ARLD) refers to liver damage caused by excess alcohol intake. There are several stages of severity and a range of associated symptoms.

ARLD doesn't usually cause any symptoms until the liver has been severely damaged. When this happens, symptoms can include:

• feeling sick
• weight loss
• loss of appetite
• yellowing of the eyes and skin (jaundice)
• swelling in the ankles and tummy
• confusion or drowsiness
• vomiting blood or passing blood in your stools

This means ARLD is frequently diagnosed during tests for other conditions, or at a stage of advanced liver damage.

If you regularly drink alcohol to excess, tell your GP so they can check if your liver is damaged.

Alcohol and the liver

With the exception of the brain, the liver is the most complex organ in the body. Its functions include:

• filtering toxins from the blood
• aiding digestion of food
• regulating blood sugar and cholesterol levels
• helping fight infection and disease

The liver is very resilient and capable of regenerating itself. Each time your liver filters alcohol, some of the liver cells die.

The liver can develop new cells, but prolonged alcohol misuse (drinking too much) over many years can reduce its ability to regenerate. This can result in serious and permanent damage to your liver.

ARLD is very common in the UK – the number of people with the condition has been increasing over the last few decades as a result of increasing levels of alcohol misuse.

Stages of ARLD

There are three main stages of ARLD, although there's often an overlap between each stage. These stages are explained below.

Alcoholic fatty liver disease

Drinking a large amount of alcohol, even for just a few days, can lead to a build-up of fats in the liver. This is called alcoholic fatty liver disease, and is the first stage of ARLD.

Fatty liver disease rarely causes any symptoms, but it's an important warning sign that you're drinking at a harmful level.

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

Alcoholic hepatitis

Alcoholic hepatitis – which is unrelated to infectious hepatitis – is a potentially serious condition that can be caused by alcohol misuse over a longer period. When this develops, it may be the first time a person is aware they're damaging their liver through alcohol.

Less commonly, alcoholic hepatitis can occur if you drink a large amount of alcohol in a short period of time (binge drinking).

The liver damage associated with mild alcoholic hepatitis is usually reversible if you stop drinking permanently.

Severe alcoholic hepatitis, however, is a serious and life-threatening illness. Many people die from the condition each year in the UK, and some people only find out they have liver damage when their condition reaches this stage.

Cirrhosis

Cirrhosis is a stage of ARLD where the liver has become significantly scarred. Even at this stage, there may not be any obvious symptoms.

It's generally not reversible, but stopping drinking alcohol immediately can prevent further damage and significantly increase your life expectancy.

A person who has alcohol-related cirrhosis and doesn't stop drinking has a less than 50% chance of living for at least five more years.

How ARLD is treated

There's currently no specific medical treatment for ARLD. The main treatment is to stop drinking, preferably for the rest of your life. This reduces the risk of further damage to your liver and gives it the best chance of recovering.

If a person is dependent on alcohol, stopping drinking can be very difficult. However, support, advice and medical treatment may be available through local alcohol support services.

A liver transplant may be required in severe cases where the liver has stopped functioning and doesn't improve when you stop drinking alcohol.

You'll only be considered for a liver transplant if you've developed complications of cirrhosis, despite having stopped drinking. All liver transplant units require a person to not drink alcohol while awaiting the transplant, and for the rest of their life.

Preventing ARLD

The most effective way to prevent ARLD is to stop drinking alcohol or stick to the recommended limits:

• men and women are advised not to regularly drink more than 14 units a week
• spread your drinking over three days or more if you drink as much as 14 units a week

A unit of alcohol is equal to about half a pint of normal-strength lager or a pub measure (25ml) of spirits.

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

Symptoms

In many cases, people with alcohol-related liver disease (ARLD) don't have any noticeable symptoms until their liver is badly damaged.

