Alcoholic Liver Disease- Gastroenterology

Alcoholic liver disease (ALD) is liver damage brought on by years of excessive alcohol consumption. ALD has different stages, and many heavy drinkers move through them over time. It may result in fat accumulation, inflammation, and scarring.

One of the effects of alcohol abuse is liver damage. Because liver failure can be fatal, this is very dangerous. Find out how to treat and prevent this serious condition.

Understanding ALD

The term "alcohol-related liver disease" (ARLD) describes liver damage brought on by excessive alcohol consumption. There are several stages of severity and various symptoms associated with it.

Alcohol-related liver illness accounted for 16.5% of all liver transplants in the United States in 2015, placing it third on the list of causes of transplants after chronic hepatitis C and liver cancer.

The Centers for Disease Control and Prevention (CDC) estimate that there were 29,505 deaths in the United States due to alcoholic liver disease in 2020, while cirrhosis and all other forms of chronic liver disease are accountable for  12 deaths per 100,000 persons each year approximately.

Stages Of Alcoholic Liver Disease

There are four main stages of Alcoholic liver disease:

1. Alcoholic fatty liver disease
2. Alcoholic hepatitis
3. Fibrosis
4. Cirrhosis

The entire body may be affected by liver disease. Since the liver is often very good at regenerating and healing itself, damage can take a while to manifest . Often, the damage is irreparable by the time medical professionals notice it.

Signs And Symptoms

Early signs of alcoholic liver disease include various bodily systems and are vague. Signs can include the following in addition to a general sense of being unwell:

• Nausea and vomiting
• Pain in the abdomen
• Decreased appetite
• Diarrhea

It is simple for someone to write off the initial symptoms as being caused by a stomach virus or general malaise. But, failing to get these symptoms checked out and treated, particularly if you keep drinking, might speed the progression of liver disease over time.

When the alcoholic liver disease advances, it becomes simpler to identify its signs. The following are some of the most apparent symptoms of advanced liver disease, such as cirrhosis or fibrosis:

• Edema (swelling in the lower limbs)
• Ascites (accumulation of fluid in the abdomen)
• Fever
• Shivering
• Clubbing (abnormally curled fingernails)
• Considerable weight loss
• General weakness
• Muscular atrophy
• Blood in the stools and vomit
• Bruising and bleeding more easily
• More sensitive responses to alcohol and medications

1. Alcoholic Fatty Liver Disease

Alcohol consumption in excess can lead to fatty acid buildup in the liver. This can occasionally occur after a short period of binge drinking, even less than a week. The alcoholic fatty liver disease typically has no symptoms and is likely reversible if the person stops drinking alcohol in the future.

2. Alcoholic Hepatitis

Alcoholic hepatitis is a serious form of alcohol-related liver illness. Hepatitis is a term used to refer to liver inflammation and swelling due to any cause.

Continued alcohol consumption will result in persistent liver inflammation. This may happen after several years of heavy drinking. Acute episodes of this can also occur when binge drinking.

Below are some typical signs of alcoholic hepatitis:

• A yellow tint of the skin and whites of the eyes (jaundice)
• Enlarged liver (hepatomegaly)
• Features of systemic inflammatory response include any two of the following:
  • Body temperature over 100.4°F (38°C) or under 96.8°F (36°C)
  • Heartbeat greater than 90 beats per minute
  • Breathing faster than 20 times per minute
  • White blood cells count greater than or equal to 12000 per microliter, or fewer than 4000

If a person continues to drink alcohol, alcoholic hepatitis typically develops into cirrhosis. When a person stops consuming alcohol, their hepatitis will heal, but any cirrhosis will not go away.

3. Fibrosis

Liver fibrosis occurs when the healthy liver tissue gets scarred and loses functionality. Fibrosis is the initial stage of liver scarring. It is the buildup of certain types of protein in the liver, including collagen.

A doctor can assess the extent of liver damage using a variety of staging scales for liver fibrosis. Many techniques can be used to achieve this, including blood testing, imaging tests, and tissue biopsies that can be further inspected under a microscope (histology).

It is crucial to remember that addressing the underlying cause is more important than focusing on any one stage, even though fibrosis staging can help you and your doctor comprehend the potential extent of liver damage.

A doctor may use the METAVIR scoring method to stage liver fibrosis following a liver biopsy and histology.

