Overview

Symptoms

In many cases, people with alcohol-related liver disease (ARLD) do not have any noticeable symptoms until their liver is badly damaged.

Early symptoms

If you do experience early symptoms of ARLD, these are often quite vague, such as:

• abdominal pain (stomach ache)
• loss of appetite
• fatigue
• feeling sick
• diarrhoea
• feeling generally unwell

Advanced symptoms

As your liver becomes more severely damaged, more obvious and serious symptoms can develop, such as:

• yellowing of the skin and whites of the eyes (jaundice)
• swelling in the legs, ankles and feet caused by a build-up of fluid (oedema)
• swelling in your abdomen, due to a build-up of fluid known as ascites
• a high temperature (fever) and shivering attacks
• very itchy skin
• hair loss
• unusually curved fingertips and nails (clubbed fingers)
• blotchy red palms
• significant weight loss
• weakness and muscle wasting
• confusion and memory problems, trouble sleeping (insomnia) and changes in your personality caused by a build-up of toxins in the brain
• passing black, tarry poo and vomiting blood as a result of internal bleeding
• a tendency to bleed and bruise more easily, such as frequent nosebleeds and bleeding gums
• increased sensitivity to alcohol and drugs because the liver cannot process them

When to seek medical advice

ARLD does not often cause symptoms until it's reached an advanced stage. If you misuse alcohol, you may have liver damage, even though you have none of the symptoms above.

Read about alcohol misuse (drinking too much)

Contact your GP for advice if you have a history of regular alcohol misuse.

A good way to assess your history and pattern of drinking is to use a short test known as the CAGE test, which consists of 4 questions:

• Have you ever thought you should cut down on your drinking?
• Have people annoyed you by criticising your drinking?
• Have you ever felt guilty about your drinking?
• Have you ever drunk an ‘eye-opener’, which means: have you ever drunk alcohol first thing in the morning to get over a hangover and steady your nerves?

If you answer "yes" to one or more of the questions above, you may have an alcohol problem and are advised to see your GP.

See your GP as soon as possible if you have symptoms of advanced ARLD.

Who can get it

Alcohol-related liver disease (ARLD) is caused by drinking too much alcohol. The more you drink above the recommended limits, the higher your risk of developing ARLD.

There are 2 ways that alcohol misuse (drinking too much) can cause ARLD.

These are:

• drinking a large amount of alcohol in a short amount of time (binge drinking) can cause fatty liver disease and, less commonly, alcoholic hepatitis
• drinking more than the recommended limits of alcohol over many years can cause hepatitis and cirrhosis, the more serious types of ARLD

Evidence suggests people who regularly drink more than the recommended maximum amounts are most at risk of developing ARLD:

• men and women are advised not to regularly drink more than 14 units a week
• spread your drinking over 3 days or more if you drink as much as 14 units a week
• if you want to cut down, try to have several drink-free days each week

Read more about alcohol units and how to calculate them.

Additional factors

As well as drinking excessive amounts of alcohol, other factors can increase your chances of developing ARLD.

These include:

• being overweight or obese
• being female (women appear to be more vulnerable than men to the harmful effects of alcohol)
• having a pre-existing liver condition, such as hepatitis C
• genetics (alcohol dependence and problems processing alcohol often run in families)

Diagnosis

Alcohol-related liver disease (ARLD) is often first suspected when tests for other medical conditions show a damaged liver.

This is because the condition causes few obvious symptoms in the early stages.

If a doctor suspects ARLD, they'll usually arrange a blood test to check how well your liver is working. They may also ask about your alcohol consumption.

It's important to be totally honest about how much and how often you drink alcohol to avoid further unnecessary testing. This could lead to a delay in the treatment you need.

Blood tests

Blood tests used to assess the liver are known as liver function tests.

But liver function tests can be normal at many stages of liver disease.

Blood tests can also detect if you have low levels of certain substances, such as a protein called serum albumin, which is made by the liver.

A low level of serum albumin suggests your liver is not functioning properly.

A blood test may also look for signs of abnormal blood clotting, which can indicate significant liver damage.

