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Alcoholic Liver Disease

by Nicholas T. Orfanidis, MD

Alcoholic liver disease is liver damage caused by drinking too much alcohol for a long time.

  • In general, the amount of alcohol consumed (how much, how often, and for how long) determines the risk and severity of liver damage.

  • Symptoms range from none at first to fever, jaundice, fatigue, and a tender, painful, and enlarged liver, then to more serious problems such as bleeding in the digestive tract and deterioration of brain function.

  • To help identify whether drinking is a problem, doctors may give the person a questionnaire and ask family members how much the person drinks.

  • If people who have been drinking in excess have symptoms of liver disease, doctors do blood tests to evaluate the liver and occasionally do a liver biopsy.

  • The best treatment is to stop drinking alcohol, but doing so is very difficult and requires help, often in rehabilitation programs.

In the United States, more than 10% of people abuse or are dependent on alcohol (see Alcohol). About twice as many men as women abuse alcohol.

Most alcohol, after being absorbed in the digestive tract, is processed (metabolized) in the liver. As alcohol is processed, substances that can damage the liver are produced. The more alcohol a person drinks, the greater the damage to the liver. When alcohol damages the liver, the liver can continue to function for a while because the liver can sometimes recover from mild damage. Also, the liver can function normally even when about 80% of it is damaged. However, if people continue to drink alcohol, liver damage progresses and may eventually result in death. If people stop drinking, some damage may be reversed. Such people are likely to live longer.

Abuse of alcohol may cause three types of liver damage (see also Cirrhosis of the Liver), which often develop in the following order:

  • Accumulation of fat (fatty liver, or steatosis): This type is the least serious and can sometimes be reversed. It occurs in more than 90% of people who drink too much alcohol.

  • Inflammation (alcoholic hepatitis): The liver becomes inflamed in about 10 to 35% of people.

  • Cirrhosis: About 10 to 20% of people develop cirrhosis (see Cirrhosis of the Liver). In cirrhosis, a large amount of normal liver tissue is permanently replaced with scar tissue (called fibrosis), which performs no function. As a result, the internal structure of the liver is disrupted, and the liver can no longer function normally. Eventually, the liver usually shrinks. People may have a few symptoms or the same symptoms as those due to alcoholic hepatitis. Cirrhosis cannot be reversed.

Cirrhosis can cause the following serious complications (see Complications):

  • Ascites: Fluid may accumulate in the abdomen, causing swelling (see Ascites).

  • Hepatic (portosystemic) encephalopathy: Brain function may deteriorate because the damaged liver is less able to remove toxic waste products from the blood (see Hepatic Encephalopathy). People may become drowsy and confused.

  • Portal hypertension: The vein that brings blood to the liver may be narrowed or blocked, increasing blood pressure in that vein (see Portal Hypertension). Oxygen levels in the arteries may be low. As a result, some people have enlarged fingertips (clubbing), and the skin may look blue (called cyanosis). Portal hypertension also causes or contributes to ascites, bleeding in the digestive tract, an enlarged spleen (splenomegaly), and sometimes portosystemic encephalopathy.

  • Bleeding in the digestive tract: Veins in the esophagus and stomach may enlarge, twist, and begin to bleed because of portal hypertension. People may vomit blood or have bloody or dark, tarry stools.

  • Liver failure: The liver becomes less and less able to function, resulting in many complications and generally failing health (see Liver Failure). Liver failure can eventually lead to kidney failure.

  • Coagulopathy: People tend to bleed and bruise more easily (see Bruising and Bleeding) because the damaged liver does not produce enough of the substances that make blood clot. Also, alcohol can reduce the number or activity of platelets, which also help blood clot. Portal hypertension leads to an enlarged spleen, which also decreases the number of platelets.

  • Splenomegaly: Portal hypertension causes the spleen to enlarge (see Enlarged Spleen). The enlarged spleen traps and destroys more white blood cells and platelets than it normally does. As a result, the risk of infections and bleeding is increased.

Risk Factors

Alcoholic liver disease is more likely to develop if people

  • Drink large amounts of alcohol

  • Have been drinking a long time (usually, for more than 8 years)

  • Are women

  • Have a genetic make-up that makes them susceptible to alcoholic liver disease

  • Are obese

Alcohol consumption

People can understand their risk of alcoholic liver disease more precisely if they know how much alcohol they are drinking. To determine how much they are drinking, they need to know the alcohol content of alcoholic beverages. Different types of beverages contain different percentages of alcohol.

