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1. Alcoholic fatty liver (ALFD): here, excess fat gets accumulated in the liver cells. This is the first stage of alcohol-induced liver disease which can be reversed by complete alcohol avoidance. This stage can develop with only 2 weeks of heavy drinking and is eventually seen developing in 90% of chronic heavy drinkers.2. Alcoholic hepatitis: in this stage, the liver cells get inflamed and swollen. In mild or early form, this condition is reversible and can be corrected with proper treatment. However, when this stage becomes severe, it may lead to liver failure and many times even death, in about 30% to 60% of people. It is found that about 10% to 20% of chronic heavy drinkers develop alcoholic hepatitis or more advanced cirrhosis.
3. Alcoholic cirrhosis: the last stage, where liver cells get damaged and fibrosed due to prolonged exposure to alcohol. This stage is irreversible with low survival rates of approximately 23% estimated for 5 years period and 7% for 10 years period. Many of the cases of cirrhosis especially, complicated ones require a liver transplant for survival.
Abstinence from alcohol is essential for treating ALD and helps at any stage of the disease. It works by halting the progression of the disease and by reducing the risk of developing complications. First of all lets have a look at signs and symptoms of alcoholic liver disease then we will move ahead to know about complications of ALD.
As discussed, ALD comprises of various liver conditions which range from mild to severe which can present with the following signs and symptoms of alcoholic liver disease:
1. Alcoholic fatty liver (ALFD): typically these people look healthy and don’t have any symptoms of alcoholic liver disease. They are usually diagnosed only on imaging such as ultrasound.
2. Alcoholic hepatitis: these people are usually unwell and have significant symptoms such as :
– Jaundice: where skin and white of the eyes become yellow in color.
– Fever- low grade
– Nausea and vomiting
– Pain in the upper abdomen on the right side
– Loss of appetite
– Weight loss and malnourishment
A case of alcoholic hepatitis may complicate and result into the accumulation of fluid in the abdomen (ascites), bleeding in the gut or hepatic encephalopathy (where the disease affects the brain causing confusion, lack of concentration, etc.)
3. Alcoholic cirrhosis: about half of the people in the early stages of cirrhosis (compensated cirrhosis) may have no signs and symptoms of alcoholic liver disease at all. The rest of the half may have a loss of appetite, weight loss, weakness, and fatigue. Eventually, these people tend to develop complications with following symptoms called decompensated cirrhosis:
– GI bleeding: bleeding in the alimentary tract resulting in black colored stools, bloody vomiting, and breathlessness on exertion (due to blood loss).
– Fluid accumulation in abdomen: called ascites, results in bloating of abdomen, discomfort, and breathlessness due to increased pressure in the abdomen.
– Hepatic encephalopathy: accumulation of toxins affects the brain causing decreased concentration, confusion, sleep issues, etc.
Complications of alcoholic liver disease occur due to damage and fibrosis of the liver cells. This in turn reduces the functioning of the liver, increases blood pressure within the liver (portal hypertension), and causes accumulation of the toxins in the body. After the signs and symptoms of alcoholic liver disease the complications are as follows:
• Dilation and bleeding of varices: increased pressure in the blood vessels of the liver (portal hypertension) results in back pressure in the vessels around the food pipe and stomach. These vessels dilate and when significant pressure develops inside them they bleed resulting in blood loss. These dilated vessels develop in about 50% of the people with cirrhosis and approx. 10% to 30% of people with varices eventually bleed.
• Ascites: increased pressure within the blood vessels of the liver causes fluid to accumulate with the abdomen. Ascites develops in about 30% of uncomplicated cirrhosis within 5 years. This can result in abdominal distention, hernia, difficulty in breathing, and discomfort.
• Hepatic encephalopathy: decreased functioning of the liver reduces its ability to remove toxins. This results in the accumulation of toxins which causes serious effects on the brain. This results in confusion, lack of orientation and concentration or sleep issues, etc. It is found to develop in about 20% of people with cirrhosis.
• Kidney failure: diseased liver can affect the blood flow to the kidneys which in turn damages the kidney.
The course of the disease and how it affects a person depends on the type of the disease. As we have talked about signs and symptoms of alcoholic liver disease you should also know about the expected course of ALD.
• Simple fatty liver can be completely reversed by just abstinence of alcohol in a matter of 4 to 6 weeks. Only about 5 to 10% of fatty liver cases further progress to fibrosis and cirrhosis even after abstinence.
• About 10 to 20% of chronic heavy drinkers eventually develop an advanced liver disease such as hepatitis or cirrhosis
• Acute alcoholic hepatitis can cause death in about 30% to 60% of people.
• Alcoholic cirrhosis has very low survival rates, where only about 23% of people live for 5 years and about 7% of people live for 10 years.
Now you already know about the signs and symptoms of Alcoholic liver disease learn about the causes of ALD. As the name indicates, the cause of the alcoholic liver disease is the excessive consumption of alcohol.
Excessive alcohol consumption is defined as
• Binge drinking, where a male consumes more than 5 drinks, and a female consumes more than 4 drinks at a single sitting on at least 1 day in the past month.
It is estimated that daily consumption of more than 3 to 5 drinks of alcohol in males and more than 1 and a half to 3 drinks in females for a period of 10 to 12 years is typically responsible for developing alcoholic liver disease.
However, no limit of alcohol is considered safe and a person should avoid consuming alcohol to prevent developing liver disease and any other condition elsewhere in the body.
The above values of the number of drinks consumed are according to US standards where a standard drink consists of 14 grams of alcohol. The reference values for the standard drink of various alcoholic beverages are given:
Beer: about 350 ml of beer having 5% alcohol content
Wine: about 150 ml of wine having 12% alcohol content
Distilled spirits: 45 ml distilled spirits such as whiskey, scotch, rum, tequila, vodka, and others having 40% alcohol content.
