The information in this article is taken from the books Concepts in Medical Physiology, Alcohol Abuse and Liver Disease, Alcoholic Liver Disease-ECAB, and A Practical Approach to the Spectrum of Alcoholic Liver Disease.
The liver performs many essential functions. Its primary function is to filter out harmful substances from the blood, but it also produces bile to aid in food digestion, stores nutrients, and manufactures proteins, enzymes, and hormones that are used by the body to ward off infections and perform numerous other functions.
Alcohol and Liver Damage
The use of alcohol can affect the functioning of the liver. The liver prioritizes metabolizing alcohol when it is in the bloodstream and works very hard to get rid of alcohol, which is a significant toxin, from the system.
Binge drinking or abusing alcohol over time can result in serious liver damage as it places a significant burden on the liver. In most cases, mild or moderate use of alcohol will not lead to liver disease, but chronic abuse of alcohol can result in liver disease. There are three major types of alcohol-related liver diseases:
- Steatosis, or fatty liver, is the early stage of alcohol-related liver disease and the most common liver disorder related to alcohol abuse. This condition is characterized by a large accumulation of fat inside liver cells, and it results in the liver having difficulty performing its normal functions. Often, individuals with this disorder have no major symptoms other than an enlarged liver and may experience discomfort on the right side of their abdomen. Steatosis can occur relatively quickly in individuals who drink heavily, though it may resolve with abstinence.
- Alcoholic hepatitis is an inflammation of the liver that is often accompanied by significant cell death in the liver. A substantial number of heavy drinkers develop alcoholic hepatitis; some sources quote up to 35 percent of heavy drinkers develop this disorder. Symptoms can range from mild to severe, and include jaundice, fever, nausea, vomiting, and pain in the abdomen. If alcoholic hepatitis is mild, it may resolve upon abstinence, but chronic and severe forms of alcoholic hepatitis may not fully resolve. Heavy drinkers may develop acute symptoms of alcoholic hepatitis suddenly after binge drinking and may suffer life-threatening consequences.
Alcoholic cirrhosis is the most serious type of alcohol-related liver disease. Cirrhosis results when the functional cells of the liver die and are replaced with scar tissue. Sources suggest that between 10%-20% of chronic heavy drinkers may develop alcoholic cirrhosis. The condition often takes years to develop. In some cases, cirrhosis may resolve with abstinence, and in many cases, the symptoms are life-threatening. The symptoms include:
- Nausea and vomiting
- Ascites, or the accumulation of fluid in the stomach
- High blood pressure in the liver, referred to as portal hypertension
- Esophageal varices, which is bleeding in the esophagus
- Enlarged spleen
- Confusion and other mental changes.
Chronic use of alcohol will result in a progression from steatosis to alcoholic hepatitis and then finally to alcoholic cirrhosis, although some very heavy drinkers and those with genetic susceptibilities may develop cirrhosis without developing alcoholic hepatitis. Because chronic heavy drinkers engage in risky behaviors, there is also the possibility that alcohol-related diseases are exacerbated by other conditions, such as the development of hepatitis C or HIV.
The complications associated with alcohol-related disease can be very serious, as mentioned above. Significant alcoholic cirrhosis can lead to an increased risk for liver cancer, other cancers, kidney failure, and neurocognitive disorders, such as dementia, in addition to the symptoms of alcoholic cirrhosis.
Liver Disease Risk factors Other Than AUD
There are several risk factors for developing alcohol-related liver disease in addition to chronic and heavy consumption of alcohol.
- Genetic factors influence the efficiency of the liver and the susceptibility of the liver to alcohol and other toxins.
- Obesity is a significant risk factor for liver disease. Interestingly, there is also a positive relationship between alcohol abuse and obesity. The combined effect of obesity and alcohol abuse on the liver is significantly worse than the effects of either one by itself.
