Alcohol related liver disease (ALD)
Overview
Alcohol-related liver disease (ALD) is a condition where the liver has been chronically damaged by alcohol. Drinking alcohol in hazardous/harmful ways can put you at risk of ALD. In Ireland, the Health Service Executive (HSE) has recommendations for low-risk levels of alcohol consumption per week:
Over the course of a 7-day week, individuals should not consume more than:
· 11 standard drinks for women (5 pints of lager, or 11 small glasses of wine)
· 17 standard drinks for men (8 pints of lager, or 17 small glasses of wine)
Alcohol consumption should be spread out over the course of the week and you should have several alcohol-free days, not consuming more than 3 pints or 6 small glasses of wine in one day.
Alcohol-related liver disease may not have any symptoms until late in the disease. Symptoms such as losing muscle mass, thinning of the skin, bruising easily, yellowing of the skin and eyes (jaundice) and swelling of the tummy (ascites) may indicate significant liver problems.
Stages of ALD
There are different types of alcohol-related liver disease (ALD).
1. Fatty liver
There may be no symptoms or findings on blood tests. An abdominal ultrasound may reveal a fatty liver. Drinking more than 4 standard drinks (2 pints or 4 small glasses of wine) each day will cause some fat to build up in your liver. As the liver breaks down alcohol, it produces by-products which can cause liver damage. This damage can be seen by high liver blood tests (or liver function tests). Specialised tests to check for liver damage include a scan of the liver (for example, FibroScan) which measures the stiffness and fat content of the liver, or a liver biopsy. If you stop drinking alcohol completely for a prolonged period of time (months to years) the liver can heal itself and recover.
2. Alcohol-related hepatitis
This stage of alcohol-related liver disease occurs after years of harmful drinking and particularly after a sudden increase in drinking. It can develop suddenly, typically with jaundice appearing over weeks. It is a very serious condition which can lead to liver failure or death.
3. Alcohol-related cirrhosis
The most advanced stage of alcohol-related liver disease (ALD) is cirrhosis of the liver, which means that the scarring is now irreversible. Up to 1 in 5 heavy drinkers will develop liver cirrhosis. It is important to be aware that if you give up alcohol entirely at this point, your liver can still work to sustain normal life, if it has not decompensated (meaning no tummy fluid, jaundice or internal bleeding). It is also very important that you are referred to a liver specialist (Hepatologist) and their team for appropriate screening and monitoring.
Liver cirrhosis is associated with an increased risk of liver cancer (Hepatocellular carcinoma) and you will need to have 6 monthly scans of the liver to check for this. If picked up at an early stage, liver cancer is curable, highlighting the need for regular checks, as treatment is very limited at late stages.
Due to scarring and hardening of the liver, a build up of pressure around the liver can occur, leading to the development of enlarged veins called varices in the food tube (oesophagus) or stomach, which can be life-threatening should they bleed. For that reason, your specialist will request an OGD or “camera test” or “endoscopy” into your stomach to look for these veins and potentially treat them.
When should I seek help?
If you or someone close to you are concerned about your drinking, medical help is available; your GP can advise but there are also free and confidential HSE helplines that you can avail of such as on 1800 459 459 from Monday to Friday between 9:30 am and 5:30 pm, or email any time on helpline@hse.ie.
If you develop any of the following signs or symptoms you should seek medical help right away:
· Yellowing of the eyes or skin (jaundice)
· Swelling in the abdomen/tummy (ascites) or legs.
· Vomiting blood or dark material
· Dark/black bowel motions
· Confusion, poor concentration, sleeping during the day and awake at night, brain fog (encephalopathy)
· Easy bruising of the skin
How is alcohol-related liver disease diagnosed?
ALD is usually diagnosed using blood tests and scans in patients with a history of alcohol excess.
1. Blood tests
In persons who consume alcohol in excess, several bloods tests may be abnormal. The liver blood tests may show signs of liver damage (e.g. increased levels of gGT or AST), and tests related to your liver function may be affected in advanced liver disease.
2. Scans
o Ultrasound: This scan involves jelly on the tummy, while a probe is used to check the organs in your abdomen, including the liver. The ultrasound machine uses sound waves to have a look at organs and structures in your abdomen and can detect signs of liver damage.
o Transient elastography (e.g. FibroScan™): This scan is similar to an ultrasound and uses vibration to send a pulse wave to your liver and back to the probe which can be felt as a gentle flick on your skin underneath the probe. This test can measure the degree of stiffness (scarring/fibrosis) in the liver as well as the amount of fat in the liver (steatosis). It is a very useful test to determine the stage of liver diseases.
