Alcoholic liver disease

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Elmedina Asani Alcoholic liver disease, also called alcoholic hepatitis, refers to a range of conditions and related symptoms that develop when the liver becomes damaged due to excessive intake of alcohol. While distinct from cirrhosis, alcoholic hepatitis is regarded as the earliest stage of alcoholic liver disease. Alcohol has long been associated with serious liver diseases such as hepatitis which is an inflammation of the liver. According to Medilexicon's medical dictionary: Hepatitis is "Inflammation of the liver, due usually to viral infection but sometimes to toxic agents." However, not all heavy drinkers develop alcoholic hepatitis. The disease can occur in people who drink only moderately or binge just once. Damage from alcoholic hepatitis can often be reversed by stopping drinking. The disease is likely to progress to cirrhosis and liver failure if alcohol dinking continues. The precise explanation of why alcoholic hepatitis develops is not clear. A person who has alcoholic hepatitis needs to avoid alcohol and other substances that can harm the liver. For some people with severe liver damage, a liver transplant may be an option. Alcoholic liver disease does not usually cause any symptoms until the liver has been extensively damaged. When this happens, alcoholic liver disease can cause: jaundice (yellowing of the eyes and skin) loss of appetite nausea weight loss The liver The liver is a complex organ in the body with more than 500 functions, most of which essential for living. The functions of the liver include: filtering toxins from the blood helping to fight infection and disease producing blood-clotting agents that prevent excessive bleeding producing important chemicals, such as proteins and hormones regulating cholesterol levels in the blood storing energy for use when the body needs an immediate energy boost Alcohol The liver is a very tough and resilient organ, capable of regenerating itself. Despite this resilience, prolonged alcohol misuse over many years can damage the liver. When there is alcohol intake, the liver filters out the poisonous alcohol from the blood. Each time the liver filters alcohol, some of the liver cells die. The liver can regenerate new

cells. But after heavy drinking, for many years, the liver will lose its ability to regenerate new cells, causing serious damage. Stages in alcoholic liver disease Alcoholic fatty liver disease: It is the first stage of alcoholic liver disease. Heavy consumption of alcohol, even for only a few days, can lead to a build-up of fatty acids in the liver. Fatty liver disease rarely causes any symptoms but it is an important warning sign that the current drinking level is harmful to the health. Fatty liver disease is reversible. After stopping drinking alcohol for two weeks, the liver should return to normal. Alcoholic hepatitis: It is the second more serious stage of alcoholic liver disease. Extended alcohol misuse over many years can cause the tissues of the liver to become inflamed. This is known as alcoholic hepatitis. In some rare cases, alcoholic hepatitis can occur after drinking a large amount of alcohol in a short period of time (binge drinking). Alcoholic hepatitis is usually reversible by stopping alcohol consumption for several months or years. Cirrhosis: It is the final stage of alcoholic liver disease. Cirrhosis occurs when prolonged inflammation of the liver has caused scarring of the liver and subsequent loss of function. Loss of liver function can result in death. The damage caused by cirrhosis is not reversible. In mild to moderate cases, stopping drinking alcohol immediately can prevent further damage. Gradual recovery of the liver function can be achieved. In more severe cases, a liver transplant may be required. A heavy drinker is someone who regularly exceeds the recommended weekly limit for alcohol consumption. This is 3 to 4 units of alcohol a day for men and 2 to 3 units for women. Women who regularly drink more than 6 units of alcohol a day (or more than 35 units a week) and men who regularly drink more than 8 units a day (or 50 units a week) are at the highest risk of alcohol-related harm. Women are more likely to develop alcoholic liver disease but men are more likely to die from it, possibly because men tend to be heavier drinkers. Death rates linked to alcoholic liver disease have risen by over 69 percent in the last 30 years. This makes alcohol one of the most common causes of death, along with smoking and high blood pressure. Fatty liver disease and hepatitis can develop at any age. Cirrhosis usually develops in people aged 40 or over. The outlook for alcoholic liver disease depends on whether the patient is willing to stop drinking alcohol. Women who drink heavily during pregnancy put their baby at risk of developing fetal alcohol syndrome or fetal alcohol spectrum disorder. These disorders can cause lifelong intellectual and behavioral problems for the child. What are the symptoms of alcoholic liver disease? A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be