- Poor diet or malnutrition contributes to the development of liver disease. Chronic and severe alcoholics often neglect their diet and are malnourished, and this can further increase the development of liver disease.
- Demographic factors, such as an individual’s ethnic background and gender, can increase the risk of alcohol-related liver disease. Women are more susceptible to alcoholic liver disease than men. African American males and Hispanic males appear to be more susceptible to alcohol-related liver disease than Caucasian males.
- Having a disease, such as hepatitis C or HIV, can increase the risk of developing an alcohol-related liver disorder.
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Maintaining Abstinence Through Therapy and Medication
Maintaining abstinence from alcohol is the single most important intervention for an individual with an alcohol-related liver disease. Abstinence is the only way that a potential reversal of liver damage can occur. For an individual with alcohol use disorder, maintaining abstinence from alcohol requires treatment for alcohol use disorder in addition to treatments for alcohol-related liver disease. Thus, the treatment for alcohol-related liver disease and treatment for an alcohol use disorder go hand in hand.
Effective treatment for substance use disorders has been outlined by organizations, such as the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA). Treatments for individuals with co-occurring liver disorders and alcohol use disorders should be supervised by a physician and include the typical protocol for effectively treating alcohol use disorder.
The typical protocol for treating alcohol use disorder and maintaining abstinence from alcohol includes:
- A comprehensive physical evaluation, psychological evaluation, and social evaluation in order to determine the full spectrum of interventions needed to help the individual be successful in their recovery from their alcohol use disorder
- Initial enrollment in a physician-assisted withdrawal management program (medical detox), often involving an inpatient program for those with alcohol-related liver disease
- Participation in an organized program of substance use disorder psychotherapy, preferably of a cognitive-behavioral nature
- Long-term participation in a social support groups, such as Alcoholics Anonymous, often for many years to avoid relapse
- Other interventions that are suitable for the individual’s needs based on the results of the initial assessment
- Treatment of any co-occurring mental health disorders, such as a major depressive disorder, an eating disorder, bipolar disorder, etc.
- Objective monitoring of the person’s abstinence by use of random drug and alcohol screenings
- Continuing participation in treatment-related activities for a minimum of 5-7 years following initial abstinence
- A lifelong commitment to total abstinence from alcohol and illicit drugs
Medically assisted treatments for alcohol use disorder and liver disease are commonly used in conjunction with one another. This includes the use of medications and other medical procedures. Typically, individuals undergoing withdrawal management are administered benzodiazepines under the supervision of an addiction medicine physician, whereas steroids are often used to deal with inflammation of the liver that is associated with alcoholic-related liver disease.
Because individuals who have alcohol-related liver disease often suffer from nutritional deficiencies, physicians may consult with nutritionists and recommend a specific diet. Nutrition therapy, including the use of supplementation and special diets, is often used in the treatment of alcohol-related liver disease.
For individuals with advanced alcoholic cirrhosis, their only option may be to get a liver transplant. Individuals with active alcohol use disorders are not considered qualified organ replacement recipient candidates. Typically, total abstinence for a minimum of a six-month period is required be placed on a waiting list for an organ. In addition, a written agreement stating that the individual will not resume drinking alcohol after the transplant is often required.
The outlook for individuals with alcohol-related liver disease is variable. Individuals with severe cirrhosis of the liver often have a poor prognosis, and unless they can receive a liver transplant and maintain abstinence, their condition is fatal. In other cases, the success of addressing alcohol-related liver disease is dependent on the individual’s ability to remain abstinent from alcohol, their body’s ability to reverse the effects of chronic alcohol abuse, and their commitment to staying involved in their recovery program.
Once an individual has been diagnosed with an alcohol-related liver disorder, there is no turning back. There must be a total commitment to abstinence, and relapse should not be tolerated. Individuals with alcohol-related liver diseases need to understand the seriousness of their condition and their need to totally change their lifestyle. This requires targeted interventions and a lifelong commitment to abstinence by the person.