3. Endoscopy
Alcohol related stomach damage includes gastritis or ulceration which can be detected by an endoscopy (OGD). In advanced alcohol related liver disease, enlarged veins in the gullet (oesophagus) or stomach called varices are a very important finding and require treatment with tablets (betablockers) or therapy during the endoscopy procedure itself.
4. Liver biopsy
A liver biopsy is rarely required to make the diagnosis of alcohol-related liver disease. However, in some cases a medical history and investigations may not provide sufficient information to make a clear diagnosis, and in these situations a liver biopsy may be necessary.
I’ve been diagnosed with ALD, what now?
If you are diagnosed with alcohol-related liver disease, management will depend on the stage of your disease. At all stages however, abstinence from alcohol offers the best outcomes.
The main goals of management are:
1) Achieving abstinence from alcohol and maintaining it
2) Stopping the liver damage worsening in order to prevent complications such as liver cirrhosis, liver failure, or liver cancer
3) Helping recovery and having a new positive outlook
Some other factors may increase your risk of liver damage with alcohol-related liver disease. These include:
· Being overweight or obese
· Having diabetes (mainly type 2 diabetes)
· Women are more vulnerable to the harms of alcohol than men
· Having a pre-existing liver condition such as Haemochromatosis or Hepatitis C
· Genetics – some alcohol-related diseases and additions often run in the family.
How is ALD treated?
1. Alcohol abstinence
The best treatment for ALD is alcohol abstinence.
2. Healthy Lifestyle
Maintaining a healthy lifestyle and reducing your risk factors is another means of protecting your liver. Eating a well-balanced diet, increasing physical activity each day, or exercising such as with long walks, jogging, cycling or swimming (aerobic exercises) is very good for your overall liver health. If you are over your ideal body weight, losing weight and fat from around the tummy area and waistline has the best effect on reducing the amount of fat around organs and in the liver.
3. Medications
For persons struggling to achieve abstinence from alcohol, there are medications available to help with this such as Campral (Acamprosate), Vivitrol (Naltrexone), and other options. Consult with your doctor to find out which one is right for you.
There is not enough strong evidence to support the use of medication or remedies to directly treat alcohol-related liver disease. “Liver detoxes” and herbal remedies which claim to heal the liver lack convincing evidence and have not been tested in appropriate studies or clinical trials.
In some patients who develop acute alcohol-related hepatitis, they may require medication to reduce inflammation in the liver, such as steroids (corticosteroids). Steroids have been shown in studies to improve survival in these patients in the short term (1 month), but has not shown benefit in survival over a longer term (3 months to 1 year). Furthermore, the use of corticosteroids greatly increases the risk of life-threatening infections and should always be given under the care of the specialist in these situations.
Other medications may be used to indirectly support the liver such as beta-blockers; a medication typically used to treat high blood pressure and heart conditions; but is used in liver disease to reduce the pressures in the veins related to the liver.
4. Liver Transplant
Alcohol-related liver disease is one of the leading condition for which liver transplants are performed in Ireland. It is usually only recommended when other management options have. To be eligible, individuals must be abstinent from alcohol and even pass an alcohol blood test (which can detect alcohol use within the previous 3 months). The criteria for liver transplantation is quite strict, given the relative shortage of liver donor supplies compared to demand.
The work-up for a liver transplant will be done by your liver specialist, who will then refer you to a liver transplant unit (St. Vincent’s University Hospital in Ireland), where the remainder of the workup for the liver transplantation will be done by liver transplant specialists (including specialist nurses, hepatologists, transplant surgeons, anaesthetists etc.)
Liver transplantation is a major operation, and patients can stay in hospital for around 10 days after their surgery. Liver transplants are very effective and successful in curing many liver diseases, however patients who have had a liver transplant will be on lifelong medications to control their immune system and to prevent it from rejecting the transplanted liver.
Who will oversee my medical care?
You will have the most important role in your management of alcohol-related liver disease as alcohol cessation is the mainstay of treatment and prevention. Other lifestyle factors such as diet, increased physical activity, exercise, and a determined spirit are crucial in supporting your liver’s health.
In early ALD, your family doctor may be involved in routine health checks as well as performing blood tests to monitor your liver. As you may not experience any symptoms with early ALD, your family doctor can check for complications of ALD. It is common to also have a liver specialist (Hepatologist) involved in your care early on. In later stages of ALD such as liver cirrhosis, it is crucial to have a liver specialist involved in your care to optimise your medications, link you in with appropriate support services, and arranging appropriate surveillance tests or referrals.
Useful links
· National Drug & Alcohol taskforces: https://www.drugsandalcohol.ie/php/drug-alcohol-task-forces.php
· HSE helpline: https://www.hse.ie/eng/services/list/5/addiction/drugshivhelpline/
· Frontline - Make Change: https://www.frontlinemakechange.com