Early symptoms

If you do experience early symptoms of ARLD, these are often quite vague, such as:

• abdominal (tummy) pain 
• loss of appetite
• fatigue
• feeling sick
• diarrhoea
• feeling generally unwell

Advanced symptoms

As the liver becomes more severely damaged, more obvious and serious symptoms can develop, such as:

• yellowing of the skin and whites of the eyes (jaundice)
• swelling in the legs, ankles and feet, due to a build-up of fluid (oedema)
• swelling in your abdomen, due to a build-up of fluid known as ascites
• a high temperature (fever) and shivering attacks
• very itchy skin
• hair loss
• unusually curved fingertips and nails (clubbed fingers)
• blotchy red palms
• significant weight loss
• weakness and muscle wasting
• confusion and memory problems, trouble sleeping (insomnia) and changes in your personality due to a build-up of toxins in the brain
• vomiting blood and black, tarry stools due to internal bleeding
• a tendency to bleed and bruise more easily, such as frequent nosebleeds and bleeding gums
• increased sensitivity to alcohol and drugs (because the liver can't process them)

When to seek medical advice

ARLD doesn't often cause symptoms until it's reached an advanced stage. If you misuse alcohol, you may have liver damage, even though you have none of the symptoms above.

Contact your GP for advice 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 problem and are advised to see your GP.

See your GP as soon as possible if you have symptoms of advanced ARLD.

Causes

Alcohol-related liver disease (ARLD) is caused by drinking too much alcohol. The more you drink above the recommended limits, the higher your risk of developing ARLD.

There are two ways alcohol misuse (drinking too much) can cause ARLD. These are:

• drinking a large amount of alcohol in a short amount of time (binge drinking) can cause 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 ARLD

Evidence suggests people who regularly drink more than the recommended maximum amounts are most at risk of developing ARLD:

• men and women are advised not to regularly drink more than 14 units a week
• spread your drinking over three days or more if you drink as much as 14 units a week

Additional factors

As well as drinking excessive amounts of alcohol, other factors can increase your chances of developing ARLD. These include:

• being overweight or obese
• being female – women appear to be more vulnerable than men to the harmful effects of alcohol
• having a pre-existing liver condition, such as hepatitis C 
• genetics – alcohol dependence and problems processing alcohol often run in families

Diagnosis

Alcohol-related liver disease (ARLD) is often first suspected when tests for other medical conditions show a damaged liver.

This is because the condition causes few obvious symptoms in the early stages.

If a doctor suspects ARLD, they'll usually arrange a blood test to check how well your liver is working. They may also ask about your alcohol consumption.

It's important to be totally honest about how much and how often you drink alcohol to avoid further unnecessary testing. This could lead to a delay in the treatment you need.

Blood tests

Blood tests used to assess the liver are known as liver function tests. However, liver function tests can be normal at many stages of liver disease.

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. A low level of serum albumin suggests your liver isn't functioning properly.

A blood test may also look for signs of abnormal blood clotting, which can indicate significant liver damage.

Lab Tests Online has more information on liver function tests.

Further testing

If your symptoms or liver function test suggest an advanced form of ARLD – either alcoholic hepatitis or cirrhosis – you may need further tests. These are described below.

Imaging tests

Scans may be needed to produce detailed images of your liver. This may include:

• an ultrasound scan
• a computerised tomography (CT) scan
• a magnetic resonance imaging (MRI) scan

Some scans may also measure the stiffness of the liver, which is a good indication of whether your liver is scarred.

Liver biopsy

During a liver biopsy, a fine needle is inserted into your body (usually between your ribs). A small sample of liver cells is taken and sent to a laboratory to be examined under a microscope.

The biopsy is usually carried out under local anaesthetic, either as a day case or with an overnight stay in hospital.

Specialist doctors will examine the liver biopsy tissue under the microscope to determine the degree of scarring in the liver and the cause of the damage.

Endoscopy

An endoscope is a long, thin, flexible tube with a light and a video camera at one end. During an endoscopy, the instrument is passed down your oesophagus (the long tube that carries food from the throat to the stomach) and into your stomach.

