Patient information from BMJ

Alcoholic liver disease

Last published:Apr 27, 2023

If you have alcoholic liver disease, your liver has been damaged from years of heavy drinking. Treatment can help stop further damage and reduce your chance of serious problems, such as liver failure. However, for treatment to work, it’s important that you stop drinking. Your doctor can help.

What is alcoholic liver disease?

Your liver sits just under your ribs, on the right side of your abdomen. It is one of the biggest organs in your body, and it does hundreds of jobs.

One of the most important is to process everything that you eat and drink, storing the nutrients that your body needs and getting rid of substances that could be harmful.

Alcohol is one of these harmful substances, and your liver can only handle so much alcohol at a time. If you drink heavily, this can damage the cells in your liver.

If you continue to drink heavily for many years, this can cause more serious damage, leading to alcoholic liver disease (ALD). 

There is no definite amount of heavy drinking that causes ALD in all people. Some people get ALD more quickly than others, and at lower drinking levels. This is more likely if you are very overweight (obese), or have other problems with your liver, such as an infection called hepatitis C.

Also, women are more likely to develop ALD than men. And the disease often gets worse more quickly in people who smoke.

There are three stages of ALD.

• The first stage is called fatty liver, or steatosis. At this stage, the damage has started to change your liver, leading to a build-up of fat.

• The second stage is called alcoholic hepatitis. This means your liver is injured and inflamed (swollen). This inflammation can lead to more damage.

• The third stage is called alcoholic liver cirrhosis. At this stage, you have scarring in your liver caused by the ongoing damage. As the scar tissue grows, it replaces healthy liver tissue. This makes it more and more difficult for your liver to do its jobs.

If ALD is treated early, the damage can be stopped and the liver can often recover. However, as ALD progresses it becomes more difficult to treat and serious problems (complications) become more likely. These can include:

• liver failure

• internal bleeding

• problems with brain function

• liver cancer, and

• kidney damage.

What are the symptoms?

ALD can cause different symptoms in different people. Some people get symptoms early on, while others have no symptoms until their liver disease is advanced. 

Some common symptoms include: 

• tiredness (fatigue)

• loss of appetite

• weight loss

• a yellow tint to your skin and the whites of your eyes (jaundice)

• fever

• nausea (feeling sick) and vomiting, and

• pain in the upper right side of your abdomen.

When the disease becomes more advanced, it can also cause: 

• swelling in your abdomen (called ascites). This is caused by a build-up of fluid in your abdomen

• swollen legs. This is also caused by a build-up of fluid

• blood in your vomit or stools. This is caused by bleeding in your digestive system. If you have blood in your stools, they may look black. Blood in vomit often looks like coffee grounds

• problems with confusion, concentration, memory, and sleep. If your liver isn’t working properly, harmful substances (toxins) can build up in your body, affecting your brain. This is called hepatic encephalopathy

• shaking in your hand when you extend your wrist (called asterixis). 

To diagnose ALD, your doctor will ask you questions about your drinking, examine you, and do tests. Tests can also show how advanced your liver disease is. These may include:

• blood tests to check on your liver health and to spot other problems that can accompany ALD, such as a low amount of red blood cells (a condition called anaemia), low levels of some important minerals, and liver infection (hepatitis A, B, or C)

• an ultrasound or CT scan of your liver

• a biopsy of your liver. This involves inserting a needle through your skin to take a small sample of tissue from your liver. But not everyone needs a biopsy.

What treatments work?

By far the most important part of treatment is stopping drinking. If you don't stop drinking, your liver won't have a chance to recover and your liver disease is likely to get worse.

If your liver is very damaged, you may be considered for a liver transplant.

Stopping drinking

Most people with ALD are dependent on alcohol. This means that they find it hard to control their drinking, and they continue to drink even when it causes problems.

Being dependent on alcohol is an illness (you may hear it called alcohol use disorder or alcoholism). But with the right support and treatment, you can stop drinking. Treatment can involve different things. Your doctor can help you explore your options. These may include:

• having counselling or a talking treatment (psychotherapy)

• joining a support group, such as Alcoholics Anonymous

• entering an alcohol rehabilitation programme.

Sometimes people who drink heavily get withdrawal symptoms when they stop drinking. These may include:

• shaking

• anxiety

• a fast heart rate, and

• nausea and vomiting.

Your doctor can prescribe medicines to help you cope with these symptoms.

Your doctor may also recommend taking medicines that can help reduce your desire for alcohol.

Vaccinations

Your doctor will probably recommend that you get vaccinations to protect your liver from two infections: hepatitis A and hepatitis B. These infections can harm your liver, especially if you have ALD. 

Your doctor will also probably recommend getting a pneumonia vaccination (if you haven’t already had one) as well as a yearly flu vaccination.

Other lifestyle changes

Being very overweight (obese) or smoking can speed up how quickly your liver disease gets worse. Losing weight and stopping smoking can help slow this damage. Your doctor can recommend treatments to help.

Many people with liver disease don’t get enough nutrition. This may be in part because they don’t eat enough, and also because their liver isn’t able to process food as well as it should.

As a result, your doctor may recommend that you change your diet and eating habits. This may involve eating several times a day to get enough calories and protein, including at bedtime and when you first get up in the morning.

You may also need to take vitamin supplements, and cut back on salt. 

Treatments for complications

If your liver disease is more advanced, you may need treatment for specific complications, such as:

• fluid build-up

• kidney problems

• bleeding in your digestive tract, and

• problems with brain function.

Your doctor will discuss these with you. 

Liver transplant

If your liver has become very damaged, it will no longer be able to do its jobs. The only treatment option at this stage is a liver transplant.

This involves having surgery to replace your liver with a healthy liver from someone who has just died. It's a major operation and a liver may take a long time to become available. 

To be considered for a transplant, you need to stop drinking. You may need to stay away from alcohol for six months or longer before you are added to the list of people waiting for a liver transplant.

What will happen?

Given the chance, the liver is very good at healing itself. This means that, if your liver disease is not advanced, your liver might recover if you stop drinking. If you keep drinking, this will lead to further damage, and possibly life-threatening complications. 

Your doctor will probably recommend that you have regular appointments and blood tests to check on your liver. If you have more advanced liver disease (cirrhosis), your doctor may also recommend having ultrasound scans every six months to check for liver cancer.

Because your liver is damaged, it may have difficulty processing certain medicines. It’s important that you check with your doctor before taking any new medicines, including herbal remedies and over-the-counter treatments.

Ibuprofen and other pain medicines called non-steroidal anti-inflammatory drugs (NSAIDs) can harm your liver if you have liver disease. But low doses of paracetamol (up to 2 grams a day) are usually safe, as long as you are eating regularly. 

You should keep a written list of all your medicines, and when you need to take them. It is a good idea to bring this list – or all your medicine bottles – to your doctor or hospital visits.

You should get medical help right away if you have any of the following symptoms. They could be a sign of a serious problem, requiring urgent treatment:

• Fever

• Abdominal pain

• Shortness of breath

• A fast heart rate

• Fast breathing

• A dizzy feeling

• Blood in your stools or vomit.

After years of heavy drinking, giving up alcohol may seem like an impossible goal. But with support and treatment, many people succeed. If you have any questions or concerns, be sure to discuss these with your doctor.