Alcohol and liver disease
Fighting liver disease
Alcohol and liver disease The liver The liver is your body’s chemical factory performing hundreds of complex functions that are vital for life. It is a very uncomplaining organ and has the ability to carry on its many functions with only a small portion actually working. The liver: ●
produces quick energy when needed
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stores sugars, vitamins and minerals including iron
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aids the digestive process by producing bile
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neutralises certain poisons
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controls the production of cholesterol
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maintains hormone balance
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helps the body resist infection by producing immune factors
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regenerates its own tissue.
Hepatic vein Liver Cystic duct Portal vein Common bile duct Pancreatic ducts emptying into duodenum
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When you drink alcohol it is quickly absorbed directly into the blood stream from the stomach and upper part of the gut (small intestine). The absorbed alcohol then passes through the liver and subsequently into the blood stream where it reaches all organs in the body. Although most tissues are capable of breaking down alcohol, this is mainly carried out by the liver, where alcohol is eventually converted into water and carbon dioxide which is removed through the lungs. Since the liver sees the highest concentrations of alcohol, it is one of the organs in the body most prone to developing alcohol related problems. However, alcohol also causes toxic effects on other organs in the body including the brain, heart, muscles and pancreas.
The effect of alcohol on your liver
Right hepatic duct Left hepatic duct
Gallbladder
When you drink alcohol...
Spleen
Almost all excessive drinkers will develop the first stage of alcoholic liver disease - fatty liver. This is a ‘side-effect’ of the liver breaking down alcohol into carbon dioxide and water. Fatty liver disappears when patients stop drinking excessively. If patients continue drinking excessively then a proportion (around 20-30%) will develop the next stage of alcoholic liver disease - alcoholic hepatitis. In this condition, the liver becomes inflamed and in its extreme form, patients can die of liver failure.
Pancreas Pancreatic duct
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An even smaller proportion of patients (around 10%) will develop a permanently scarred and damaged liver (cirrhosis), if they continue to drink excessively. Why certain heavy drinkers remain at the stage of fatty liver and others progress to alcoholic hepatitis and cirrhosis is not known at present, although undoubtedly, the more you drink, the greater the frequency and duration of heavy drinking, the more likely you are to develop the more advanced forms of disease. Recent evidence suggests that being overweight increases the risk of developing serious alcoholic liver disease and as yet largely unidentified genetic (inherited) factors may also be important.
Other harm caused by alcohol
Sensible drinking If you are healthy and eat a good diet, sensible drinking should not harm you. The Government published a report, which focused on daily rather than weekly limits and emphasised that for some groups of people, small quantities of alcohol can help protect against heart disease. It is not clear why or what it is in alcohol that offers the benefit. A reduction in coronary heart disease can be achieved by several other more important means. These may include giving up smoking, taking regular exercise, losing weight if you are overweight and eating a diet high in fruit and vegetables and low in fat and salt.
Excessive drinking can also cause:
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stomach disorders
Units of alcohol
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pancreatitis leading to diabetes
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high blood pressure
One (125ml) glass of wine (alcohol 12% vol) is 1.5 units.
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heart muscle damage leading to heart failure
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One measure (25ml) of spirits or sherry is 1 unit.
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strokes
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cardiac rhythm disturbances
Half a pint of standard beer or lager (alcohol 3.5% vol) is 1 unit.
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sudden cardiac death
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Half a pint of regular cider (alcohol 5% vol) is 1.4 units.
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vitamin deficiencies
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sexual difficulties
One pint of standard beer or lager (alcohol 3.5% vol) is 2 units.
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problems with the brain
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depression
One pint of regular cider (alcohol 5% vol) is 2.8 units.
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problems with nerves in the limbs
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cancer of the liver, mouth, throat, gullet, large bowel and breast.
This is only a rough guide. Some beers, lagers and ciders are much stronger. Most home poured drinks contain more than one unit of alcohol.
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The Department of Health’s advice on drinking The Department of Health’s current advice on sensible drinking is:
Men Regular consumption of 3-4 units a day by men of all ages will not accrue a significant health risk, but regularly drinking 4 or more units a day is not advised. The health benefit from drinking relates to men over 40 and the major part of this can be obtained at levels as low as one unit a day, with the maximum health advantage lying between 1 and 2 units a day.
Women Regular consumption of 2-3 units a day by women of all ages will not accrue a significant health risk, but regularly drinking 3 or more units a day is not advised. The health benefit from drinking for women relates to postmenopausal women and the major part of this can be obtained at levels as low as one unit a day, with the maximum health advantage lying between 1 and 2 units a day.
Pregnant women If you are pregnant or planning a pregnancy, it is best to drink as little as possible. Drinking one or two units once or twice a week is very unlikely to cause you or your baby any harm. Binge drinking, or drinking until you are drunk, should be avoided.
