Alcohol-related liver disease

Alcohol-related liver disease (ARLD) means damage to the liver caused by drinking too much alcohol. It has several stages of severity, and a range of symptoms can go with it.

ARLD doesn't usually cause any symptoms until the liver has been severely damaged. When that 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

Because of this, ARLD is often found during tests for other conditions, or only when the liver damage is already advanced.

If you regularly drink alcohol to excess, tell your doctor so they can check whether your liver is damaged.

Read more about:

• symptoms of ARLD
• diagnosing ARLD

Apart from the brain, the liver is the most complex organ in your body. Its jobs include:

• filtering toxins from the blood
• aiding digestion of food
• regulating blood sugar and cholesterol levels
• helping fight infection and disease

The liver is very resilient and can regenerate itself. Each time it filters alcohol, though, some of the liver cells die.

It can grow new cells, but drinking too much over many years can reduce its ability to do so. This can leave you with serious and permanent damage to your liver.

Alcohol-related liver disease (ARLD) is very common in the UK. The number of people with it has been rising over the last few decades, as alcohol misuse has increased.

Alcohol-related liver disease (ARLD) has 3 main stages, though the stages often overlap. They're explained below.

Drinking a large amount of alcohol, even for just 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.

Alcoholic fatty liver disease rarely causes any symptoms. Still, it's an important warning sign that you're drinking at a harmful level.

The good news is that the condition is reversible. If you stop drinking alcohol for 2 weeks, your liver should return to normal.

Alcoholic hepatitis is a potentially serious condition, and it has nothing to do with infectious hepatitis. It can develop when someone misuses alcohol over a long period. For some people, this is the first sign they've had that alcohol is damaging their liver.

Less commonly, alcoholic hepatitis can happen if you drink a large amount of alcohol in a short time (binge drinking).

When the alcoholic hepatitis is mild, the liver damage can usually be reversed if you stop drinking permanently.

Severe alcoholic hepatitis is a different matter. It is a serious, life-threatening illness. Many people die from it each year, and some only find out they have liver damage once they reach this stage.

Cirrhosis is the stage of alcohol-related liver disease (ARLD) where the liver has become badly scarred. You may still have no obvious symptoms even at this stage.

The damage is generally not reversible. But if you stop drinking alcohol straight away, you can prevent further harm and your life expectancy can improve a great deal.

If you have alcohol-related cirrhosis and keep drinking, your chance of living for at least 5 more years is less than 50%.

There's currently no specific medical treatment for alcohol-related liver disease (ARLD). The main treatment is to stop drinking, preferably for the rest of your life. This lowers the risk of further damage to your liver and gives it the best chance of recovering.

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

In severe cases, a liver transplant may be needed. This is when the liver has stopped functioning and doesn't improve even after you stop drinking alcohol.

You'll only be considered for a transplant if you've developed complications of cirrhosis despite having stopped drinking. Every liver transplant unit requires a person to stay off alcohol while waiting for the transplant, and for the rest of their life.

Deaths linked to alcohol-related liver disease (ARLD) have risen a great deal over the last few decades. Alcohol is now one of the most common causes of death in the UK, alongside smoking and high blood pressure.

ARLD can cause complications that threaten life, including:

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

The best way to prevent alcohol-related liver disease (ARLD) is to stop drinking alcohol or keep to the lower-risk drinking guidelines.

Even if you've been a heavy drinker for many years, cutting down or stopping will help your liver and your general health, both in the short term and over the long term.

Many people with alcohol-related liver disease (ARLD) have no symptoms you would notice until the liver is badly damaged.

If you do get early symptoms of alcohol-related liver disease (ARLD), they're often quite vague. They can include:

• abdominal pain
• loss of appetite
• fatigue
• feeling sick
• diarrhoea
• feeling generally unwell

As alcohol-related liver disease gets worse and the liver becomes more severely damaged, more obvious and serious symptoms can develop, 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, trouble 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 can't process them)

Alcohol-related liver disease (ARLD) doesn't often cause symptoms until it has reached an advanced stage. If you misuse alcohol, you may have liver damage even though you have none of these symptoms.

Contact your doctor for advice if you have a history of regular alcohol misuse.

