Alcohol-related liver disease

The name covers three separate conditions with one cause behind them: fatty liver, alcoholic hepatitis and cirrhosis. What they share is more than the drink — it is an awkward habit of destroying the liver quietly, over years. The person feels much as usual, blood tests can come back normal, and the amount of scar inside the liver keeps growing. The encouraging part is that the early steps are reversible, and what decides the outcome is not a medicine but stopping alcohol.

What happens inside the liver

The liver breaks ethanol down into intermediate substances, every one of which is poisonous to its own cells. Some of those cells die; others rearrange their metabolism so that fat builds up inside them. As long as the gaps between drinking episodes are long enough, the cells recover. When the load continues for years without a pause, scar tissue grows where working tissue used to be.

Scar neither works nor melts away. It does not filter blood, does not make proteins, does not hold an energy store, and on top of that it squeezes the vessels running through the liver. Blood then looks for detours through the small veins of the oesophagus and stomach, and almost every serious complication comes from there.

There is no safe amount that guarantees none of this will happen. The risk rises with quantity and with years, and drinking every day without a break does more harm than the same total spread across the week.

Three steps of one disease

• Fatty liver. It appears fast — a few days of heavy drinking in a row can be enough. It causes almost no symptoms and is usually found by chance on an ultrasound scan. This is the point that matters most, because a few months without alcohol normally return the liver to where it was.
• Alcoholic hepatitis. Inflammation of the liver with no connection at all to viral hepatitis, misleading though the name is. It develops on a background of years of drinking, and sometimes a single heavy episode sets it off. It brings yellow eyes and skin, weakness, nausea, pain under the right ribs and fever. The mild form settles once drinking stops; the severe form is life-threatening and is treated in hospital.
• Cirrhosis. A large share of the liver has been replaced by scar. It can stay silent for years and then announce itself straight away with a complication. The scar itself does not go back, but stopping drinking halts the destruction and transforms the outlook.

The steps have no clean border between them: fat, inflammation and scar often exist in the same person at the same time.

Why the symptoms arrive last

The liver has an enormous reserve and no pain endings inside it — only the capsule around it hurts, and only when stretched. So the first complaints are vague: tiredness that rest does not fix, a flat appetite, morning nausea, heaviness under the right ribs, unsettled bowels, weight slipping away. All of it is easy to put down to age and poor sleep.

Obvious signs mean the liver is already failing to cope: yellow whites of the eyes and yellow skin, swollen feet and ankles, an abdomen that swells while the rest of the body thins, stubborn itching, bruises from the lightest knock, bleeding gums and nosebleeds, spider-like vessels across the chest and shoulders, blotchy red palms, muscle wasting, fingertips that look thickened. Alongside them come daytime drowsiness and sleepless nights, forgetfulness, irritability and a changed personality — the outward face of toxins building up in the brain. One more telling sign is falling tolerance to alcohol and to medicines: the old dose now floors the person, because the liver no longer clears it.

Who reaches cirrhosis sooner

• women, in whom damage develops at lower amounts and over a shorter time;
• people carrying excess weight, diabetes or metabolic fatty liver, where the two mechanisms add up;
• carriers of viral hepatitis B and C, in whom the combination with alcohol speeds cirrhosis up several times over;
• anyone with a family history of drinking problems or liver disease;
• smokers;
• those who drink on an empty stomach and without days off, rather than on occasions.

Paracetamol deserves a separate mention: with regular drinking the liver becomes more sensitive to it, and an ordinary packet bought for a headache can do more harm than expected.

When waiting is not an option

Call the emergency services straight away if any of this appears:

• vomiting blood, or vomit that looks like dark coffee grounds;
• black, tarry stools;
• confusion, disorientation, sudden drowsiness, tremor when the hands are held out, or failure to recognise close family;
• fever and chills alongside a distended abdomen and pain — that is how infection of the fluid in the abdomen begins;
• jaundice that is deepening quickly.

There is also a danger running the other way, and it is rarely spelled out. After long-standing daily drinking you must not stop abruptly without a doctor. Six to forty-eight hours later a severe withdrawal can begin: trembling, sweating, swings in blood pressure, seizures, hallucinations, confusion. That state can kill on its own and needs medical supervision, sometimes in hospital. Giving up alcohol is the right decision, but after years of heavy use it is planned together with a doctor.

How the damage is found

The disease usually surfaces by accident, during tests done for something else. The conversation about how much is drunk is not a formality: an honest answer spares unnecessary investigations and saves time.

Routine liver blood tests can stay normal even in cirrhosis, so the picture is drawn more widely: bilirubin, albumin, clotting measurements, and platelets, whose fall is often the first trace of scarring. Next come ultrasound and elastography, which measures the stiffness of the liver without any needle and is the simplest way to tell whether scar is present. A biopsy is kept for cases where the picture is unclear or several causes may be at work. Where cirrhosis is suspected, an upper endoscopy is arranged to spot widened veins in the oesophagus before they bleed.

An important part of the work-up is ruling other causes out. Viral hepatitis, iron overload, autoimmune damage and metabolic fatty liver occur in people who drink as well, and they are treated differently.

What actually changes the outcome

No drug repairs the liver. One thing works — removing alcohol completely — and it is worth doing at every step, cirrhosis included.

The decision on its own rarely holds without support, and this is not about willpower: most people with this diagnosis are dependent. What helps is a combination of psychological therapy, support groups and medicines that reduce craving, prescribed by a doctor and ineffective in isolation. During supervised withdrawal, sedative medicines are used along with vitamin B1, whose lack can cause severe brain damage.

The second underrated element is food. Undernutrition is almost the rule in this illness, and muscle disappears because the liver holds no energy store between meals. Hence the practical measures: small meals four or five times a day, always something to eat before bed, no cutting protein without medical instruction, and less salt once there is swelling or fluid in the abdomen. B group vitamins are prescribed to nearly everyone.

Severe alcoholic hepatitis is treated in hospital, and in selected cases a doctor adds steroid anti-inflammatory treatment. Cirrhosis calls for monitoring and prevention of complications: an ultrasound scan every six months to catch liver cancer early, endoscopy on a schedule, and diuretics when fluid gathers. It is worth being vaccinated against hepatitis A and B, and worth asking before taking any painkiller, supplement or herbal preparation. Transplant is discussed once the liver has failed outright, and only with lasting abstinence.

Online consultation

In an online appointment a doctor will go through your blood results and ultrasound report, explain what elastography measures and whether you need it, put the investigations in a sensible order, weigh up the risk of severe withdrawal and advise how to stop drinking safely after years of heavy use, check your medicines against the state of your liver, and tell you which specialist to see and how soon.

This material is for information only and does not replace medical advice.