Pictures of your oesophagus and stomach are transmitted to an external screen. The doctor will be looking for swollen veins (varices), which are a sign of cirrhosis.

Treatment

Successful treatment for alcohol-related liver disease (ARLD) often depends on whether someone is willing to stop drinking alcohol and make changes to their lifestyle.

Stopping drinking alcohol

Treatment for ARLD involves stopping drinking alcohol. This is known as abstinence, which can be vital, depending on what stage the condition is at.

If you have fatty liver disease, the damage may be reversed if you abstain from alcohol for at least two weeks. After this point, it's usually safe to start drinking again if you stick to the NHS guidelines on alcohol consumption.

If you have a more serious form of ARLD – alcoholic hepatitis or cirrhosis – life-long abstinence is recommended. This is because stopping drinking is the only way to prevent your liver damage getting worse and potentially stop you dying of liver disease.

Stopping drinking isn't easy, especially as an estimated 70% of people with ARLD have an alcohol dependency problem.

Nevertheless, if you have alcohol-related cirrhosis or alcoholic hepatitis and don't stop drinking, no medical or surgical treatment can prevent liver failure.

Withdrawal symptoms

If you're abstaining from alcohol, you may suffer withdrawal symptoms. These will be at their worst for the first 48 hours, but should start to improve as your body adjusts to being without alcohol. This usually takes three to seven days from the time of your last drink.

Many people initially experience disturbed sleep when abstaining from alcohol, but in most cases their sleep pattern returns to normal within a month.

In some cases, you may be advised to reduce your alcohol intake in a gradual and planned way to help avoid withdrawal problems. You may also be offered a medication called a benzodiazepine and psychological therapy, such as cognitive behavioural therapy (CBT), to help you through the withdrawal process.

Some people need to stay in hospital or a specialist rehabilitation clinic during the initial withdrawal phases, so their progress can be closely monitored.

If you're staying at home, you'll regularly see a nurse or other health professional. You might see them at home, at your GP surgery or at a specialist NHS service.

Preventing relapses

Once you've stopped drinking, you may need further treatment to help ensure you don't start drinking again.

The first treatment usually offered is psychological therapy. This involves seeing a therapist to talk about your thoughts and feelings, and how these affect your behaviour and wellbeing.

If psychological therapy alone isn't effective, you may also need medication to help you abstain from alcohol, such as: 

• acamprosate
• naltrexone
• disulfiram

Diet and nutrition

Malnutrition is common in people with ARLD, so it's important to eat a balanced diet to help ensure you get all the nutrients you need.

Avoiding salty foods and not adding salt to foods you eat can reduce your risk of developing swelling in your legs, feet and abdomen (tummy) caused by a build-up of fluid. See tips for a lower salt diet for more information.

The damage to your liver can also mean it's unable to store glycogen – a 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. Therefore, you may need extra energy and protein in your diet.

Healthy snacking between meals can top up your calories and protein. It may also be helpful to eat three or four small meals a day, rather than one or two large meals.

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 inserted through the nose and into the stomach.

Medication for symptoms

The use of medication to directly treat ARLD is controversial. Many experts have argued there's limited evidence for its effectiveness.

For people with severe alcoholic hepatitis, treatment in hospital may be necessary. Specific treatment with corticosteroids or pentoxifylline medication may be used to reduce inflammation of the liver in some people with this condition.

Nutritional support (see above) is also an important part of treatment in these cases.

Other medications that have been used to treat liver damage include:

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

However, there's a lack of good evidence that these help and they're no longer used for severe alcoholic hepatitis.

Liver transplants

In the most serious cases of ARLD, the liver loses its ability to function, leading to liver failure. A liver transplant is currently the only way to cure irreversible liver failure.

A liver transplant may be considered if:

• you develop progressive liver failure, despite not drinking alcohol
• you're otherwise well enough to survive such an operation
• you commit to not drinking alcohol for the rest of your life

Complications