Alcohol-associated liver disease

What is it?

According to MedlinePlus: “damage to the liver and its function due to alcohol abuse”, with cirrhosis as the final stage. The NHS describes it as liver damage caused by drinking too much alcohol over a long period, and notes that early intervention may prevent the condition from getting worse.

Stages according to the NHS: (1) fatty liver: fat builds up in the liver, usually with no symptoms, and recovery is possible with stopping alcohol; (2) alcohol-related hepatitis: the liver is swollen and damaged and symptoms are possible, and partial recovery may occur; (3) cirrhosis: the most serious stage, in which the liver becomes scarred and severely damaged and “this damage cannot usually be reversed”.

NIAAA (Alcohol Research reference) adds that alcohol-related hepatitis can occur at any stage of the disease. On its “Alcohol and the Human Body” page, NIAAA counts the liver among the organs in whose diseases alcohol plays a causal role, and lists fatty change, steatohepatitis, alcohol-related hepatitis, fibrosis, cirrhosis and hepatocellular carcinoma.

According to NIDDK, alcohol-related liver disease (“damage to the liver and its function due to drinking too much alcohol”) is one of the most common causes of cirrhosis; other causes may be present together, and genetic factors play a role in the amount of damage.

Causes

According to MedlinePlus, the disease occurs after years of heavy drinking, and risk increases with the duration and amount of drinking. The NHS states that it results from regularly drinking too much alcohol.

NIDDK states that causes may combine and that genetic factors affect the amount of damage these conditions cause.

Risk factors

Factors mentioned according to the NHS: having another liver disease such as hepatitis C, type 2 diabetes, obesity, and family history. It notes that women develop the disease faster at lower levels of drinking. According to MedlinePlus, men are more likely to be affected but women develop it with less exposure, and some people may have an inherited predisposition.

According to the NIAAA reference: factors that drive progression include female sex, obesity, dietary factors, multiple gene variants, harmful drinking patterns, smoking, and co-existing conditions such as viral hepatitis, haemochromatosis and HIV.

Symptoms

Early stage according to the NHS: tiredness, poor appetite, unintentional weight loss, nausea and vomiting, abdominal pain or discomfort. According to MedlinePlus: loss of energy and poor appetite with weight loss, nausea, abdominal pain, and tiny spider-like blood vessels on the skin. There may be no symptoms in the fatty liver stage (NHS).

With progression according to the NHS and MedlinePlus: jaundice (yellowing), fever, abdominal swelling, swollen legs, tremor, gastrointestinal bleeding, disturbed thinking and concentration or confusion, easy bruising, red palms, pale stools, and sexual dysfunction in men.

How is it diagnosed?

According to the NHS, assessment includes estimating drinking history, blood tests and imaging (ultrasound or CT), and possibly a liver biopsy.

According to MedlinePlus: a clinical examination (enlarged liver or spleen, abdominal swelling, skin changes), laboratory tests including a blood count, liver function tests, clotting tests and liver biopsy, imaging by CT, MRI, ultrasound or elastography, and an upper endoscopy to look for oesophageal varices.

Treatment

The treatment categories usually used are listed here; this is not a prescription. The doctor chooses the plan according to each person's condition; do not change any medicine or dose without a specialist.

According to the NHS, the main goal is to stop drinking alcohol completely, and support includes cognitive behavioural therapy, medicines and support groups; hospital care or a liver transplant may be needed in severe cases. According to MedlinePlus, measures include complete abstinence from alcohol and a low-sodium diet, together with treatment of complications (diuretics, vitamin K, antibiotics, treatment of confusion, treatment of dilated veins and drainage of fluid).

In its discussion of cirrhosis treatment, NIDDK states that doctors advise complete abstinence from alcohol in alcohol-related disease and may refer people to alcohol treatment programmes, and that liver transplant is considered in liver failure after other options have been ruled out.

According to the NIAAA reference: it is recommended to combine treatment of alcohol use disorder with treatment of the liver disease. This includes motivational interviewing, counselling, cognitive behavioural therapy, family involvement and support groups, and medicines for treating the use disorder (such as disulfiram, naltrexone, acamprosate and baclofen) whose suitability varies in advanced liver disease; it was noted that disulfiram is not used in cirrhosis. In severe alcohol-related hepatitis, corticosteroids may be used when there are no contraindications. All of this is decided by the specialist doctor.

Liver transplant: according to NIAAA, many centres in the United States require six months of abstinence, and recent evidence indicates that early transplantation without the waiting period gave similar survival and relapse outcomes. According to MedlinePlus, six months of abstinence is required before transplant in end-stage cases; this page does not cover the criteria of any particular centre.

Follow-up

According to the NIAAA reference: in advanced cases, a formal assessment is recommended, and for those undergoing transplant evaluation, screening for continued alcohol use at every visit; rehabilitation treatment after discharge from hospital is linked to fewer readmissions and relapses. This page does not cover specific follow-up schedules.

Complications

According to MedlinePlus: bleeding disorders, fluid build-up, oesophageal varices, portal hypertension, kidney failure, liver cancer, and hepatic encephalopathy. The NHS lists liver failure, internal bleeding, ascites, impaired cognition, liver cancer and kidney damage.

According to the NIAAA reference: about 21% of cases of compensated cirrhosis were attributed to chronic alcohol consumption, and about 30% of hepatocellular carcinoma cases were caused by alcohol-related liver disease (global figures quoted from studies published up to 2020).

Prevention

This page does not cover detailed preventive recommendations. This page's sources state that stopping alcohol completely is the fundamental step in treatment, and that early intervention may prevent the condition from getting worse (NHS). This page does not give practical advice on drinking amounts because there is no single international source for them; consult a doctor on this.

Living with it

According to MedlinePlus: the disease is treatable if detected early, but continuing to drink shortens life, and severe damage prevents the liver from recovering. The NIAAA reference states that the most important predictor of long-term death in alcohol-related hepatitis is a return to drinking, and that outcomes improve with integrated care. Alcohol use disorder is a health condition treated with support and therapy, and is not regarded here as a matter of willpower.

According to NIAAA (2023), alcohol is involved in about half of liver disease deaths each year in the United States, and deaths linked to alcohol-related liver disease rose 22.4% between 2019 and 2020, at a faster pace among women and among people aged 25 to 34. On the human body page: of 96,610 liver disease deaths (age 12 and over) in 2023, 44.5% (43,004) were alcohol-related.

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