Alcohol-related liver disease

Alcohol-related liver disease (ARLD) refers to liver damage caused by alcohol misuse. It
covers a range of conditions and associated symptoms.
ARLD does not 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 that alcohol-related liver disease is frequently diagnosed during tests for other
conditions.
If you consistently or intermittently drink alcohol to excess you should 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. It's functions
include:

filtering toxins from the blood

aiding digestion of food

regulating blood sugar and cholesterol levels

helping to fight infection and disease

The liver is very resilient and is 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 over many years can reduce your livers ability to regenerate, resulting in serious
damage to the liver.
ARLD is widespread in the UK, and the number of people with the condition has been
increasing over the last few decades because of increasing levels of alcohol misuse.

Stages of alcohol-related liver disease

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

Alcoholic fatty liver disease

Drinking a large amount of alcohol, even for only a few days, can lead to a build-up of fats in
the liver. This is called alcoholic fatty liver disease, and it's the first stage of ARLD.
Fatty liver disease rarely causes any symptoms but it is an important warning sign that you
are drinking at a level harmful to your health.
Fatty liver disease is reversible. If you stop drinking alcohol for two weeks, your liver should
return to normal.

Alcoholic hepatitis

Alcoholic hepatitis (not related to infectious hepatitis) is often the second, more serious stage
of ARLD. It occurs when alcohol misuse over a longer period causes the tissues of the liver to
become inflamed. 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. Unfortunately, some people will only find out they
have liver damage for the first time when their condition reaches this stage.

Cirrhosis

Cirrhosis is the final stage of alcohol-related liver disease, which occurs when the liver
becomes significantly scarred. Cirrhosis is generally not reversible, but stopping drinking
alcohol immediately can prevent further damage and significantly increase your life
expectancy.
If you have alcohol-related cirrhosis and you do not stop drinking, you have a less than 50%
chance of living for at least five more years.

How alcohol-related liver disease is treated

There is currently no specific medical treatment for ARLD. The main treatment is to stop
drinking, preferably for the rest of your life. This will prevent further damage to your liver
and in some cases can allow your liver to repair itself.
If you are dependent on alcohol, stopping drinking can be very difficult. However, support,
advice and medical treatment may be available to help you through local alcohol support
services.

In severe cases, where the liver has stopped functioning despite being completely abstinent
from alcohol, a liver transplant may be required. You will only be considered for a liver
transplant if you have developed complications of cirrhosis despite abstinence from alcohol.
You will also need to remain abstinent from alcohol while awaiting the transplant and for the
rest of your life afterwards.

Complications
Death rates linked to ARLD have risen considerably over the last few decades and alcohol is
now one of the most common causes of death in the UK, along with smokingand high blood
pressure.
Life-threatening complications of ARLD can develop. These include internal (variceal)
bleeding, a build-up of toxins in the brain (encephalopathy), fluid accumulation in the
abdomen (ascites) with associated kidney failure and also liver cancer.

Preventing alcohol-related liver disease

The most effective way to prevent ARLD is to stop drinking alcohol, or stick to the
recommended daily limits and have at least two alcohol-free days a week.
The recommended limits of alcohol consumption are:

Men should not regularly drink more than 3-4 units of alcohol a day.

Women should not regularly drink more than 2-3 units a day.

A unit of alcohol is equal to about half a pint of normal strength lager or a pub measure
(25ml) of spirits. You can use the drinking self-assessment tool to work out whether you're
drinking too much.
Even if you have 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 your overall
health.

Symptoms of alcohol-related liver disease

In many cases, people with alcohol-related liver disease (ARLD) do not 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:

tummy (abdominal) pain

loss of appetite

fatigue

feeling sick (nausea)

diarrhoea

feeling generally unwell

Advanced symptoms
As your liver becomes more severely damaged, you will usually develop more obvious and
serious symptoms, 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, problems 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 cannot process
them)

When to seek medical advice

ARLD often causes no symptoms until it has reached an advanced stage. If you misuse
alcohol, you may have liver damage even though you have none of the symptoms above.
It is recommended that you 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 misuse
problem and are advised to see your GP.
You should see your GP as soon as possible if you have symptoms of advanced alcoholrelated liver disease.

Causes of alcohol-related liver disease

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 that alcohol misuse can cause ARLD:
drinking a large amount of alcohol in a short amount of time (known as 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 hepatitisand cirrhosis, the more serious types of ARLD
Evidence suggests that people who regularly drink more than the maximum amounts of
alcohol recommended by the NHS are most at risk of developing ARLD.
The NHS recommendations are:

men should not regularly drink more than 3-4 units of alcohol a day

women should not regularly drink more than 2-3 units a day

It is also recommended that you avoid alcohol for 48 hours after a heavy drinking session.
Read more about alcohol units and how to calculate them.
Additional factors
As well as drinking excessive amounts of alcohol, there are other factors that can increase
your chances of developing ARLD, including:
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 (a chronic viral

infection of the liver)

genetics - dependence on alcohol and problems processing alcohol often run in

families

Diagnosing alcohol-related liver disease

Alcohol-related liver disease (ARLD) is often first suspected when tests for other medical
conditions show that the liver has been damaged.
This is because the condition causes few obvious symptoms in the early stages.
If a doctor suspects you may have ARLD, they will usually arrange a blood test to check how
well your liver is working. They may also ask you about your alcohol consumption.
It is important to be totally honest about how much and how often you drink alcohol. If you
say you drink less alcohol than you do or deny drinking any alcohol, you may be referred for
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. They can detect enzymes
in your blood that are normally only present if your liver has been damaged.
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. Low levels of serum albumin suggest that
your liver is not 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 about liver function tests.