  • Beers: 2 to 7% in most

  • Wines: 10 to 15% in most

  • Hard liquors: 40 to 45% in most

However, in typical servings of these different types of beverages, the amount of alcohol is similar even though the amount of liquid is very different:

  • A 12-ounce can of beer: About 1/7 to 4/5 ounce

  • A 5-ounce glass of wine: About 2/3 to 1 ounce

  • A 1 1/2-ounce shot (or typical mixed drink) of hard liquor: About 1/2 ounce

In hard liquor, the alcohol concentration is often described as proof. The proof is about twice the percentage of alcohol. For example, an 80-proof hard liquor contains 40% alcohol.

For men, risk increases if they drink more than about 1 1/2 ounces of alcohol a day (especially if they drink more than about 3 ounces) for more than 10 years. Consuming 1 1/2 ounces a day involves drinking about 3 cans of beer, 3 glasses of wine, or 3 shots of hard liquor. For cirrhosis to develop, men usually must drink more than about 3 ounces a day for more than 10 years. Consuming 3 ounces a day involves drinking 6 cans of beer, 5 glasses of wine, or 6 shots of liquor. About half the men who drink more than 8 ounces a day for 20 years develop cirrhosis.

Generally, the more and the longer people drink, the greater their risk of alcoholic liver disease. However, liver disease does not develop in every person who drinks heavily for a long time. Thus, other factors are involved.


Sex

Women are more vulnerable to liver damage by alcohol, even after adjustments are made for smaller body size. Women are at risk of liver damage if they drink about half as much alcohol as men. That is, drinking more than 3/4 to 1 1/2 ounces of alcohol a day puts women at risk. Risk may be increased in women because their digestive system processes alcohol less quickly.


Genetic make-up

Genetic make-up is thought to be involved because alcoholic liver disease often runs in families. Family members may share genes that make them less able to process alcohol.


Obesity

Obesity makes people more vulnerable to liver damage by alcohol.


Other factors

Accumulation of iron in the liver and hepatitis C also increase the risk of liver damage by alcohol.

Iron may accumulate when people have hemochromatosis (a hereditary disorder that results in absorption of too much iron) or when they drink fortified wines that contain iron. However, iron accumulation is not necessarily related to how much iron is consumed.

More than 25% of heavy drinkers also have hepatitis C, and the combination of heavy drinking and hepatitis C greatly increases the risk of cirrhosis.

If iron has accumulated in the liver or if people have had hepatitis C for more than 6 months, the risk of liver cancer (hepatocellular carcinoma) is increased.


Symptoms

Heavy drinkers usually first develop symptoms during their 30s or 40s and tend to develop severe problems about 10 years after symptoms first appear.

Fatty liver often causes no symptoms. In one third of people, the liver is enlarged and smooth but is not usually tender.

As alcoholic liver disease progresses to alcoholic hepatitis, symptoms may range from mild to life threatening. People may have a fever, jaundice, and a tender, painful, enlarged liver. They may feel tired.

Heavy drinking can make the bands of fibrous tissue in the palms tighten, causing the fingers to curl (called Dupuytren contracture—see Dupuytren Contracture), and make the palms look red (called palmar erythema). Small spiderlike blood vessels veins (spider angiomas) may appear in the skin of the upper body. Salivary glands in the cheeks may enlarge, and muscles may waste away. Peripheral nerves (nerves outside the brain and spinal cord) may be damaged, causing loss of sensation and strength. The feet and hands are affected more than the upper legs and arms.

Men who drink heavily may develop female characteristics, such as smooth skin, enlarged breasts, and changes in pubic hair. Their testes may shrink.

The pancreas may become inflamed (called pancreatitis), causing severe abdominal pain and vomiting.

People may become undernourished because drinking too much alcohol, which has calories but little nutritional value, decreases the appetite. Also, the damage caused by alcohol can interfere with the absorption and processing of nutrients. People may have deficiencies of folate, thiamin, other vitamins, or minerals. Deficiencies of certain minerals can cause weakness and shaking. Also, nutritional deficiencies probably cause or contribute to peripheral nerve damage.

In heavy drinkers, thiamin deficiency can lead to Wernicke encephalopathy (see Wernicke’s Encephalopathy), which can cause confusion, difficulty walking, and eye problems. If not promptly treated, Wernicke encephalopathy may result in Korsakoff syndrome (see Korsakoff’s Syndrome), coma, or even death. Korsakoff syndrome causes memory loss and confusion.

Anemia may develop because bleeding occurs in the digestive tract or because people develop deficiencies of a nutrient needed to make red blood cells (certain vitamins or iron).

Symptoms may also result from the complications of cirrhosis (see Introduction, above).

After cirrhosis develops, the liver usually shrinks.

Liver cancer develops in 10 to 15% of people with cirrhosis due to alcohol abuse.

Diagnosis

Doctors suspect alcoholic liver disease in people who have symptoms of liver disease and who drink a substantial amount of alcohol.