This calculates a "score" based on two variables: damage (fibrosis) and inflammation (activity). A higher number could signify more damage and inflammation, while a lower score might indicate less.

Batts and Ludwig is another histologically based scoring system that assigns fibrosis a grade from 1 to 4, with grade 4 being the most severe.

In addition to a liver biopsy and histology, other tests may also be used to stage fibrosis. For instance, a blood test that evaluates fibrosis 4 (Fib4) in the blood may be used by a specialist to confirm liver fibrosis.

Imaging examinations can also be used to confirm the stage of fibrosis. They examine your liver's size and shape and any excess fat, tumors, or shrinkage.

4. Cirrhosis

Long-term liver inflammation that results in scarring and function loss is known as cirrhosis. This condition has the potential to be fatal. Damage from cirrhosis is irreversible. However, by continuing to abstain from alcohol, one can stop further damage.

Although lifelong abstinence might improve liver health, the severe, irreversible damage from cirrhosis may necessitate a liver transplant for the patient to survive. In addition, a person will become more sensitive to drugs and alcohol as the liver cannot absorb toxins efficiently. Alcohol consumption speeds up the destruction of the liver and lowers its capacity to repair the harm already done.

Who Is At Risk?

Several factors influence the risk of alcoholic liver disease. For example, compared to individuals who drink other alcoholic beverages, like wine, people who drink beer and liquor may be more likely to develop liver disease.

Even at the same amounts of alcohol use as men, women are more vulnerable to the harmful effects of alcohol and more likely to experience fibrosis, inflammation, and liver damage right away.

Males and females who consume more than three drinks per day for more than five years, respectively, are at an elevated risk for developing alcoholic liver disease, according to the American College of Gastroenterology.

The likelihood of developing chronic liver disease is higher in females who drink heavily and are overweight. However, even for men, being obese is a risk factor.

Hepatitis C raises the risk, and anyone who regularly drinks alcohol and has ever had any kind of hepatitis is more likely to develop liver disease.

Genetic changes may also influence the risk. For example, a person will have a higher risk of developing the alcoholic liver disease if they have alterations in the genetic profiles of specific enzymes necessary for alcohol metabolisms, such as ALDH, ADH, and CYP4502E1.

Diagnosing Alcoholic Liver Disease

Other disorders besides ALD can damage the liver. Your doctor will want to assess the condition of your liver to rule out other disorders. Your doctor might suggest:

Blood tests. Blood tests including liver function tests, which demonstrate how well the liver is functioning. The liver function test also includes examinations of liver enzymes. Three liver enzymes are measured in these tests:

• Alanine aminotransferase (ALT)
• Aspartate aminotransferase (AST)
• Gamma-glutamyltransferase (GGT)

If your AST level is twice as high as your ALT level, you probably have ALD. Around 80% of patients with ALD had this result, according to the National Institute on Alcohol Abuse and Alcoholism.

Liver biopsy. This involves using a needle or a surgical procedure to remove tiny tissue samples from the liver. Then, the type of liver disease is determined by examining these samples under a microscope.

Ultrasound. High-frequency sound waves are used in this examination to visualize the organs.

CT scan. This imaging test creates images of the body—often called slices—using X-rays and a computer. Any aspect of the body, including the bones, fat, muscles, and organs, can be seen in great detail on a CT scan. Compared to regular X-rays, CT scans are more detailed.

MRI. MRI technology combines radio frequency pulses, a magnetic field, and a computer to provide precise images of inside body structures. Occasionally, dye injections into veins are utilized to create pictures of body sections. For example, the dye makes the liver and other abdominal organs more visible.

Treating ALD

Eliminating alcohol from the diet is the preliminary step in treating any level of alcoholic liver damage.

Abstinence

This may help in reversing some early liver disease stages. For instance, quitting drinking after receiving a fatty liver disease diagnosis may cure it in 2 to 6 weeks.

A doctor will advise a patient never to start drinking again after being diagnosed with alcoholic liver disease, regardless of the stage. This is because once drinking resumes, any problems that have reversed will likely recur.

Those who routinely consume more alcohol than is advised every day should not stop without medical assistance. The effects of alcohol withdrawal might be fatal. To safely handle alcohol withdrawal, people should get medical aid.

Therapy

In a person with alcohol dependence, cognitive behavioral treatment (CBT) and drugs called benzodiazepines help reduce withdrawal symptoms. For closer supervision, those with severe alcoholism may check into an inpatient recovery center.