a sign. Mild forms of alcoholic hepatitis may not cause noticeable problems, but as the disease becomes more advanced and the liver more damaged, signs and symptoms are likely to develop. Alcoholic fatty liver disease Alcoholic fatty liver disease does not usually cause any noticeable symptoms unless the build-up of fatty acids in the liver is severe. Symptoms of alcoholic fatty liver disease include: a general sense of feeling unwell abdominal pain loss of appetite nausea weakness Alcoholic hepatitis Symptoms of alcoholic hepatitis include: abdominal pain and/or tenderness fatigue high temperature (usually around 38C (101F)) loss of appetite nausea the appearance of 'spider-like' red blood vessels in the skin yellowing of the skin and eyes (jaundice) Cirrhosis Early stage symptoms when the liver starts to lose some of its function include: blotchy red palms feeling sick loss of appetite problems sleeping tenderness or pain around the liver tiredness and weakness very itchy skin weight loss End stage symptoms when the liver loses more or all of its function include: a tendency to bruise easily ascites (build-up of fluid in the abdomen) black, tarry stools or very pale stools breathlessness changes in personality (due to toxins in the bloodstream affecting the brain) dark urine dizziness and fatigue edema (build-up of fluid in the legs, ankles and feet) fever and shivering attacks frequent nosebleeds and bleeding gums hair loss increased sensitivity to alcohol and drugs (because the liver cannot process them) jaundice (yellowing of skin and white of the eyes) loss of sexual desire memory loss and confusion

weight loss from the body and upper arms muscle cramps rapid heartbeat right shoulder pain staggering when walking vomiting blood Alcoholic liver disease often causes no symptoms until it has reached an advanced level. A person may have liver damage even though they have none of the symptoms above. These symptoms may vary, depending on the severity of the disease, and are likely to become worse after a bout of binge drinking. Seek medical advice if any of the signs or symptoms of alcoholic hepatitis have developed, including severe fatigue. Severe symptoms such as gastrointestinal hemorrhage or serious mental confusion require emergency care. What are the causes of alcoholic liver disease? The liver performs hundreds of vital functions, including processing most nutrients, producing bile and substances that help the blood clot, and removing drugs, alcohol and other harmful substances from the bloodstream. The liver has a great capacity for regeneration; but constant exposure to toxins can cause serious and sometimes irreversible damage. It is unclear how alcohol damages the liver. Experts know that the process of breaking down ethanol (the alcohol in beer, wine and liquor) produces highly toxic chemicals such as acetaldehyde. These chemicals trigger inflammation that destroys liver cells. Over time, scars and small knots of tissue form on the liver and interfere with its ability to function. This scarring is irreversible. It is called cirrhosis and is the final stage of alcoholic liver disease. There are two ways that alcohol misuse can cause alcoholic liver disease: Drinking a large amount of alcohol in a short amount of time (known as binge drinking) can cause alcoholic 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 alcoholic liver disease. Long-term alcohol abuse can lead to liver disease. But because many people who drink heavily or binge drink never develop alcoholic hepatitis or cirrhosis, it is likely that other factors play a role: Genetic factors. Having mutations in certain genes that affect alcohol metabolism may increase the risk of alcoholic liver disease and alcohol-associated cancers. Other types of hepatitis. Long-term alcohol abuse worsens the liver damage caused by other types of hepatitis, especially hepatitis C. People who have hepatitis C and also drink, even moderately, are more likely to develop cirrhosis. Other diseases. People who drink alcohol and have a pre-existing liver condition are more likely to develop alcoholic hepatitis. Malnutrition. Many people who drink heavily are malnourished, either because they eat poorly because they often substitute alcohol for food or because alcohol and its toxic