Doctors may give the person a questionnaire to help identify whether drinking is a problem. Doctors may also ask family members how much the person drinks (see Screening for Alcohol Abuse).

There is no definitive test for alcoholic liver disease. But if doctors suspect the diagnosis, they do blood tests to evaluate the liver (liver function tests). A complete blood count (CBC) to check for a low platelet count and anemia is also done.

Imaging tests are not routinely done. If ultrasonography or computed tomography (CT) is done for other reasons, doctors may see evidence of fatty liver or portal hypertension, an enlarged spleen, or accumulation of fluid in the abdomen.

A technique called ultrasound elastrography may be done to determine how stiff the liver is. A stiff liver indicates fibrosis. For this test, ultrasonography is done while pressure or vibration is applied to the liver. This test often makes a biopsy unnecessary.

Even if examination and test results suggest alcoholic liver disease, doctors periodically check for other forms of liver disease that can be treated, especially viral hepatitis. Other causes of liver problems may coexist and, if present, must be treated.

Liver biopsy is sometimes done when the diagnosis is uncertain or when liver disease appears to have more than one cause. Liver biopsy can confirm liver disease, provide evidence that alcohol is the likely cause, and determine the type of liver damage present. It can also identity whether iron has accumulated in the liver. Such accumulation may indicate hemochromatosis (see Hemochromatosis).

If people have cirrhosis, tests for liver cancer are done. They include ultrasonography and blood tests to measure levels of alpha-fetoprotein, which are high in about half the people with liver cancer.

Prognosis

The prognosis depends on how much fibrosis and inflammation are present.

If people stop drinking and no fibrosis is present, fatty liver and inflammation can be reversed. Fatty liver completely resolves within 6 weeks. Fibrosis and cirrhosis cannot be reversed.

Certain biopsy and blood test results can help doctors predict a person's prognosis better. Doctors can also use formulas and models (which combine various test results) to help predict prognosis.

Once cirrhosis and its complications (such as fluid accumulation in the abdomen and bleeding in the digestive tract) develop, the prognosis is worse. Only about half the people are still alive after 5 years. People who stop drinking tend to live longer than those who do not.

Treatment

Treatment can include

  • Stopping drinking (abstinence) and assistance in doing so

  • Treatment of symptoms and complications

  • Treatments for liver damage

Abstinence

Abstinence is usually the best treatment. Other than liver transplantation, it is the only treatment that can slow or reverse alcoholic liver disease. In addition, it is available to all and has no side effects.

Because abstinence is difficult, several strategies are used to help motivate people and to help them change their behavior. Strategies include behavioral therapy and psychotherapy (talk therapy)—often as part of a formal rehabilitation program—as well as self-help and support groups (such as Alcoholics Anonymous) and counseling sessions with the primary care doctor. Therapies that explore and help people clarify why they want to abstain from alcohol (called motivational enhancement therapy) may also be used.


Drugs

Drugs are sometimes used but only to supplement behavioral and psychosocial therapies (see Detoxification and Rehabilitation). Some drugs (such as naltrexone, nalmefene, baclofen, or acamprosate) help by reducing withdrawal symptoms and the craving for alcohol. Disulfiram helps because it causes unpleasant symptoms (such as flushing) when people take it and then drink alcohol. However, disulfiram has not been shown to promote abstinence and consequently is recommended only for certain people.


Treatment of symptoms and complications

Doctors treat the problems caused by alcoholic liver disease and the withdrawal symptoms that develop after people stop drinking.

A nutritious diet and vitamin supplements (especially B vitamins) are important during the first few days of abstinence. They can help correct nutritional deficiencies that can cause complications such as weakness, shaking, loss of sensation and strength, anemia, and Wernicke encephalopathy (see Wernicke’s Encephalopathy). Supplements can also improve general health. Often, if inflammation is severe, people are hospitalized and may need to be fed through a tube to receive adequate nutrition.

Benzodiazepines (sedatives) are used to treat withdrawal symptoms (see Emergency Treatment). However, if alcoholic liver disease is advanced, sedatives are used in small doses or avoided because they can trigger portosystemic encephalopathy.


Treatments for liver damage

Abstinence is tried first. Several drugs, including some antioxidants (such as S -adenosyl- L -methionine, phosphatidylcholine, and metadoxine) and drugs to reduce inflammation, may be useful, but further study is needed. Many nutritional supplements that are antioxidants, such as milk thistle and vitamins A and E, have been tried but are ineffective.

Corticosteroids can help relieve severe liver inflammation and are safe to use if people do not have an infection, bleeding in the digestive tract, kidney failure, or pancreatitis.

Liver transplantation may be done if the damage is severe. Transplantation enables people to live longer. However, because about half the people start drinking again after transplantation, most transplantation programs require that people be abstinent for 6 months to qualify.


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  • LIORESAL
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