A good way to look at your history and pattern of drinking is a short test known as the CAGE test. It has 4 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'? That means drinking alcohol first thing in the morning to get over a hangover and steady your nerves.

If you answer yes to 1 or more of these questions, you may have an alcohol problem, and you are advised to see your doctor.

See your doctor as soon as possible if you have symptoms of advanced ARLD.

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 2 ways alcohol misuse (drinking too much) can cause ARLD:

• drinking a large amount of alcohol in a short amount of time (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 hepatitis and cirrhosis, the more serious types of ARLD

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

Drinking too much alcohol isn't the only thing that raises your chances of developing alcohol-related liver disease (ARLD). Some other factors play a part too:

• being overweight or obese
• being female, because women appear to be more vulnerable than men to the harmful effects of alcohol
• having a pre-existing liver condition, such as hepatitis C
• genetics, as alcohol dependence and problems processing alcohol often run in families

Alcohol-related liver disease (ARLD) is often first suspected when tests for some other medical condition show a damaged liver. That's because in the early stages it causes few obvious symptoms.

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.

You need to be completely honest about how much alcohol you drink and how often. If you aren't, you may have further tests that weren't necessary, and this could delay the treatment you need.

The blood tests used to assess the liver are called liver function tests. But in alcohol-related liver disease, these tests can be normal at many stages, so a normal result doesn't rule out liver disease.

Blood tests can also pick up low levels of certain substances. One example is a protein called serum albumin, which is made by the liver. If your serum albumin is low, it suggests your liver isn't working properly.

A blood test may also look for signs of abnormal blood clotting, which can point to significant liver damage.

Lab Tests Online has more information on liver function tests.

If your symptoms or your liver function test point to an advanced form of alcohol-related liver disease (ARLD), either alcoholic hepatitis or cirrhosis, you may need more tests.

Your doctor may ask for scans to get detailed pictures of your liver in alcohol-related liver disease. These may include:

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

Some scans can also measure how stiff the liver is, which is a good sign of whether it's scarred.

In a liver biopsy, the doctor passes a fine needle into your body, usually between your ribs. This takes a small sample of liver cells, which is sent to a laboratory and looked at under a microscope.

The biopsy is usually done under local anaesthetic. You may go home the same day, or you may stay in hospital overnight.

Specialist doctors then examine the tissue under the microscope. They are looking at how much scarring there is in the liver and what has caused the damage.

An endoscope is a long, thin, flexible tube with a light and a video camera at one end. During an endoscopy, the doctor passes it down your oesophagus (the long tube that carries food from the throat to the stomach) and into your stomach.

The pictures of your oesophagus and stomach appear on a screen outside your body. The doctor will be looking for swollen veins (varices), which are a sign of cirrhosis.

Treatment for alcohol-related liver disease (ARLD) often works only if the person is willing to stop drinking alcohol and change how they live.

The treatment for alcohol-related liver disease (ARLD) is to stop drinking alcohol. Doctors call this abstinence, and how much it matters depends on what stage the condition has reached.

If you have fatty liver disease, the damage may be reversed if you stay away from alcohol for at least 2 weeks.

If you have a more serious form of ARLD, which means alcoholic hepatitis or cirrhosis, doctors recommend that you never drink again. Stopping is the only way to keep your liver damage from getting worse, and it may stop you dying of liver disease.

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

Even so, if you have alcohol-related cirrhosis or alcoholic hepatitis and keep drinking, no medical or surgical treatment can prevent liver failure.

If you stop drinking alcohol, you may get withdrawal symptoms. They are usually at their worst in the first 48 hours, and then they should begin to ease as your body adjusts to being without alcohol. This normally takes 3 to 7 days from your last drink.

Many people sleep badly at first when they stop drinking. In most cases their sleep returns to normal within a month.

Sometimes you may be advised to cut down your alcohol in a gradual, planned way, to help avoid withdrawal problems. You may also be offered a medicine called a benzodiazepine, along with psychological therapy such as cognitive behavioural therapy (CBT), to help you get through withdrawal.

Some people need to stay in hospital or a specialist rehabilitation clinic during the early stages of withdrawal, so that their progress can be watched closely.