Special circumstances The drinking advice is only a guide to what amount of alcohol is sensible before there is a risk to your health. The guidelines cannot take into account people’s tolerance or their physical differences in gender (whether male or female), height, weight or genetic make-up, all of which can affect the way alcohol is handled by the body and the effect it has on the liver. There are situations where people should not drink at all for their own or other people’s safety, such as caring for babies or children, before or during driving, working at heights, before using machinery or electrical equipment and if taking certain medicines.
Drink-free days After an episode of heavy drinking it is advisable to refrain from drinking for a least 48 hours to allow recovery. Heavy drinking should be discouraged.
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Symptoms of alcoholic liver disease Unfortunately most people with alcoholic liver damage have few symptoms until the disease is far advanced. Not many people experience pain because the liver is relatively free of nerve fibres. If pain occurs it is usually over the right side of the upper abdomen and indicates that the liver is enlarged and/or inflamed. The majority of people with alcoholic liver disease either feel relatively well or have a general feeling of poor health and fatigue. Some lose their appetite and suffer nausea, particularly in the mornings and it is often associated with diarrhoea. The first specific symptoms of liver disease such as jaundice (whites of the eyes turn yellow and in more severe cases the skin does too) don’t appear until alcoholic hepatitis and/or cirrhosis develop and extensive and, in some cases, irreversible, liver damage has occurred.
Types of liver damage due to alcohol
Alcoholic hepatitis This is a serious condition in which the liver is inflamed due to the effects of alcohol. The symptoms can vary from one person to another and range from discomfort, nausea and pain all over the abdomen, to profound and progressive jaundice which may lead to death within a few weeks. Importantly, as with all forms of alcoholic liver disease, hepatitis can be present without any symptoms. Treatment, as with all stages of alcoholic liver disease, is to stop drinking alcohol which, in the majority of patients with the milder forms of the disease, will lead to resolution of the condition. Patients with the more severe forms of alcoholic hepatitis, with signs of profound jaundice and abnormal blood clotting, require admission to hospital, ideally under the supervision of a doctor with a particular interest in liver disease. These patients have up to a 50% death rate at 3 months and require intensive therapy. Steroids (drugs used to control inflammation in the body) may be used in some patients as they have been shown to improve mortality. There is a significant risk that the liver will go on to develop cirrhosis if drinking alcohol continues or sometimes even if it doesn’t.
Fatty liver When someone consistently drinks too much, the alcohol causes fat to be deposited in the liver. The fat will disappear if alcohol is avoided for weeks or months. In many people who continue to drink, the fatty change persists to some extent throughout their life without significant problems, but in some the liver goes on to develop alcoholic hepatitis or cirrhosis. Please see our fact sheet on Fatty liver.
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Cirrhosis The onset of cirrhosis is usually silent with few early warning symptoms. Cirrhosis is the result of continual long term liver damage. If the liver is damaged for a short time, some of the cells die and the liver regrows to its original size and shape. When the inflammation is severe and continuous, scar tissue, called fibrosis develops. In addition, the liver regrows imperfectly. Smooth liver tissue is replaced by irregular nodules and the liver becomes much harder than normal. The combination of nodules and fibrosis is called cirrhosis. Cirrhosis is irreversible, even if drinking is stopped, although recent research shows encouraging results in understanding how cirrhosis occurs leading to the possibility of developing new drugs to fight the process of scarring of the liver. This doesn’t mean that it’s too late to stop drinking because stopping drinking will slow down or even halt further damage, and prolong life. The following are some of the symptoms of cirrhosis (any in italics may require urgent medical advice):
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General feeling of ill health.
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Loss of appetite.
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Nausea and vomiting.
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Vomiting of blood - this may occur from swollen ruptured veins that burst in the lower end of the gullet (oesophageal varices) or the top end of the stomach (gastric varices). This occurs because blood passing from the gut cannot pass easily through the scarred liver.
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Dark black tarry stools - when blood passes through the bowel, it becomes partly digested giving it this appearance.
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Weight loss.
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Hard, perhaps enlarged liver (felt by a doctor on examination).
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Increased sensitivity to some medicines.
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Episodes of confusion - these may be due to the liver’s inability to clear body poisons adequately (hepatic encephalopathy). Initally there may be subtle mental changes such as poor memory or uncharacteristic patterns of behaviour.
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Jaundice.
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Swelling of the abdomen (ascites) and legs (peripheral oedema) - due to build up of fluid.
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Itching.
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Fever - possibly accompanied by shivering attacks. Patients with cirrhosis are more prone to developing infection. Please see our leaflet on Cirrhosis of the liver.
Any of the symptoms described here may be caused by other illnesses. Cirrhosis can be caused by other liver diseases that have nothing to do with alcohol. If you are worried by any of the symptoms mentioned, it is important you are checked by a doctor.
Liver cancer In a few people liver cancer may develop as a late result of cirrhosis. For further information on liver cancer contact CancerBacup 0808 800 1234 www.cancerbacup.org.uk.
