Alcoholic liver disease
Alcohol consumption is steadily increasing among the Indian population, especially among the younger generation. Excessive drinking can lead to liver damage, involve other organs and could even be fatal.
Excessive consumption of alcohol can cause an acute or chronic inflammation of the liver and may even harm other organs in the body. In India, even though there is a greater incidence of cirrhosis of the liver due to viral and other infectious types of hepatitis, alcohol induced liver disease remains a major problem.
How much alcohol is harmful?
The amount of alcohol that can cause liver damage seems to vary from person to person. But the following points are proven:
A person may be genetically susceptible to the harmful effects of alcohol. Women are more sensitive to the harmful effects of alcohol than men. Daily drinking is definitely more harmful than only drinking occasionally or at weekends. There is clear evidence that the risk of developing Alcoholic Liver Disease increases proportionately with the amount of alcohol intake.
What happens to the liver in a person suffering from Alcoholic Liver Disease?
Alcoholic Liver Disease may progress in three stages, but the way in which the liver is affected may vary from person to person. The doctor can study this progress by studying a biopsy of the liver tissue.
Fatty liver with minimal changes: Heavy drinkers often develop fatty change in the liver. This may not be linked to deterioration in liver function, but abnormalities may be seen in Liver Function Tests (LFT's). If a person stops drinking alcohol, fatty liver changes may be reversed. Otherwise this can be considered as the first stage in the progression towards Cirrhosis of the Liver.Alcoholic Hepatitis: This stage could be anything from mild to life threatening. The LFT's will almost always be abnormal, and the patient may develop jaundice. Just as with fatty liver changes, abstinence from alcohol can reverse the effects, but people who continue to drink heavily even after this stage are at high risk of developing cirrhosis. Cirrhosis: This is the final, irreversible stage of Alcoholic Liver Disease. It is characterized 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 coloring of the eyes and skin) and sometimes bruising or bleeding caused by abnormalities of the blood clotting system. Complications of so-called 'decompensated cirrhosis' may develop (see below).
What are the symptoms of Alcoholic Liver Disease?
The symptoms of Alcoholic Liver Disease may be 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), diarrhea, or abdominal pains. Even when the problem is in an advanced stage, some people may not have any symptom. In such people the problem may be discovered only when Liver Function Tests are done as part of some other routine testing or when investigations are done to detect some other disease. When the disease progresses to an advanced stage and severe alcoholic hepatitis or cirrhosis develops, the person will have 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 causing coma). These are signs of severe liver damage (decompensated cirrhosis) and require urgent medical treatment.
How does the doctor diagnose Alcoholic Liver Disease?
A history of excessive alcohol consumption by a person, will prompt the doctor to request for some tests to assess the liver function. Blood tests may give an idea of the degree of liver damage though the extent of the damage cannot be predicted accurately. Ultrasound scans of the liver and even a biopsy may be requested for. An ultrasound scan can help assess the severity of disease and exclude other common causes of abnormal LFT's such as gallstones. Liver biopsy is the most accurate test to determine the stage of Alcoholic Liver Disease and to ensure that alcohol is the cause of the liver disease. Research has shown that in up to 20% of heavy drinkers with abnormal LFT's an alternate cause of liver disease is found on investigation. Liver biopsies are performed under local anaesthetic. A tiny sample of the liver is taken and studied under the microscope.
What other problems could cause symptoms similar to Alcoholic Liver Disease?
The following problems could present with symptoms similar to Alcoholic Liver Disease:
Viral hepatitis, including hepatitis B and C. Hemochromatosis (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).
What is the treatment for Alcoholic Liver Disease?
Alcoholic Liver Disease can be treated by non-medical and medical methods, depending on the stage of the disease.Good Nutrition : A good diet and avoiding obesity can significantly improve the outcome of Alcoholic Liver Disease. Obesity seems to increases the risk of advanced liver disease in heavy drinkers. Many people with this problem are severely malnourished, due to loss of appetite and nausea. In advanced liver disease (alcoholic hepatitis and cirrhosis) nutritional supplements have been shown to significantly improve the liver function tests. A diet high in antioxidants such as vitamin E and selenium may help prevent and treat ALD. These can be taken as supplements or by increasing dietary fresh fruit and vegetables. Abstinence : Even in advanced liver disease, it is still important and beneficial to stop drinking. People with compensated cirrhosis, who continue to drink, are far more likely to develop decompensated disease. Those who stop drinking, will definitely have a better survival rate than those who continue to drink. Supervision may be required to safely reduce alcohol consumption. Rapid reduction of alcohol consumption could lead to physical withdrawal symptoms in up to 40% of people. This is characterized by agitation, sweating, anxiety and fits. A small percentage of people may experience visual hallucinations known as Delirium Tremens. Withdrawal symptoms can be life threatening at times. Sedatives and hospital admission may be necessary. Medical and Surgical Treatment: Alcoholic Hepatitis: Treatment of alcoholic hepatitis depends on the severity of disease. In mild cases, abstinence from alcohol and nutritional support are most essential. In acute severe alcoholic hepatitis the doctor may advice hospitalization. Steroids may help some patients. Even with steroids, the mortality is high, especially when kidney damage is also present. Cirrhosis: Cirrhosis of the liver can be 'compensated' (cirrhosis without complications) or 'decompensated'. Complications that may develop include bleeding from varices (abnormal veins that form in the gullet), ascites (accumulation of fluid in the abdomen), jaundice and encephalopathy (confusion, reduction in conscious level and coma). Compensated cirrhosis could be managed with abstinence from alcohol and nutritional. Decompensated cirrhosis: Specific measures are aimed at treating the complications of decompensated cirrhosis. Bleeding Varices may be treated by a surgeon, using an endoscope (a flexible camera which can be passed into the stomach) to visualize the abnormal veins in the wall of the gullet. A 'screening' endoscopy test may be done to identify any varices, before a bleed occurs. Where varices are found, treatment with beta-blockers may reduce the chances of a first bleed. Ascites requires a low salt diet and reduction in fluid intake. Diuretics (water tablets) may be given. Intermittent drainage of the fluid is possible with a catheter or plastic drainage tube inserted into the abdomen (paracentesis). In some cases these measures will be unsuccessful, and further interventions such as a liver transplant may be necessary. Encephalopathy is usually linked to additional stress on the body as when inappropriate sedatives or painkilling drugs are used in patients with a damaged liver. Bleeding from the gullet or stomach, constipation, infections and abnormalities in the salts (electrolytes) in the blood can also cause a stress on the body. Treatment is to correct the underlying problem. Purging of the bowel either with enemas or with a liquid laxative may be required. Laxatives may need to be taken on a long-term basis to prevent recurrence of the encephalopathy. Liver Transplant may be required in some patients in whom the cirrhosis and liver function continue to deteriorate and there may be severe complications despite abstinence from alcohol.
