Alcohol-related liver disease

Alcohol-related liver disease (ARLD) happens when someone drinks too much alcohol. The more you drink beyond the recommended limits, the greater your risk of developing it.

There are 2 ways drinking too much alcohol can lead to ARLD:

• drinking a large amount of alcohol in a short time (binge drinking) can cause fatty liver disease and, less commonly, alcoholic hepatitis
• drinking more than the recommended limits over many years can cause hepatitis and cirrhosis, the more serious forms of ARLD

Evidence shows that people who regularly drink more than the recommended maximum are most at risk of developing ARLD.

Read more about alcohol units and how to calculate them.

Additional factors

Besides drinking too much alcohol, other things can raise your chances of developing ARLD. These include:

• being overweight or obese
• being female, as women seem to be more vulnerable than men to alcohol's harmful effects
• having an existing liver condition, such as hepatitis C
• genetics, since alcohol dependence and trouble 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 a damaged liver.

This is because the condition causes few obvious symptoms in the early stages.

If a doctor suspects ARLD, they’ll usually arrange a blood test to check how well your liver is working. They may also ask about your alcohol consumption.

It’s important to be totally honest about how much and how often you drink alcohol to avoid 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. However, liver function tests can be normal at many stages of liver disease.

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. A low level of serum albumin suggests your liver isn’t 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 on liver function tests.

Further testing

If your symptoms or liver function test suggest an advanced form of ARLD – either alcoholic hepatitis or cirrhosis – you may need further tests.

Imaging tests

Scans may be needed to produce detailed images of your liver. This may include:

• an ultrasound scan
• a computerised tomography (CT) scan
• a magnetic resonance imaging (MRI) scan

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, either as a day case or with an overnight stay in hospital.

Specialist doctors will 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 long, thin, 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.

How ARLD is treated

There’s currently no specific medical treatment for ARLD. The main treatment is to stop drinking, preferably for the rest of your life. This reduces the risk of further damage to your liver and gives it the best chance of recovering.

If a person is dependent on alcohol, stopping drinking can be very difficult. However, support, advice and medical treatment may be available through local alcohol support services.

A liver transplant may be required in severe cases where the liver has stopped functioning and doesn’t improve when you stop drinking alcohol.

You’ll only be considered for a liver transplant if you’ve developed complications of cirrhosis, despite having stopped drinking. All liver transplant units require a person to not drink alcohol while awaiting the transplant, and for the rest of their life.

Read more about treating ARLD.

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 ARLD involves stopping drinking alcohol. This is known as abstinence, which 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 2 weeks. After this point, it’s 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 – alcoholic hepatitis or cirrhosis – life-long abstinence is recommended. This is because stopping drinking is the only way to prevent your liver damage getting worse and potentially stop you dying of liver disease.

Stopping drinking isn’t easy, especially as an estimated 70% of people with ARLD have an alcohol dependency problem.

Nevertheless, if you have alcohol-related cirrhosis or alcoholic hepatitis and don’t stop drinking, no medical or surgical treatment can prevent liver failure.

The best way to prevent ARLD is to stop drinking alcohol altogether, or at least stay within the lower risk drinking guidelines.

Even if you have been drinking heavily for many years, cutting down or quitting will bring real benefits to your liver and your overall health, both right away and over the long term.

Read our drinking and alcohol pages for more information and advice.

Preventing relapses

Once you have stopped drinking, you may need further treatment to help make sure you do not start again.

The first treatment usually offered is psychological therapy. This means talking with a therapist about your thoughts and feelings, and how they affect your behaviour and wellbeing.

If psychological therapy alone does not work well enough, you may also be given medication to help you stay off alcohol, such as:

• acamprosate
• naltrexone
• disulfiram

Read our page on treating alcohol misuse to learn more about the treatments on offer.

Self-help groups

Many people with alcohol dependence find it helpful to join self-help groups to support them in stopping drinking. Alcoholics Anonymous is one of the best known, but there are many other groups that can help too.

Read the alcohol support page to find out more about the help that is available.

Diet and nutrition

Malnutrition is common in people with ARLD, so eating a balanced diet is important to make sure you get all the nutrients your body needs.

Cutting back on salty foods and not adding extra salt to your meals can lower your risk of swelling in your legs, feet and abdomen (tummy), which happens when fluid builds up in the body.

Liver damage can also stop your body from storing glycogen properly, a carbohydrate that normally supplies quick energy. When this happens, your body starts using its own muscle tissue for energy between meals, which leads to muscle wasting and weakness. Because of this, you may need extra energy and protein in your diet.

Healthy snacks between meals can help top up your calories and protein. It can also help to eat 3 or 4 small meals through the day rather than 1 or 2 large ones.

Your doctor can advise you on a suitable diet, and in some cases may refer you to a dietitian.

In the most serious cases of malnutrition, nutrients may need to be given through a feeding tube passed through the nose and into the stomach.

Death rates linked to ARLD have gone up considerably over the last few decades. Alcohol is now one of the leading causes of death in the UK, alongside smoking and high blood pressure.

Life-threatening complications of ARLD include:

• internal (variceal) bleeding
• a build-up of toxins in the brain (encephalopathy)
• fluid collecting in the abdomen (ascites), along with associated kidney failure
• liver cancer

Below you can read more about each of these complications.

Complications of alcohol-related liver disease

A number of serious complications can develop if you have alcohol-related liver disease (ARLD).

Portal hypertension and varices

Portal hypertension is a common complication of cirrhosis, and a less common one of alcoholic hepatitis. It happens when the blood pressure inside your liver rises to a potentially serious level.

When the liver becomes severely scarred, it becomes harder for blood to move through it. This causes the pressure of blood around the intestines to increase.

The blood then has to 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 your oesophagus (the long tube that carries food from your throat to your stomach). These new blood vessels are known as varices.

If the blood pressure rises past a certain level, it can become too high for the varices to cope with, and the walls of the varices can split and bleed.

This can lead to long-term bleeding, which in turn can cause anaemia.

Alternatively, the bleeding can be sudden and severe, causing you to vomit blood and pass stools that are very dark or tar like.

Split varices can be treated using an endoscope to locate them. A tiny band can then be placed around the base of the varices to seal them.

Ascites

A person with portal hypertension may also develop a build-up of fluid in their abdomen (tummy) and around the intestines. This fluid build-up is known as ascites.

At first, this can be treated with water tablets (diuretics). If the problem gets worse, many litres of fluid can build up and need to be drained. This procedure is known as paracentesis, and involves placing a long, thin tube into the fluid through the skin, under local anaesthetic.

One of the risks that comes with ascites is infection developing in the fluid, known as spontaneous bacterial peritonitis. This is a potentially very serious complication and is linked to a higher risk of kidney failure and death.

Hepatic encephalopathy

One of the liver's most important jobs is removing toxins from your blood. If the liver cannot do this properly because of hepatitis or cirrhosis, toxin levels in the blood start to rise. A high level of toxins in the blood caused by 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, a coma

Hepatic encephalopathy may require admission to hospital. There, the body's functions are supported and medication is given to help clear toxins from the blood.

Liver cancer

Liver damage caused by heavy drinking over many years can also raise your risk of developing liver cancer.

Over the past few decades, rates of liver cancer in the UK have risen sharply because of increased alcohol misuse. It is estimated that, each year, 3 to 5% of people with cirrhosis will go on to develop liver cancer.