Find more informaiton on liver blood tests on the Lab Tests Online website.

Further testing

If your symptoms or liver function test suggest an advanced form of ARLD (either alcoholic hepatitis or cirrhosis)  you may need further tests.

Imaging tests

Scans may be needed to produce detailed images of your liver.

This may include:

• an ultrasound scan
• a CT scan
• an MRI scan

Some scans may also measure the stiffness of the liver, which is a good indication of whether your liver is scarred.

Liver biopsy

During a liver biopsy a fine needle is inserted into your body (usually between your ribs).

A small sample of liver cells is taken and sent to a laboratory to be examined under a microscope.

The biopsy is usually carried out under local anaesthetic, either as a day case or with an overnight stay in hospital.

Your liver tissue will be examined to determine the degree of scarring in the liver and the cause of the damage.

Endoscopy

An endoscope is a long, thin, flexible tube with a light and a video camera at one end.

During an endoscopy, the instrument is passed down your oesophagus (the long tube that carries food from the throat to the stomach) and into your stomach.

Pictures of your oesophagus and stomach are transmitted to an external screen. The doctor will be looking for swollen veins (varices), which are a sign of cirrhosis.

Treatment

Successful treatment for alcohol-related liver disease (ARLD) often depends on whether someone is willing to stop drinking alcohol and make changes to their lifestyle.

Stopping drinking alcohol

Treatment for ARLD involves stopping drinking alcohol. This is known as abstinence, which can be vital, depending on what stage the condition is at.

If you have fatty liver disease, the damage may be reversed if you abstain from alcohol for a period of time (this could be months or years).

After this point, it's usually safe to start drinking again if you stick to the NHS guidelines on alcohol units. However, it's important to check with your doctor first..

If you have a more serious form of ARLD (alcoholic hepatitis or cirrhosis) lifelong abstinence is recommended.

This is because stopping drinking is the only way to prevent your liver damage getting worse and potentially stop you dying of liver disease.

Stopping drinking is not easy, especially as an estimated 70% of people with ARLD have an alcohol dependency problem.

Nevertheless, if you have alcohol-related cirrhosis or alcoholic hepatitis and don't stop drinking, no medical or surgical treatment can prevent liver failure.

Withdrawal symptoms

If you're abstaining from alcohol, you may suffer withdrawal symptoms.

These will be at their worst for the first 48 hours, but should start to improve as your body adjusts to being without alcohol. This usually takes 3 to 7 days from the time of your last drink.

Many people initially experience disturbed sleep when abstaining from alcohol, but in most cases their sleep pattern returns to normal within a month.

In some cases, you may be advised to reduce your alcohol intake in a gradual and planned way to help avoid withdrawal problems.

You may also be offered a medication called a benzodiazepine and psychological therapy, such as cognitive behavioural therapy (CBT), to help you through the withdrawal process.

Some people need to stay in hospital or a specialist rehabilitation clinic during the initial withdrawal phases so their progress can be closely monitored.

If you're staying at home, you'll regularly see a nurse or another health professional. You might see them at home, your GP surgery or a specialist NHS service.

Preventing relapses

Once you have stopped drinking, you may need further treatment to help ensure you do nott start drinking again.

The first treatment usually offered is psychological therapy. This involves seeing a therapist to talk about your thoughts and feelings, and how these affect your behaviour and wellbeing.

If psychological therapy alone isn't effective, you may also need medication to help you abstain from alcohol, such as:

• acamprosate
• naltrexone
• disulfiram

Find out more about treatment for alcohol misuse

Self-help groups

Many people with alcohol dependence find it useful to attend self-help groups to help them stop drinking.

One of the most well-known is Alcoholics Anonymous (see the AA website for details), but there are many other groups that can help.

Diet and nutrition

Malnutrition is common in people with ARLD, so it's important to eat a balanced diet to help ensure you get all the nutrients you need.

Avoiding salty foods and not adding salt to foods you eat can reduce your risk of developing swelling in your legs, feet and abdomen (tummy) caused by a build-up of fluid.

