Alcohol-related Liver Disease
In the United States, the consumption of alcohol is often woven into the fabric of social life. Close to 90% of adults in the United States have had an alcoholic beverage at some point in their life, and when asked about their drinking habits, around 55% report having had a drink within the past month.
While the occasional alcoholic drink is not usually harmful, excessive alcohol consumption can lead to a number of health consequences. It can raise your risk for heart disease, various types of cancer, high blood pressure and, of course, alcohol use disorder. Drinking can also lead to injuries and death by accidents, including motor vehicle crashes and falls, and can result in social and legal problems.
Chronic drinking can also result in a condition known as alcohol-related liver disease. This is a disease in which alcohol use—especially long-term, excessive alcohol consumption—damages the liver, preventing it from functioning as it should.
In its advanced stages, alcohol-related liver disease is a serious, life-threatening condition. In 2019, for instance, alcohol-related liver disease resulted in the death of approximately 37,000 people in the U.S. Between 1999 and 2016, the number of U.S. deaths caused by cirrhosis—or end-stage liver disease—rose more than 10% each year among people aged 25 to 34 years, due to rising rates of alcohol-related liver disease.
The single best treatment for alcohol-related liver disease is abstinence from alcohol. When indicated, specific treatments are available that can help people remain abstinent, reduce liver inflammation, and, in the case of liver transplantation, replace the damaged liver.
“Alcohol-related liver disease refers to a spectrum of disorders, and treatments vary based on the severity of liver disease. Abstinence from alcohol is the recommended in all cases to prevent further injury and complications,” says Lamia Haque, MD, MPH, Director of the Yale Clinic for Alcohol and Addiction Treatment in Hepatology and Digestive Diseases. “Treatment for alcohol-related liver disease requires a multifaceted and individualized approach including nutritional support, treatment of coexisting alcohol use disorder, and in severe cases, medications to treat inflammation and complications of advanced liver disease as well as liver transplantation.”
What is alcohol-related liver disease?
Alcohol-related liver disease (ALD) occurs when the liver is damaged by excessive consumption of alcohol, usually over a period of several years. The disease encompasses a spectrum of liver damage that is divided into three stages: alcohol-related fatty liver disease, alcohol-related hepatitis, and alcohol-related cirrhosis.
- Alcohol-related fatty liver disease. When the liver metabolizes alcohol, it can lead to the build-up of lipids, or fats, in the liver. These fats can impair liver function. At this stage of the disease, the liver may become enlarged.
Alcohol-related fatty liver disease is common. About 90% of people who regularly consume excessive amounts of alcohol have fatty liver disease—it can even occur after drinking too much alcohol for as little as two weeks.
The liver damage caused by alcohol-related fatty liver disease can usually be reversed if the person stops drinking alcohol. But if people with fatty liver disease do not stop drinking, the condition may progress to alcohol-related hepatitis or alcohol-related cirrhosis. Because alcohol-related fatty liver disease usually does not cause any symptoms, it can go undiagnosed.
- Alcohol-related hepatitis. This stage is characterized by inflammation, or swelling of the liver as a result of alcohol consumption. This liver inflammation can result in the degeneration of liver cells, which impairs the liver’s ability to function.
Typically, it takes several years of unhealthy drinking to develop alcohol-related liver disease. The liver damage that occurs in the early, milder stages can often be reversed by abstaining from the consumption of alcohol. Severe alcohol-related hepatitis, however, develops rapidly over weeks or months, and it can result in death.
- Alcohol-related cirrhosis. Cirrhosis occurs when the liver has become permanently damaged by alcohol, to the point where scar tissue replaces healthy tissue. The liver will no longer function normally if scar tissue builds up beyond a certain point. This type of damage cannot be reversed.
People who have alcohol-related cirrhosis are at increased risk for developing liver cancer as well as complications such as retention of fluid in the abdomen, bleeding from veins in the esophagus, and changes in mental status. Also, it is possible to have alcohol-related cirrhosis and alcohol-related hepatitis at the same time.