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Diet Many long term drinkers substitute alcohol for food and become malnourished. Established liver disease often diminishes the appetite and attention to a good eating pattern is very important. A damaged liver affects the body’s ability to absorb and make use of the nourishment in food. Deficiencies of vitamin B often occur in alcoholic liver damage. Recovery from severe liver damage may be helped by improving nutrition, if necessary with supplements prescribed by a doctor. If you are worried about your diet or think you may be short of vitamins because of excessive alcohol consumption, talk to your doctor. For further details please read our Diet and Liver Disease leaflet.
Tests for alcoholic liver damage There may or may not be visible signs of liver damage. Part of the palms of the hand may be red and mottled and the fingernails partly white. Other signs of a long term heavy drinker are enlargement of male breasts which may be tender, a swollen abdomen, thinning body hair and weakness and wasting of the muscles. If a doctor suspects liver damage he or she may refer you to a liver disease specialist (hepatologist) or a digestive disease specialist (gastroenterologist) for further investigations. These tests may include blood tests called liver function tests, scans and an endoscopy examination. Ultimately, a liver biopsy is needed to confirm a diagnosis of alcoholic hepatitis or cirrhosis. A
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biopsy involves taking a small sample of liver tissue for examination under a microscope. The test is usually performed under a local anaesthetic. Please see our fact sheet guides to liver function tests, liver biopsy and liver ultrasound.
Treatment Stop drinking The most important part of treatment in all forms of alcoholic liver disease is to stop drinking, preferably for life. At the stage of fatty liver and alcoholic hepatitis this would lead to complete resolution of the condition in the majority of cases and, even for patients with cirrhosis, stopping drinking improves survival. The amount of alcohol that it is safe to drink varies from one person to another. People who have already developed alcoholic hepatitis or cirrhosis can damage their livers even further if they continue to drink. Cutting down only reduces the rate of damage. Symptoms due to alcoholic liver damage such as pain or jaundice may well disappear if drinking is cut down, but this doesn’t mean that damage is no longer taking place. Cirrhosis can develop even after drinking only a little too much over the years, and there may be no early warning symptoms.
Diet Diet is also important - eat a well balanced diet, if necessary with supplements prescribed by a doctor. Nutrition can play an important part in treatment and the doctor may refer you to a State Registered Dietitian for advice.
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Other treatments For patients with advanced alcoholic hepatitis, admission to hospital and more intensive therapy is required (see pages 8-11) and steroids may also be prescribed. Unfortunately, no specific treatments have been shown to improve the outcome of patients with established cirrhosis. Stopping drinking, therefore, remains the mainstay of treatment along with standard therapy for the complications of cirrhosis including oesophageal varices, encephalopathy and ascites.
Transplantation For some people with cirrhosis who develop life threatening complications, liver transplantation is an option. Many factors must be taken into consideration, including a continuing alcohol problem and the effect alcohol has already had on the health of other parts of the body such as the heart and brain, general health and whether the patient is strong enough physically and mentally to withstand the major surgical procedure.
Drinking if you have liver disease from other causes This depends on many things such as the type, severity and stage of liver disease you have, as well as your general health. Some people can drink within recommended guidelines, others should not drink at all. People with any liver condition should be very cautious about drinking as there is strong evidence that it accelerates the damage. Drinking advice will vary from person to person, even with the same liver disease. This may be because the disease takes a different form or is more severe, or it may depend on susceptibility to liver damage. It may also be because doctors take different views. Many people with liver disease find they can no longer tolerate alcohol and do not drink. Others drink a little on special occasions. If you are unsure whether it is advisable for you to drink, talk to your doctor.
Most people will have stopped drinking for at least six months before being accepted for liver transplantation.
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Who else can help? Alcoholics Anonymous General Service Office, PO Box 1 Stonebow House, Stonebow, York YO1 7NJ Tel: 01904 644026 www.alcoholics-anonymous.org.uk AA is the largest and best known self-help group for people with alcohol problems. Anonymity is guaranteed. AA sees alcoholism as a disease which can be managed by abstinence and group support. Alcohol Concern Watergate House, 32-36 Loman Street London SE1 0EE Tel: 020 7922 8667 www.alcoholconcern.org.uk Alcohol Concern provides information & guidance on alcohol issues. It raises awareness of key issues among public & policy makers & offers advice on training matters to professionals working with people with alcohol problems. Runs a bookshop & resource centre.
Al-Anon Family Groups UK & Eire 61 Great Dover Street, London SE1 4YF Tel: 020 7403 0888 www.hexnet.co.uk/alanon/ Al-Anon offers understanding and support for relatives and friends of problem drinkers, whether the alcoholic is still drinking or not. Alateen, a part of Al-Anon is for young people aged 12-20 who have been affected by someone else’s drinking, usually a parent. Drinkline Alcohol Helpline (England and Wales) 0800 917 8282 (freephone) Drinkline provides information and help to callers who are worried about their own drinking and supports family and friends of people who are drinking.
Special thanks Professor Chris Day MA PhD MD FRCP Professor of Liver Medicine, Centre for Liver Research, University of Newcastle-upon-Tyne.
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