Alcoholic Liver Disease (Alcohol-Related Liver Disease)

How alcohol damages the liver

The liver breaks down alcohol. In the process, it produces acetaldehyde, a toxic chemical, and harmful molecules that damage liver cells and trigger inflammation. Heavy drinking also changes how the liver handles fat. Over years, repeated injury leads to scarring (fibrosis), which can progress to cirrhosis.

The risk rises with the amount and duration of drinking. Risk is higher in women, people with obesity or diabetes, people with hepatitis B or C, smokers, and people with certain genetic variants. Daily drinking and binge drinking both contribute. In the US, heavy drinking is defined as more than 4 drinks on any day or 14 a week for men, and more than 3 on any day or 7 a week for women.

Stages of alcoholic liver disease

The stages often overlap. People can have alcoholic hepatitis on top of cirrhosis.

Symptoms

Early stages

Fatty liver usually causes no symptoms. Some people have tiredness, discomfort under the right ribs or an enlarged liver found on examination.

Alcoholic hepatitis

• Yellow skin and eyes (jaundice), often appearing over a few weeks
• Fever
• Tender, enlarged liver
• Loss of appetite, nausea and weight loss
• In severe cases, confusion, fluid in the belly and kidney failure

Cirrhosis

• Tiredness and weakness, muscle wasting
• Swollen belly from fluid (ascites) and swollen legs
• Easy bruising and bleeding
• Itchy skin
• Small spider-like blood vessels on the chest, red palms
• Confusion, poor concentration, sleep reversal (hepatic encephalopathy)
• Vomiting blood from varices
• In men, breast enlargement and shrinking testicles

Diagnosis

• History of alcohol use: including amount, pattern and duration. Questionnaires such as AUDIT help assess drinking.
• Blood tests: liver enzymes (AST is typically higher than ALT in alcohol-related disease, often at least twice as high), GGT, bilirubin, albumin, clotting time (INR) and blood count. Low platelets suggest advanced disease.
• Ultrasound: shows fatty liver, liver size and shape, ascites and signs of cirrhosis.
• Liver stiffness measurement (transient elastography, FibroScan): a painless scan that estimates scarring.
• Liver biopsy: sometimes needed if the diagnosis is uncertain.
• Tests for other causes: hepatitis B and C, iron overload and others.
• Scores: such as the Maddrey discriminant function and MELD score to judge severity of alcoholic hepatitis and cirrhosis.

Treatment

Stop drinking

Complete, lifelong abstinence is the most important treatment. It reverses fatty liver, improves alcoholic hepatitis and slows or halts cirrhosis. Help is available:

• Medically supervised withdrawal: heavy daily drinkers should not stop suddenly without medical advice, because withdrawal can cause seizures and delirium tremens. See alcohol withdrawal.
• Medicines to prevent relapse: options include acamprosate and baclofen, which are considered safer in liver disease. Naltrexone and disulfiram are generally avoided in advanced liver disease.
• Counseling and support: behavioral therapy, mutual support groups and specialist services. See alcohol use disorder.

Nutrition

Malnutrition is common. A diet with enough calories and protein, a late-evening snack, vitamin supplements (especially thiamine) and sometimes nutritional supplements help recovery.

Treating alcoholic hepatitis

Severe alcoholic hepatitis needs hospital care. Corticosteroids (prednisolone) may be used for selected patients with severe disease, along with nutrition support and treatment of infection.

Managing cirrhosis and complications

• Ascites: salt restriction, diuretics and drainage of fluid.
• Esophageal varices: beta blockers and endoscopic banding to prevent bleeding.
• Hepatic encephalopathy: lactulose and rifaximin.
• Liver cancer screening: an ultrasound every 6 months, because cirrhosis raises the risk of hepatocellular carcinoma.
• Vaccination against hepatitis A and B, flu and pneumococcus.
• Avoid NSAIDs and herbal remedies. Acetaminophen is often preferred for pain at reduced doses under medical advice.

Liver transplant

Transplant is an option for people with end-stage liver disease who have stopped drinking and are committed to abstinence. Selected people with severe alcoholic hepatitis not responding to treatment may also be considered at some centers.

Outlook

Fatty liver usually resolves fully within weeks to months of stopping alcohol. Mild alcoholic hepatitis improves with abstinence, but severe alcoholic hepatitis carries a high short-term risk of death. In cirrhosis, people who stop drinking live significantly longer than those who continue, and some regain enough liver function to avoid transplant.

Prevention

Drinking within low-risk limits, or not at all, prevents alcoholic liver disease. Alcohol-free days, smaller servings and tracking your intake help. If you are concerned about your drinking, speak to your doctor or contact the SAMHSA National Helpline at 1-800-662-4357 (US), which is free and confidential.

Frequently asked questions

What are the stages of alcoholic liver disease?

The main stages are alcoholic fatty liver, alcoholic hepatitis and cirrhosis, with fibrosis (scarring) building up along the way. Fatty liver develops in most heavy drinkers and is reversible. Hepatitis involves inflammation. Cirrhosis is extensive scarring that is largely permanent.

Can alcoholic liver disease be reversed?

Fatty liver usually reverses completely within weeks to months of stopping alcohol. Alcoholic hepatitis can improve substantially. Cirrhosis scarring is mostly permanent, but stopping drinking stops further damage, improves liver function and significantly increases life expectancy.

What are the first signs of alcoholic liver disease?

Early liver damage often causes no symptoms. When signs appear, they may include tiredness, loss of appetite, nausea, discomfort under the right ribs and abnormal liver blood tests. Yellowing of the skin or eyes, a swollen belly and easy bruising suggest more advanced disease.

How much alcohol causes liver damage?

There is no completely safe amount, and risk varies between people. Risk rises steadily with heavy drinking over years, typically above 4 drinks a day or 14 a week for men and above 3 a day or 7 a week for women. Women, people with obesity and those with hepatitis are more vulnerable.

Is it safe to stop drinking suddenly with liver disease?

If you drink heavily every day, stopping suddenly can cause dangerous withdrawal, including seizures and delirium. Speak to a doctor before stopping. Medically supervised withdrawal with medication makes it much safer, and it is the most important step for your liver.