What causes alcohol-related liver disease?
In order to understand alcohol’s effect on the liver, it’s helpful to know the role of the liver in overall health. The liver is located on the right side of the abdomen, just below the ribs. A large organ, it performs many functions essential for good health. Among other things, the liver produces and secretes bile, a fluid that helps digest fats; metabolizes carbohydrates, fats, and proteins; and produces substances that are essential for blood clotting.
The liver also filters and removes toxic substances—like alcohol—from the blood. When a person drinks alcohol, the alcohol passes into stomach and intestines where it is absorbed into the bloodstream. In turn, the alcohol-containing blood is transported to the liver.
Liver cells then use enzymes to metabolize—or break down—the alcohol. The process of metabolizing alcohol can result in the production of substances that damage liver cells. It can also lead to the production of abnormal levels of fats, which are stored in the liver. Finally, alcohol ingestion can also cause liver inflammation and fibrosis (the formation of scar tissue).
So, if someone drinks too much alcohol, the liver can become damaged by substances produced during the metabolism of that alcohol, the buildup of fats in the liver, and inflammation and fibrosis. This damage impairs the liver’s ability to function properly, which causes various symptoms and can even be fatal.
What are the risk factors for alcohol-related liver disease?
In general, people who drink more alcohol are at elevated risk for alcohol-related liver disease. While the amount of alcohol and duration of alcohol use necessary to result in ALD can vary by person, studies have shown that there is a threshold of alcohol consumption at which the risk for the disease increases:
- Men: more than 2 standard drinks per day
- Women: more than 1 standard drink per day
Binge drinking can also raise the risk of developing ALD. Binge drinking is defined as:
- Men: 5 or more standard drinks in a 2- to 3-hour period
- Women: 4 or more standard drinks in a 2- to 3- hour period
A “standard” drink contains 14 grams (0.6 ounces) of alcohol. This amount of alcohol is contained in:
- 12 fl. oz. of beer (5% alcohol by volume)
- 5 fl. oz. of wine (12% alcohol by volume)
- 1.5 fl. oz. of distilled spirits (40% alcohol by volume)
Several other factors may contribute to an elevated risk for ALD, including:
- Female gender. Women are more susceptible to ALD than men.
- Genetic factors. People with a family history of ALD may be at increased risk.
- Other underlying causes of liver disease. Liver damage caused by alcohol consumption may occur at a faster rate in people who have underlying viral hepatitis (hepatitis B and C) infections, non-alcoholic fatty liver disease, hemochromatosis (a condition in which excess iron accumulates in the body).
- Smoking tobacco
What are the symptoms of alcohol-related liver disease?
The signs and symptoms of ALD can vary significantly depending on the severity of liver damage. Patients with alcohol-related fatty liver disease, for example, usually do not have any symptoms.
Symptoms for alcohol-related hepatitis and cirrhosis may include:
- Skin and/or whites of eyes turn yellow (jaundice)
- Loss of appetite (anorexia)
- Weight loss
- Muscle weakness
- Pain in abdomen (especially in the upper right abdomen)
- Abdominal swelling from fluid buildup (ascites)
- Swelling of legs or ankles (edema)
- Appearance of red blood vessels on the skin’s surface that resemble a spider web (spider telangiectasis)
- Changes in mood
- Vomiting blood
- Blood in stools
- Skin bruises easily
- Bleeding easier than normal
- In men, swollen breasts (gynecomastia) and/or shrinking of testicles
- Decreased libido
How is alcohol-related liver disease diagnosed?
Diagnosis usually begins with a medical history. In addition to asking about symptoms that might indicate ALD, the doctor will ask questions about the patient’s consumption of alcohol. The patient may need to fill out a questionnaire about his or her drinking habits. At this stage, depending on the patient’s use of alcohol, the doctor may diagnose alcohol use disorder.
During the physical exam, the doctor will feel the abdomen to assess the size and tenderness of the liver. They can also determine whether the spleen is enlarged, which may be a sign of advanced liver disease.