You have learned about signs and symptoms of Alcoholic liver disease above, basically, Alcohol causes the development of the alcoholic liver disease by multiple mechanisms given below:
Fat accumulation: alcohol causes accumulation of the fat in the liver by affecting fat metabolism which prevents the conversion of fat into glucose.
Free radical generation: chronic alcohol consumption causes the generation of free radicals which causes inflammation and liver cell damage subsequently inducing fibrosis and scarring.
Lack of antioxidants: chronic alcoholics are found to have deficiency of antioxidants such as vitamin E and glutathione which destroys free radicals protecting liver cells from damage.
It is estimated that about 200 crore people in the world (more than 25% of the world population) drink alcohol, out of which more than 7.5 crore people have alcohol use disorders.
Every year about 20 lakh deaths occur due to alcoholic liver diseases, out of which 10 lakh deaths occur due to cirrhosis.
In India, alcohol is found as the commonest cause of cirrhosis, accounting for more than 1/3rd of the cases.
However, the rate of liver transplantation which is considered as the treatment of choice for complicated cirrhosis is less than 10% of the global requirement.
After the complications, causes and symptoms of alcoholic liver disease the diagnostic workup of ALD involves the following:
I. Medical history: the first and the critical step of ALD workup. Your doctor would take a thorough clinical history especially emphasizing your alcohol intake. The doctor would ask about the quantity and duration of alcohol intake. If there is an excessive intake of alcohol (more than 3 drinks in men and more than 2 drinks in women) for a prolonged period, he would consider you at high risk for developing ALD. He would order lab tests and imaging to evaluate you accordingly. Thus, it of the utmost importance for you to give correct information and get yourself evaluated properly.
Doctors may also use a screening tool to identify people with alcohol abuse. One of the commonly used tools for this purpose is the AUDIT (Alcohol Use Disorders Inventory Test).
Find out your AUDIT score to know if you have alcohol dependence or you abuse alcohol Score above 8 is considered suggestive of alcohol abuse/dependence.
II. General tests: Following tests are advised in people for diagnosing alcoholic liver disease:
1. Blood tests: LFT including AST, ALT, GGT, and bilirubin is done in all. Serum albumin, Prothrombin/INR, and CBC with platelet count are especially required in advanced cases of fibrosis or cirrhosis.
2. Ultrasound abdomen: is done to look for any abnormality in the appearance of the liver which may indicate changes of ALD, such as fatty liver or cirrhosis. There are some cases of cirrhosis, ones with mild changes in structure that can not be picked by simple ultrasound and may need to be evaluated with CT or MRI.
3. Doppler abdomen: can be done to look for increased blood pressure within the liver vessels (portal hypertension).
4. Fibroscan/ Elastography is also done which uses an ultrasound machine to detect and grade fibrosis. Fibrosis which suggests liver damage can only be detected by this test or a more invasive test called a liver biopsy.
III. Additional tests: If the above tests suggest or raise a doubt of the liver disease, the following tests might be done to rule out other diseases:
1. Hepatitis B & C serology: to rule out viral infections of the liver with tests such as HBsAg, Anti-HBc IgG, and Anti-HCV.
2. Autoimmune markers: to test for autoimmune hepatitis using following tests, ANA (antinuclear antibody), ASMA (anti-smooth muscle antibody), Anti-LKM-1 (anti-liver/kidney microsomal-1) antibodies and total IgG or γ-globulin level.
3. Transferrin and transferrin saturation to rule out hemochromatosis.
4. Alpha1-antitrypsin level to rule out its deficiency.
5. Ceruloplasmin level to test for Wilson’s disease.
IV. Liver biopsy is usually not done except for the following cases:
1. Severe cases of alcoholic hepatitis presenting with sudden onset of fever, jaundice, abdominal pain, etc.
2. Atypical cases
3. To determine the severity of the disease
If you ever found the signs and symptoms of alcoholic liver disease then just follow the treatment of alcoholic liver disease consists of abstinence of alcohol, supportive treatment, medicines, and if required liver transplant.
• Quitting alcohol at any stage of the disease can reduce the risk of progression of the disease and the development of complications.
Amount of alcohol consumed: is considered a major risk factor. There is no absolute threshold limit. However, it is estimated that daily consumption of more than 3 to 5 drinks of alcohol in males and more than 1 and a half to 3 drinks in females for a period of 10 to 12 years is typically responsible for developing alcoholic liver disease.
Co-existing liver disease: such as hepatitis B or hepatitis C can increase the chances of developing liver damage and cirrhosis. Hepatitis C along with heavy alcohol consumption increases the chances of cirrhosis by 100 times.
Obesity: increases the risk of developing alcoholic liver disease. 5 The risk of developing cirrhosis in heavy drinkers is double who has been overweight for at least 10 years.
Cigarette smoking: increases the risk of developing advanced liver disease and hepatocellular carcinoma.
Vitamin deficiencies such as vitamin B (thiamine, pyridoxine), Folic acid etc, can increase the risk of development of ALD in heavy drinkers.
Age: Alcoholic hepatitis usually presents between 40 to 50 years of age.
Sex: Females are at a higher risk of developing ALD than men when they consume the same amount of alcohol. This is due to a higher fat percentage in the body of females and lower activity of an enzyme (alcohol dehydrogenase)in the stomach which breaks down the alcohol.
Genetic factors: Certain genetic changes are considered to be responsible for predisposing a person to alcohol use disorder and in developing alcoholic liver disease.
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