The damage to your liver can also mean it's unable to store glycogen, a carbohydrate that provides short-term energy.

When this happens, the body uses its own muscle tissue to provide energy between meals, which leads to muscle wasting and weakness. This means you may need extra energy and protein in your diet.

Healthy snacking between meals can top up your calories and protein. It may also be helpful to eat 3 or 4 small meals a day, rather than 1 or 2 large meals.

Your GP can advise you on a suitable diet or, in some cases, refer you to a dietitian.

In the most serious cases of malnutrition, nutrients may need to be provided through a feeding tube inserted through the nose and into the stomach.

Medicine for symptoms

The use of medicine to directly treat ARLD is controversial. Many experts have argued there's limited evidence for its effectiveness.

For people with severe alcoholic hepatitis, treatment in hospital may be necessary.

Specific treatment with corticosteroids may be used to reduce inflammation of the liver in some people with this condition.

Nutritional support is also an important part of treatment in these cases.

Liver transplants

In the most serious cases of ARLD, the liver loses its ability to function, leading to liver failure.

A liver transplant is currently the only way to cure irreversible liver failure.

A liver transplant may be considered if:

• you develop progressive liver failure, despite not drinking alcohol
• you're otherwise well enough to survive such an operation
• you commit to not drinking alcohol for the rest of your life

Taking medications with ARLD

If you have ARLD, it's important to talk to your GP or pharmacist before taking over-the-counter or prescription medicines

ARLD can affect the way the body processes some medicines.

Complications

A number of serious complications can develop if you have alcohol-related liver disease (ARLD).

Portal hypertension and varices

Portal hypertension is a common complication of cirrhosis and, less commonly, alcoholic hepatitis.

It occurs when the blood pressure inside your liver has risen to a potentially serious level.

When the liver becomes severely scarred, it's harder for blood to move through it. This leads to an increase in the pressure of blood around the intestines.

The blood must also find a new way to return to your heart. It does this by using smaller blood vessels.

But these vessels are not designed to carry the weight of blood, so they can become strecthed-out and weakened. These weakened blood vessels are known as varices.

If the blood pressure rises to a certain level, it can become too high for the varices to cope with, causing the walls of the varices to split and bleed.

This can cause long-term bleeding, which can lead to anaemia.

Alternatively, the bleeding can be rapid and massive, causing you to vomit blood and pass stools that are very dark or tar-like.

Split varices can be treated by using an endoscope to locate the varices. A tiny band can then be used to seal the base of the varices.

Ascites

A person with portal hypertension may also develop a build-up of fluid in their abdomen (tummy) and around the intestines. This fluid is known as ascites.

Initially, this can be treated with water tablets (diuretics). If the problem progresses, many litres of fluid can build up, which needs to be drained.

This is a procedure known as paracentesis and involves a long, thin tube being placed into the fluid through the skin under local anaesthetic.

One of the problems associated with the development of ascites is the risk of infection in the fluid (spontaneous bacterial peritonitis).

This is a potentially very serious complication and is linked to an increased risk of kidney failure and death.

Hepatic encephalopathy

One of the most important functions of the liver is to remove toxins from your blood.

If the liver is unable to do this due to hepatitis or cirrhosis, the levels of toxins in the blood increase.

A high level of toxins in the blood due to liver damage is known as hepatic encephalopathy.

Symptoms of hepatic encephalopathy include:

• agitation
• confusion
• disorientation
• muscle stiffness
• muscle tremors
• difficulty speaking
• in very serious cases, a coma

Hepatic encephalopathy may require hospital admission. In hospital, body functions are supported and medication is used to remove toxins from the blood.

Infection

Damage to the liver can weaken the immune system.

This can make the body more vulnerable to infection, particularly urinary infections and respiratory infections (such as pneumonia).

Liver cancer

Liver damage due to heavy drinking over many years can also increase your risk of developing liver cancer.

Over the past few decades, rates of liver cancer in the UK have risen sharply due to increased levels of alcohol misuse.

It's estimated that 3 to 5% of people with cirrhosis will develop liver cancer every year.