Fibrosis of the liver (scarring) and alcoholic sclerosis (much more commonly referred to as cirrhosis) can be consequences of heavy and chronic alcohol use.
The 3 Stages of Liver Diseases
The liver performs many essential functions that include making bile to digest food, storing nutrients and energy, filtering out toxic and waste materials from the blood, and producing important enzymes, hormones, proteins, etc., used by the body to ward off diseases. Chronic moderate to heavy use of alcohol (through binge drinking or even small amounts of alcohol taken throughout the day) have significant effects on the functioning of the liver.
In general, there are three types or stages of diseases of the liver that are related to alcohol use and abuse.
- Steatosis (fatty liver): The first stage of any alcohol-related liver disease is the accumulation of fat inside liver cells that results in impairment of the liver to perform its normal functions. This can lead to a large liver and discomfort in the abdominal area, particularly on the right side. Some level of fat accumulation in the liver occurs in nearly everyone who begins to use alcohol heavily. The liver gives priority to processing alcohol over all other substances and metabolizes it first, resulting in the potential accumulation of fat deposits within liver cells. For most people, becoming abstinent from alcohol will result in this condition resolving to some level.
- Alcoholic hepatitis: Inflammation (swelling) of the liver and cell death within the liver can occur with continued use of alcohol. Heavy drinkers are most susceptible to developing alcoholic hepatitis to some degree. The symptoms of alcoholic hepatitis can include abdominal pain, tenderness in the abdominal area, nausea, vomiting, fever, and even jaundice. This can become a chronic condition in people who chronically abuse alcohol and can even be an acute condition in severe binge drinkers. Over time, if this condition is not reversed, some individuals may move on to the next stage of liver disease. In this stage, scarring (fibrosis) of liver tissue will often occur to some extent.
- Alcoholic sclerosis (cirrhosis): In this condition, there is significant scarring of liver tissue (the replacement of functioning cells with nonliving scar tissue). Fibrosis of the liver typically refers to scarring of the liver that has not become significantly extensive; sclerosis or cirrhosis refers to a condition where scarring is extensive and may be irreversible. Heavy drinkers (people who binge drink five or more times per month) can develop cirrhosis at rates between 10 percent and 20 percent after years of chronic drinking (typically 10 years or more). Some individuals with genetic susceptibilities (see below) can develop cirrhosis much sooner.The symptoms of cirrhosis can include the above symptoms that are associated with alcoholic hepatitis and portal hypertension (increased blood pressure in the liver), ascites (buildup of fluid in the abdomen), bleeding from the esophagus (esophageal varies), bleeding from other veins, an enlarged spleen, and changes in behavior that include confusion and a dementia-like state. Depending on the extent of the damage, cirrhosis may be reversible to some extent or may not be reversible.
Some sources include a fourth stage of liver disease: liver failure.
Associated Risk Factors
There are numerous potential risk factors that can increase the probability that someone may develop fibrosis and sclerosis of the liver. The major risk factors include:
- Alcohol consumption: The major preventable risk factor that can lead to these conditions is the consumption of alcohol. The risk of developing these conditions increases with the amount of alcohol a person normally consumes and the period of time an individual has been drinking. However, not everyone who drinks heavily for years develops significant issues with cirrhosis, and some individuals who do not drink alcohol may develop these problems. Like all risk factors, no single risk factor by itself can be considered a cause of the disorder but must interact with other factors to produce the disorder. Nonetheless, the single most preventable risk factor in the development of liver disease is one’s level of alcohol consumption.
- Genetic makeup: A person’s genetic makeup (often evaluated by their family history) is a significant risk factor for the development of fibrosis and sclerosis of the liver. Individuals with increased susceptibility (e.g., a family history of liver disease) and who drink alcohol heavily are prime candidates to develop these conditions.
- Ethnicity: No one fully understands the reason, but the development of fibrosis and cirrhosis is higher in Hispanic males and African American males than it is in Caucasian males. This may represent some genetic risk factor or lifestyle factor interacting with genetic factors.
- Gender: Females are more susceptible to the development of these conditions than males. This is primarily because they process alcohol differently than males, and it takes less alcohol to produce these effects in females than it does in males. Genetic factors may also be at play.
- Other health-related issues: Other health-related issues that can increase the risk to develop liver disease include obesity, viral hepatitis (especially hepatitis C), malnutrition, regular needle sharing in intravenous drug users, unprotected sex, and even some co-occurring mental health disorders.
Risk factors are not deterministic. They simply increase the probability that one might develop a disorder or disease. While a person cannot change their genetic makeup, gender, or ethnic background, they can alter their behavior to control the amount of alcohol they consume, their diet, and their exercise regime, and get treatment for other conditions that may increase the risk to develop liver disease.
Most people will go through the normal progression of developing a fatty liver, to the symptoms of alcoholic hepatitis, to later developing problems with cirrhosis. Individuals with high genetic susceptibilities may skip the middle step and move from fatty liver to cirrhosis rather quickly. Individuals who consume large amounts of alcohol on a regular basis may have a much shorter progression from the early stages of the disease to the later stages. Of course, mixing alcohol with other potentially dangerous drugs can complicate the entire situation and result in a faster progression of liver disease.
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Diagnosis and Co-Occurring Treatment
A physician may suspect that an individual is suffering from some disease related to alcohol abuse based on their history and symptoms. The use of laboratory tests such as blood tests and radiologic studies (e.g., x-rays, CTs, MRIs, etc.) or other imaging procedures can help to diagnose liver disease. Physicians may take a biopsy of the liver to determine the extent of scarring and any potential cirrhosis.
The treatment of liver disease may involve many different routes. In some cases, individuals may be required to engage in nutrition therapy and take certain nutritional supplements. Medications to combat inflammation of the liver, such as steroids like prednisone, may be prescribed. However, for individuals with chronic alcohol-related liver disorders, the first and foremost intervention is to become abstinent from alcohol and other potentially damaging substances.
Because individuals who develop liver disease related to alcohol abuse are most likely suffering from moderate to severe alcohol use disorders (and may be suffering from co-occurring disorders), it is often essential to get these individuals into treatment for their alcohol use disorder as soon as possible. Once the situation is diagnosed, immediate abstinence from alcohol is required. Treatment may need to include:
- Initial inpatient admission with detox procedures: Depending on the severity of the person’s liver disorder and alcohol abuse, inpatient admission and withdrawal management procedures may need to be implemented immediately.
- Substance use disorder therapy: Becoming immediately involved in substance use disorder therapy, with a strong emphasis on stress management and relapse prevention, is a must for these individuals.
- Other medical management issues: Medications may be used to deal with cravings and to avoid relapse.
- Support: All individuals in treatment for alcohol abuse need significant support. This support should come from numerous sources, including family members, friends, coworkers, and peer support groups like Alcoholics Anonymous (AA).
- Other interventions as identified in the assessment: Before an individual is placed in the treatment, they are assessed thoroughly. Any other needs identified in the assessment should be addressed alongside treatment for their substance use disorder and management of their liver disease. This can include different types of complementary or alternative treatments, such as exercise programs, meditation, art therapy, etc.
For some individuals with chronic cirrhosis of the liver, the only option may be a liver transplant. These individuals often need to demonstrate a significant period of abstinence before they can be placed on a waiting list or before they can get an organ; most often, individuals must demonstrate through random drug and alcohol testing at least six months of abstinence before considerations will be made. In very chronic cases, individuals may not be able to maintain abstinence or may not have the time to wait.