If you're staying at home, you'll see a nurse or another health professional regularly.

Once you've stopped drinking, you may need more treatment to help you stay off alcohol and not start again.

Psychological therapy is usually the first thing offered. You see a therapist and talk about your thoughts and feelings, and how they affect your behaviour and wellbeing.

If therapy on its own doesn't work, you may also need medicine to help you abstain from alcohol, such as:

• acamprosate
• naltrexone
• disulfiram

If you are dependent on alcohol, a self-help group can be a real help in stopping drinking, and many people find them useful. Alcoholics Anonymous is the best known, but there are plenty of other groups that can help too.

Malnutrition is common in people with alcohol-related liver disease (ARLD), so eating a balanced diet matters. It helps you get all the nutrients you need.

Avoid salty foods and don't add salt to your meals. This can lower your risk of swelling in your legs, feet and abdomen (tummy), which happens when fluid builds up.

Damage to your liver can also stop it from storing glycogen, a carbohydrate that gives you short-term energy. When that happens, your body uses its own muscle tissue for energy between meals, and this leads to muscle wasting and weakness. So you may need extra energy and protein in your diet.

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

Your doctor 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 given through a feeding tube. The tube is passed through the nose and into the stomach.

Using medicine to treat alcohol-related liver disease (ARLD) directly is controversial. Many experts argue that there's limited evidence it works.

People with severe alcoholic hepatitis may need treatment in hospital. In some of them, doctors may use corticosteroids or pentoxifylline to reduce inflammation of the liver. Nutritional support is also an important part of treatment in these cases.

Other medicines that have been used to treat liver damage include:

• anabolic steroids (a more powerful type of steroid medicine)
• ropylthiouracil (a type of medicine originally designed to treat overactive thyroid glands)

But there's a lack of good evidence that these help, and they're no longer used for severe alcoholic hepatitis.

In the most serious cases of alcohol-related liver disease (ARLD), the liver stops working properly, and this is called liver failure. A liver transplant is currently the only way to cure liver failure that can't be reversed.

A transplant may be considered if:

• you develop progressive liver failure, even though you've stopped drinking alcohol
• you're otherwise well enough to survive such an operation
• you commit to not drinking alcohol for the rest of your life

If you have alcohol-related liver disease (ARLD), several serious complications can develop.

Portal hypertension is a common complication of cirrhosis and, less often, of alcoholic hepatitis. It means the blood pressure inside your liver has risen to a level that can be serious.

When the liver is badly scarred, blood has a harder time moving through it. The pressure of blood around the intestines then goes up.

The blood still has to get back to your heart, so it finds a new route. It opens 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 vessels are called varices.

If the pressure climbs high enough, the varices can't cope with it. Their walls may split and bleed.

This can cause bleeding over a long period, and that can lead to anaemia.

The bleeding can also be sudden and massive. You may vomit blood and pass stools that are very dark or tar-like.

Split varices can be treated with an endoscope, which is used to find them. A tiny band is then placed to seal the base of the varices.

Someone with portal hypertension can also develop a build-up of fluid in the abdomen (tummy) and around the intestines. This fluid is called ascites.

At first, it can be treated with water tablets (diuretics). If the problem gets worse, many litres of fluid can collect, and it then has to be drained. The procedure is called paracentesis. A long, thin tube is passed through the skin into the fluid, under local anaesthetic.

One problem that comes with ascites is the risk of infection in the fluid (spontaneous bacterial peritonitis). This can be very serious, and it is linked to a higher risk of kidney failure and death.

One of the main jobs of the liver is to clear toxins out of your blood. When hepatitis or cirrhosis stops the liver doing this, toxins build up in the blood. A high level of toxins in the blood because of liver damage is called hepatic encephalopathy.

The symptoms of hepatic encephalopathy include:

• agitation
• confusion
• disorientation
• muscle stiffness
• muscle tremors
• difficulty speaking
• in very serious cases, a coma

Hepatic encephalopathy may need a stay in hospital. There, the body's functions are supported and medicine is given to remove the toxins from the blood.

Liver damage from 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 alcohol misuse has increased. It's estimated that every year, 3-5% of people with cirrhosis will go on to develop it.