Alcoholic liver disease

Written by Dr Matthew Warren, specialist registrar in liver medicine and Professor Christopher P Day, professor of liver medicine

Alcohol consumption in the UK

Most people in the UK drink alcohol. Total alcohol consumption per head in the UK rose steeply between 1950 and 1975 and then levelled off until the mid 1990s, when it again started to climb.

The General Household Survey of 2001 found that 39 per cent of men and 22 per cent of women were likely to have exceeded the recommended daily maximum (4 units for men and 3 for women) in the week preceding interview.

There has been a marked increase in the past decade in the proportion of women drinking more than 14 units weekly, the steepest increase being in those aged 16-24. (A unit of alcohol is a single measure of spirits, a half pint of ordinary beer or lager or a standard size glass of wine.)

What is alcoholic liver disease?

Excessive consumption of alcohol can cause liver disease, as well as harming many other body organs.

The prevalence of alcoholic liver disease (ALD) in a population is usually determined by measuring death rates from alcoholic cirrhosis (in which healthy liver tissue becomes increasingly replaced by scar tissue).

These rates have increased alarmingly in recent years. Death rates in the UK rose by up to 88 per cent between 1974 and 1994 with the highest increase in young men aged 35-44 (7.6 deaths per year per 100,000 people).

How much alcohol is harmful?

The amount of alcohol that can cause liver damage seems to vary widely between individuals. But it is certain that:

there is a genetically inherited susceptibility to the harmful effects of alcohol.

women are also believed to be more sensitive to the harmful effects of alcohol than men.

daily drinking, and drinking outside meal times is more harmful than only drinking at weekends.

there is good evidence that the more you drink the greater your risk of developing ALD.

How does ALD progress?

There are three main stages of ALD, although the progression through these stages is variable. Examining a sample of the liver under the microscope from a biopsy gives the most accurate measure of the degree of liver damage.

Minimal change, or fatty liver: heavy drinkers often develop fatty change in the liver. This is not linked to deterioration in liver function, but abnormalities may be seen in some of the blood tests that give an indirect measure of liver disease (also called 'liver function tests' or 'LFTs'). Fatty liver is reversible with abstinence from alcohol, but it is the first stage in the progression to cirrhosis.

Alcoholic hepatitis: the effects of this condition can be mild but may also be life threatening. The LFTs will almost always be abnormal, and the patient may develop jaundice. As with fatty liver, abstinence from alcohol can reverse the effects, but those who continue to drink heavily have a high risk of developing cirrhosis.

Cirrhosis: this is the final, irreversible stage of ALD and is characterised by scarring of the liver and development of liver nodules. It severely affects liver function and reduces life expectancy. The LFT's are usually abnormal, there may be jaundice (yellow colouring of the eyes and skin) and sometimes bruising or bleeding caused by abnormalities of the blood clotting system. In an advanced stage of ALD (severe alcoholic hepatitis or cirrhosis) the remaining liver capacity is insufficient for it to carry out its normal functions, then the body's metabolism becomes badly affected and the stage of 'decompensated ALD' is reached. Complications of this are discussed below.

What are the symptoms?

The symptoms of ALD are usually non-specific, and do not necessarily indicate the severity of the underlying liver damage.

Many people will have vague symptoms such as fatigue, nausea and vomiting ( typically in the morning), diarrhoea or abdominal pains.

Many patients, even with advanced ALD will have no symptoms and are detected by the finding of liver blood tests performed as part of routine health screening, or during the investigation of other conditions.

Only in the more advanced stages of decompensated ALD will the sufferer present with more specific liver-related symptoms such as jaundice, ascites (fluid collecting in the abdomen, causing distension), haematemesis (vomiting of blood) or encephalopathy (confusion, reduced level of awareness and altered sleep pattern, eventually progressing to coma). These are signs of severe liver damage and require urgent medical treatment.

How is ALD diagnosed?

If there is a history of alcohol excess sufficient to cause liver damage, tests can establish the presence and severity of the liver damage. Blood tests can give an idea but they are not accurate predictors.

Further tests in hospital can confirm the diagnosis and determine the severity of the disease. Ultrasound scans create an image of the liver and surrounding organs, which helps in taking a liver biopsy. The ultrasound scan can help to assess the severity of disease and exclude other common causes of abnormal LFTs such as gallstones.

Liver biopsy is the most accurate test to determine the stage of ALD present and to ensure alcohol is the cause of the liver disease.

Research has shown that in up to 20 per cent of heavy drinkers with abnormal LFTs an alternate cause of liver disease is found on investigation.

Liver biopsies are performed under local anaesthetic, and provide a tiny sample of the liver for analysis under the microscope.

What else could it be?

The above investigations will rule out whether the symptoms are caused by any of the following:

viral hepatitis, including hepatitis B and C.

haemochromatosis (an inherited disorder of iron metabolism).

Wilson's disease (an inherited disorder of copper metabolism).

autoimmune hepatitis (a liver disorder caused by the immune system attacking the liver).

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