Laboratory and imaging tests are often needed as well. Blood tests to evaluate liver function and blood coagulation, and to check for other markers that may indicate liver damage, allow the doctor to assess the severity of liver disease and to rule out non-alcohol-related causes of liver damage, such as viral hepatitis (e.g., hepatitis B and C) or autoimmune or metabolic liver diseases.
Imaging studies of the abdomen such as an ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI), allow doctors to see the liver and check for abnormalities that may be indications of alcohol-related liver disease. An test called transient elastography, which uses an ultrasound or magnetic resonance imaging, measures the stiffness of the liver, which can aid in diagnosing cirrhosis.
Sometimes a liver biopsy will be ordered. In this procedure, a small piece of the liver is removed and sent to a laboratory to be studied for signs of inflammation and scarring.
The doctor may also perform an endoscopy to check whether the veins in the esophagus are enlarged. This is a condition known as esophageal varices, and it can develop in people with alcohol-related hepatitis or cirrhosis. These veins can rupture, which may result in severe, life-threatening bleeding.
During an endoscopy, a doctor inserts an endoscope, which is a thin tube equipped with a camera, into the mouth and down the throat to the esophagus. The camera transmits video to a monitor which allows the doctor to evaluate the esophagus.
How is alcohol-related liver disease treated?
Treatment for ALD may involve lifestyle changes, medications, and, in severe cases, liver transplantation.
Abstinence from alcohol. The best treatment for ALD, regardless of the stage of the disease, is abstinence from alcohol.
For people who have alcohol-related fatty liver disease, abstaining from alcohol is the principal—and usually only—treatment. Usually at this stage of liver disease, damage to liver can be reversed only if alcohol consumption stopped.
However, if someone drinks heavily and/or regularly, it can be difficult to stop and it may be unsafe to do so without medical guidance. This is even more the case if the problem has progressed to alcohol use disorder. Several treatment options are available to help people safely through withdrawal, and to support them in maintaining abstinence and preventing relapse. These treatments include medications, counseling, support groups, and behavioral therapy.
Diet. People who have developed alcohol-related hepatitis and alcohol-related cirrhosis are often malnourished, which can lead to worse health outcomes. Therefore, it’s vital for those with any stage of ALD to maintain a healthy diet. People with signs of malnourishment may need to increase the number of calories and amount of protein they consume, as well as take nutrient or vitamin supplements.
Corticosteroids. Patients with severe alcohol-related hepatitis may be treated with corticosteroids, such as prednisolone, to reduce some of the liver inflammation.
Liver transplantation. For patients with severe alcohol-related hepatitis or severe alcohol-related cirrhosis who aren’t helped by other therapies, liver transplantation may be an option. During a liver transplantation, a surgeon replaces the patient’s damaged liver with all or part of a healthy liver from a deceased or a living donor.
To be considered for a liver transplant, patients must remain abstinent from alcohol prior to transplantation surgery. The purpose of this is to ensure that patients are able to maintain abstinence and are likely to remain abstinent after the transplant surgery.
What is the outlook for people with alcohol-related liver disease?
The outlook for people with ALD depends on the severity of liver damage, the presence of risk factors and complications, and their ability to permanently stop drinking. In general, those with mild disease, who have no or few risk factors and complications, and who remain abstinent have better outcomes.
Still, around 10 to 20% of people who develop alcohol-related fatty liver disease go on to develop cirrhosis. People with alcohol-related cirrhosis tend to have a less favorable prognosis, in part because the liver scarring cannot be reversed and additional complications may develop. For these patients, a liver transplant is often the best option.
What is unique about Yale Medicine’s approach to alcohol-related liver disease?
“The treatment of alcohol-related liver disease requires a multidisciplinary approach,” says Dr. Haque. “Our team at Yale Medicine includes experts in liver diseases, addiction medicine/psychiatry, nutrition, and liver transplantation to provide a comprehensive, individualized, and evidence-based treatment plan for each patient at any stage of alcohol-related liver disease.”