It could then be necessary to continue therapy to avoid relapsing into alcohol use. Additionally, certain medications can also prevent relapse, such as the following:

• Vivitrol (naltrexone)
• Acamprosate
• Topamax (topiramate)
• Disulfiram
• Baclofen

Lifestyle Changes

Doctors might advise losing weight and giving up smoking because both excess weight and smoking have been shown to make alcoholic liver disease worse. Moreover, doctors might recommend taking a daily multivitamin.

Medications

While getting hospital therapy, patients with acute alcoholic hepatitis may benefit from corticosteroids or pentoxifylline to help reduce inflammation.

Additional drugs being researched now that have the potential to treat include:

• Stem cell therapy
• Probiotics and antibiotics
• Medicines that target the inflammation pathway.

Liver transplant

When a person has liver failure, their liver entirely stops working. This results from liver disease that has progressed to an advanced stage and frequently implies that a liver transplant is the only choice for extending survival. The success of a liver transplant is dependent on the availability of a suitable donor.

Only those who are able to demonstrate that they have given up alcohol for at least six months before the procedure are typically eligible for a transplant. After that, a liver transplant is the last option. Therefore, the best strategy for a person to maximize their chances of reversing or reducing the disease is to stop drinking and address this issue as soon as possible.

Following a transplant, antirejection drugs may raise your chance of developing life-threatening infections and some malignancies.

Complications Of Alcoholic Liver Disease

• Hepatitis C virus is present in about 30% of persons with alcoholic liver disease.
• Hepatitis B virus is present in others. Your doctor will check for both, providing necessary treatments.
•  Liver cancer is more likely to affect those with alcoholic liver disease.
• Gallstones are present in 50%.
• Cirrhosis patients frequently experience kidney issues, intestinal bleeding, abdominal fluid accumulation, confusion, liver cancer, and severe infections.
• A decline in brain function is brought on by an accumulation of poisons in the blood (hepatic encephalopathy).
• Loss of function and chronic liver damage are potential further ALD side effects.
• High blood pressure in the liver's blood arteries (portal hypertension)
• Bleeding esophageal varices (those with liver illness who have enlarged veins in the esophagus)

Prevention

Doctors encourage patients to abide by National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommendations to prevent alcoholic liver disease and other disorders associated with alcohol intake.

According to the recommendations, moderate drinking is up to one drink per day for ladies and two drinks per day for men who are at least 21 years old.

The equivalent of one drink is:

• 5 oz of wine at 12% alcohol.
• 12 fluid ounces (oz) of beer at 5% alcohol.
• 1.5 oz of spirits at 40% alcohol.

According to the NIAAA, For women, binge drinking is consuming four or more alcoholic drinks at once, whereas for men, it is five or more, at least once within the previous month.

Outlook

A person with alcoholic liver disease has a significantly shorter life expectancy as the illness worsens. But quitting drinking can be beneficial.

The average survival rate after two years is 1 in 3 for those with the most severe liver disease and cirrhosis. The usual lifespan is 6–12 years when the body can manage cirrhosis and compensate. People with less severe illnesses will live longer if they do not  drink.

People can significantly alter their lifestyles to lower the risk by quitting smoking and managing their weight. Malnutrition can also be treated by altering your diet and taking the proper nutrients (if needed). If you or a loved one consumes alcohol excessively, it is still possible to change your lifestyle.

See your doctor if you think you may have a drinking problem or are at risk of developing liver disease. They can suggest programs that can assist you in quitting drinking and improving the health of your liver.

Resources:

• Kling, Catherine E et al. “Recent trends in liver transplantation for alcoholic liver disease in the United States.” World journal of hepatology vol. 9,36 (2017): 1315-1321. doi:10.4254/wjh.v9.i36.1315
• “FastStats.” FastStats - Alcohol Use, 18 Jan. 2023, www.cdc.gov/nchs/fastats/alcohol.htm.
• Osna, Natalia A et al. “Alcoholic Liver Disease: Pathogenesis and Current Management.” Alcohol research : current reviews vol. 38,2 (2017): 147-161.
• Patel R, Mueller M. Alcoholic Liver Disease. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546632/
• Roerecke, Michael et al. “Alcohol Consumption and Risk of Liver Cirrhosis: A Systematic Review and Meta-Analysis.” The American journal of gastroenterology vol. 114,10 (2019): 1574-1586. doi:10.14309/ajg.0000000000000340

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