Further testing

If your symptoms or liver function test suggest that you may have an advanced form of
alcohol-related liver disease, either alcoholichepatitis or cirrhosis, you may need further tests
to assess the state of your liver. These are described below.

Imaging tests

An ultrasound scan, computerised tomography (CT) scan or a magnetic resonance imaging

(MRI) scan may also be carried. These scans can produce detailed images of your liver. 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, as a day case or with an
overnight stay in hospital.
Specialist doctors are able to 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 thin, long, 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.

Treating alcohol-related liver disease

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 alcohol-related liver disease involves stopping drinking alcohol. This is known
as abstinence. Abstinence 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 is 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 - alcoholichepatitis or cirrhosis - life-long
abstinence is recommended. This is because stopping drinking is the only way to prevent
damage to your liver getting worse and potentially stop you dying of liver disease.
Stopping drinking is not easy, especially as an estimated 70% of people with alcohol-related
liver disease have an alcohol dependency problem. Nevertheless, if you have alcohol-related
cirrhosis or alcoholic hepatitis and do not stop drinking, no medical or surgical treatment can
prevent liver failure occurring.

Withdrawal symptoms

If you are 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 between three and 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 are staying at home, you will 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 have 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 feelings and thoughts and how these affect your behaviour and wellbeing.
If psychological therapy alone is ineffective, you may also need medication to help you
abstain from alcohol, such as acamprosate, naltrexone or disulfiram.
See treating alcohol misuse for more information about treatments offered.
Self-help groups
Many people with a dependence on alcohol find it useful to attend self-help groups to help
them stop drinking. One of the most well-known is Alcoholics Anonymous, but there
are many other groups that can help.
See alcohol support for more information about the help available.
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 help 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 is 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 is 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) and propylthiouracil (a type of medicine originally
designed to treat overactive thyroid glands), but there is a lack of good evidence these help
and they are no longer used for severe alcoholic hepatitis.

Liver transplants
In the most serious cases of alcohol-related liver disease, the liver loses its ability to function,
leading to liver failure. A liver transplant is currently the only way to cure irreversible liver
failure.
If you develop progressive liver failure despite abstinence from alcohol, you are otherwise
well enough to survive such an operation, and you commit to not drinking alcohol for the rest
of your life, liver transplantation can be considered.

Complications of alcohol-related liver disease

There are a number of serious complications that can develop if you have alcohol-related
liver disease (ARLD).
Some of the main complications associated with the condition are described below.

Portal hypertension and varices

Portal hypertension is a common complication of cirrhosis and, less commonly,
alcoholic hepatitis. It occurs when the blood pressure inside your liver has risen to a
potentially serious level.
When the liver becomes severely scarred it is harder for blood to move through it. This leads
to an increase in blood pressure.
The blood must also find a new way to return to your heart. It does this by opening up new
blood vessels, usually along the lining of your stomach or oesophagus (the long tube that
carries food from the throat to the stomach). These new blood vessels are known as varices.
If the blood pressure rises to a certain level, it can become too high for the varices to cope
with, causing the walls of the varices to split and bleed.
This can cause long-term bleeding, which can lead to anaemia (a condition where the body
does not have enough oxygen-carrying red blood cells).
Alternatively, the bleeding can be rapid and massive, causing you to vomit blood and pass
stools that are very dark or tar-like.
Split varices can be treated using an endoscope (a narrow tube with a camera at the end that
is passed down into the stomach) to locate the varices. A tiny band can then be used to seal
the base of the varices.

Ascites
If you have portal hypertension, you may also develop a build-up of fluid in your abdomen
(tummy) and around your intestines. This fluid is known an ascites.
Initially this can be treated with water tablets (diuretics). If the problem progresses, many
litres of fluid can build-up and this will need to be drained. This is a procedure known as
paracentesis and involves a long thin tube being placed into the fluid through the skin
under local anaesthetic.
One of the problems associated with the development of ascites is the risk of infection in the
fluid (spontaneous bacterialperitonitis). This is a potentially very serious complication and is
linked to an increased risk of kidney failure and death.

Hepatic encephalopathy

One of the most important functions of the liver is to remove toxins from your blood. If your
liver is unable to do this due to hepatitis or cirrhosis, the levels of toxins in your blood
increase. A high level of toxins in the blood due to liver damage is known as hepatic
encephalopathy.
Symptoms of hepatic encephalopathy include:

agitation

confusion

disorientation

muscle stiffness

muscle tremors

difficulty speaking

in very serious cases, coma

Hepatic encephalopathy may require admission to hospital. In hospital, body functions are
supported while medication is given to remove toxins from the blood.

Liver cancer
Damage to the liver due to heavy drinking over many years can also increase your risk of
developing liver cancer.
Over the past few decades, rates of liver cancer in the UK have risen sharply as a result
of increased levels of alcohol misuse and it's estimated that 3-5% of people with cirrhosis will
develop liver cancer every year.