byproducts prevent the body from properly absorbing and metabolizing nutrients. In both cases, the lack of nutrients contributes to liver cell damage. Additional risk factors Possible additional risk factors include: Obesity Being female. Women appear to be more vulnerable than men to the harmful effects of alcohol. This disparity may result from differences in the way alcohol is absorbed and broken down. Because women tend to metabolize alcohol more slowly, their livers are exposed to the higher blood concentrations of alcohol for longer periods of time, with potentially greater toxicity. eating a high-fat diet People vary greatly in their sensitivity to alcohol. Moderate drinking is generally defined as no more than two drinks a day for men and one for women. Binge drinking is usually defined as more than four alcoholic drinks in a two-hour period for women, and more than five drinks in two hours for men. Also a matter of debate is whether certain types of alcohol cause more harm than others. Some experts believe that wine is less damaging than hard liquor is because ounce per ounce, wine drinkers may end up consuming less alcohol overall. However, it may just be that wine drinkers generally tend to have healthier lifestyles. What are the complications of alcoholic hepatitis? Complications of alcoholic hepatitis include: Increased blood pressure in the portal vein. Blood from the intestine, spleen and pancreas enters the liver through a large blood vessel called the portal vein. If scar tissue blocks normal circulation through the liver, this blood backs up, leading to increased pressure within the vein (portal hypertension). Enlarged veins (varices). When circulation through the portal vein is blocked, blood may back up into other blood vessels in the stomach and esophagus. These blood vessels are thin walled and more likely to bleed. Massive bleeding in the upper stomach or esophagus from these blood vessels is a life-threatening emergency that requires immediate medical care. Fluid retention. Alcoholic liver disease can cause large amounts of fluid to accumulate in the abdominal cavity (ascites). Several factors play a role in fluid buildup, including portal hypertension and changes in the hormones and chemicals that regulate fluids in the body. Although not life-threatening in itself, ascites is usually a sign of advanced alcoholic hepatitis or cirrhosis. Bruising and bleeding. Alcoholic hepatitis interferes with the production of proteins that help the blood clot and with the absorption of vitamin K, which plays a role in synthesizing these proteins. As a result, this increases risk of bleeding and bruising. Bleeding in the gastrointestinal tract is a common complication. Jaundice. This occurs when the liver is not able to remove bilirubin from the blood. Eventually, bilirubin builds up and is deposited in the skin and the whites of the eyes, causing a yellow color.

Hepatic encephalopathy. A liver damaged by alcoholic hepatitis has trouble removing toxins from the body. The buildup of toxins such as ammonia (a byproduct of protein digestion) can damage the brain. This leads to changes in the mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms include: mood changes forgetfulness agitation confusion disorientation muscle stiffness muscle tremors difficulty speaking delirium and coma in the most severe cases Cirrhosis. Cirrhosis frequently leads to liver failure, which occurs when the damaged liver is no longer able to adequately function. How is alcoholic liver disease diagnosed? Often, alcoholic liver disease is first suspected when tests for other medical conditions show that the liver has been damaged. It is important during a medical examination to be totally honest about alcohol consumption. In addition to a full medical history, including questions about drinking habits and a physical exam, certain tests will be recommended including: Blood tests. These tests check for high levels of certain liver-related enzymes: gammaglutamyltransferase (GGT), aspartate aminotransferase (AST) and alanine aminotransferase (ALAT). Elevated levels of these enzymes are likely to occur in people with alcoholic hepatitis. Tests to check for viral infections that affect the liver, such as hepatitis B and C may be recommended. Ultrasound. This noninvasive imaging test is used to view the liver. People with alcoholic hepatitis may have enlarged liver. This helps to rule out other problems such as gallstones or bile duct obstruction. Liver biopsy. A small sample of tissue is removed from the liver and examined under a microscope. A thin cutting needle may be used to obtain the sample. Needle biopsies are relatively simple procedures requiring only local anesthesia. It may not be an option in patients who have bleeding problems or severe abdominal swelling (ascites). Risks include bruising, bleeding and infection. What is the treatment for alcoholic liver disease? Abstinence. Complete abstinence from alcohol is the single most important treatment for alcoholic hepatitis. It is the only way to reverse liver damage or, in more advanced cases, to prevent the disease from becoming worse. Patients dependent on alcohol can have a therapy that is tailored for their needs. This might be a chemical dependency evaluation, a brief intervention, counseling, an outpatient treatment program or a residential inpatient stay. People with a dependence on alcohol can find attending self-help groups useful. The most famous one is Alcoholics Anonymous. Medication is available to help people abstain from alcohol. Disulfiram (sold under the brand name Antabuse) can be used for people trying to abstain and concerned that they may relapse, or people who have relapsed in the past. Other treatments for alcoholic hepatitis include:

Nutritional therapy. This is an essential part of the treatment because malnutrition contributes to liver damage. People who drink heavily usually have poor diets, many people with alcoholic liver disease experience a loss of appetite. Also, loss of normal liver function can interfere with the production of bile, a type of fluid produced in the liver which digests many important nutrients. Research has also found that being malnourished makes the liver more vulnerable to the harmful effects of alcohol. A high-calorie diet that contains plenty of protein and carbohydrates is usually recommended for people with alcoholic liver disease. A doctor or dietitian is likely to recommend a high-calorie, nutrient-dense dietary plan to help liver cells regenerate. Doctors also often recommend reducing dietary fat because alcohol interferes with the normal metabolism of fatty acids, leading to deposits of fat in the liver (alcoholic fatty liver). In some cases, medium-chain triglycerides may be prescribed as a supplement. This is a type of fat that may actually help reduce the buildup of harmful fats in the liver. Supplementing with vitamins and minerals (especially vitamins B-1, B-2 and B-6 and calcium and iron) may be recommended. Lifestyle changes. Quitting smoking and maintaining a healthy weight can help improve liver function. Smoking has been shown to increase the rate of liver scarring in people with alcoholic hepatitis, and obesity contributes to fatty liver. It is essential to avoid the use illicit drugs because these can further damage the liver. Drug therapies. People with severe alcoholic hepatitis may benefit from short-term treatment with corticosteroids to reduce inflammation and with pentoxifylline. This is a drug that prevents the body from making tumor necrosis factor-alpha (a powerful substance linked to inflammation). Other therapies that inhibit tumor necrosis factor, such as etanercept (Enbrel) and infliximab (Remicade), also may be considered. Antioxidants. Harmful oxygen molecules called free radicals play a major role in alcoholic hepatitis by causing extensive damage to liver cells. Treatment with antioxidants can help prevent this damage. The supplement SAMe may be of some benefit. Other natural supplements, such as the herb milk thistle, also may be helpful, though study results have been mixed. The chief constituent of milk thistle, silymarin, may assist in healing and rebuilding the liver by stimulating the production of antioxidant enzymes. Get medical advice before taking any supplements or over-the-counter preparations. Liver transplant. When liver function is severely impaired, a liver transplant may be the only option for some people. There are large waiting lists of people awaiting transplants. Liver transplantation in people with alcoholic liver disease is controversial. Some medical centers will not perform liver transplants on people with alcoholic liver disease because they believe a substantial number will return to drinking after surgery, will not take the necessary anti-rejection medications, or will require more care and resources than will other patients. How to prevent alcoholic liver disease? The most effective way to prevent alcoholic liver disease is to stop drinking alcohol or at least follow the recommended daily limits. If you have been diagnosed with alcoholic hepatitis, you should not drink alcohol again. The recommended daily limits of alcohol consumption are three to four units of alcohol for men, and two to three units for women. A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine or a pub measure (25ml) of spirits.

To reduce the risk of alcoholic liver disease: Protection from hepatitis C. Hepatitis C is a highly infectious liver disease caused by the hepatitis C virus. Untreated, it can lead to cirrhosis. A person who has hepatitis C and drinks alcohol is far more likely to develop cirrhosis than someone who does not drink. Because there is no vaccine to prevent hepatitis C, the only way to protect oneself is to avoid exposure to the virus. Contaminated drug paraphernalia is responsible for the majority of all new cases of hepatitis C. Avoid sharing needles or other drug paraphernalia. Hepatitis C can sometimes be transmitted sexually. See your doctor if you have or have had hepatitis C or think you may have been exposed to the virus. Limit medications and supplements. The liver detoxifies and eliminates drugs from the system. Most medications, including nonprescription ones, can damage liver cells. Particularly if the drugs are taken in excess or with alcohol. Be especially careful not to mix acetaminophen (paracetamol) or medicine containing acetaminophen with alcohol because the combination can cause liver failure. Before taking any medications or supplements, consult your doctor about the potential effect on the liver. Living with liver disease Stop drinking. If you have been diagnosed with cirrhosis, stop drinking immediately. Regardless of the cause, alcohol increases the rate at which the condition progresses. Over-the-counter medications. Consult a doctor or pharmacist when taking over-the-counter or prescription medications. The liver processes some medications. Salt intake. People who have ascites should reduce the amount of sodium (salt) in their diet to 1,000mg a day (500mg if possible). This will help reduce the amount of fluid in the body. Well-balanced diet. Extra energy and protein may be needed. Liver disease can cause the liver to stop working properly, so it may be unable to store glycogen, the carbohydrate that provides short-term energy. In this case, the body uses its own muscle tissue to provide energy between meals, which leads to muscle wasting and weakness. Healthy snacking. Between meals, snacking can keep up calories and protein. This helps preserve muscles and keeps them strong. Improved nourishment will make you feel better. Try to eat regularly, about every two to three hours. Limit caffeine intake. Caffeine is processed through the liver and eliminated from the body by the kidneys. This process is drastically affected by the presence of cirrhosis, and can result in a higher concentration of caffeine in the blood. This can cause headaches, fatigue, insomnia and anxiety. Avoid drinks that contain caffeine such as coffee, tea and some soft drinks.