Alcoholic liver disease: symptoms, stages and treatment

Alcoholic liver disease is the older name for what the NHS now calls alcohol-related liver disease (ARLD): damage to the liver caused by drinking too much alcohol over months or years. NHS inform explains that each time your liver filters alcohol some liver cells die. The liver can grow new cells, but prolonged heavy drinking over many years can reduce its ability to regenerate, leading to serious and permanent damage.

NHS inform says ARLD is very common in the UK and that the number of people with the condition has been increasing over the last few decades, alongside rising levels of harmful drinking. It is frequently found during tests for another problem, or at an advanced stage, because it causes few obvious symptoms early on.

The NHS says ARLD does not always cause symptoms in the early stages. When early symptoms do appear they are often vague, and the NHS lists the following. NHS inform adds abdominal pain, diarrhoea and feeling generally unwell.

• Feeling very tired (fatigue).

• Feeling less hungry than usual.

• Losing weight without trying.

• Feeling or being sick.

• Pain or discomfort in the upper right side of the tummy.

As liver damage gets worse, the NHS says symptoms may include yellowing of the skin or whites of the eyes (jaundice, which can be harder to see on black or brown skin), a high temperature, swelling of the tummy from a build-up of fluid, swollen legs, shaking hands, blood in vomit or poo, and problems with confusion, concentration and memory.

NHS inform adds very itchy skin, hair loss, clubbed fingertips, blotchy red palms, muscle wasting, a tendency to bleed and bruise more easily, such as nosebleeds and bleeding gums, and increased sensitivity to alcohol and drugs because the liver cannot process them. Black, tarry stools or vomiting blood point to internal bleeding.

The NHS says ARLD develops over months or years of drinking too much alcohol and has 3 stages, depending on how serious the damage is. NHS inform notes that there is often overlap between stages. If you stop drinking, the liver can often recover, but the later stages are harder to treat and more likely to cause serious complications.

The NHS says the aim of treatment is usually to help you stop drinking alcohol completely, whatever stage of ARLD you have. Your GP or a specialist alcohol addiction service can help you reduce your drinking safely and offer support. NHS inform adds that there is currently no specific medical treatment for ARLD itself and that, for people with alcohol-related hepatitis or cirrhosis, lifelong abstinence is recommended.

Support can include talking therapies such as cognitive behavioural therapy (CBT), medicines to help you stop drinking safely or reduce cravings, and support groups such as Alcoholics Anonymous. NHS inform lists acamprosate, naltrexone and disulfiram as medicines used to help prevent relapse, usually after psychological therapy has been tried.

Stopping can be difficult. NHS inform estimates that around 70% of people with ARLD have an alcohol dependency problem. If your liver is badly damaged you may need treatment in hospital. For severe alcohol-related hepatitis, NHS inform says corticosteroids or pentoxifylline may be used in hospital to reduce liver inflammation in some people, alongside nutritional support.

The NHS warns that if you regularly drink too much alcohol it can be very dangerous to stop suddenly, and to get medical help before you try. NHS inform says withdrawal symptoms are at their worst in the first 48 hours and usually improve over 3 to 7 days from the last drink, and that many people have disturbed sleep that settles within a month.

The NHS alcohol-use disorder page says withdrawal symptoms begin within 6 to 12 hours of your last drink, and can include anxiety, sweating, shaking, a racing heartbeat, seeing or hearing things that are not there, confusion and seizures. Severe withdrawal symptoms, such as visible shaking, confusion, hallucinations or a seizure, need 999 or A&E. Some people are advised to reduce intake gradually, or to withdraw in hospital or a specialist clinic where progress can be monitored.

It depends on the stage. NHS inform says fatty liver is reversible, with the liver returning to normal after at least 2 weeks without alcohol, and that the liver damage of mild alcoholic hepatitis is usually reversible if you stop drinking permanently. Cirrhosis is generally not reversible, but stopping immediately can prevent further damage.

NHS inform is blunt about the alternative: a person with alcohol-related cirrhosis who does not stop drinking has a less than 50% chance of living for at least 5 more years, and if you have cirrhosis or alcoholic hepatitis and keep drinking, no medical or surgical treatment can prevent liver failure.

The NHS says ARLD is caused by regularly drinking too much alcohol, and that anyone can get it. NHS inform explains two routes: drinking a large amount in a short time (binge drinking) can cause fatty liver and, less commonly, alcoholic hepatitis, while drinking above the recommended limits over many years can cause hepatitis and cirrhosis.

The NHS says you are more likely to develop ARLD if you drink too much and you already have a liver condition such as hepatitis C, have diabetes (especially type 2), are overweight or obese, or have a family history of alcohol-related diseases and addiction. It adds that ARLD develops more quickly and at lower drinking levels in women than in men.

To keep health risks from alcohol low if you drink most weeks, the NHS advises not drinking more than 14 units a week on a regular basis, and spreading your drinking over 3 or more days if you regularly drink as much as 14 units. It says 14 units is equivalent to 6 pints of average-strength beer or 10 small glasses of lower-strength wine, and that several drink-free days each week can help you cut down.

Units are worked out by multiplying the strength (ABV) by the volume in millilitres and dividing by 1,000. Drinking less, or not at all, reduces your risk of ARLD and helps prevent serious liver damage.

The NHS says a doctor will ask about your drinking and how it is affecting your life, and may arrange tests to see whether alcohol is affecting your liver. NHS inform stresses the importance of being honest about how much and how often you drink, to avoid unnecessary testing and delay.

• Blood tests (liver function tests). NHS inform notes these can be normal at many stages of liver disease, and that low albumin or abnormal clotting can point to significant damage.

• Scans such as ultrasound, CT or MRI; some scans also measure liver stiffness, a good indicator of scarring.

• A liver biopsy, in which a small sample is taken with a fine needle, usually under local anaesthetic, to show the degree of scarring and the cause.

• An endoscopy to look for swollen veins (varices) in the gullet, a sign of cirrhosis.

The NHS says ARLD can be life-threatening and lists liver failure, fluid build-up in the tummy, internal bleeding, problems with confusion, concentration and memory, liver cancer and kidney damage as possible complications. NHS inform explains that severe scarring raises the pressure in the liver's blood vessels (portal hypertension), which can create fragile swollen veins called varices that may bleed, and can cause fluid to collect in the abdomen (ascites).

NHS inform says a liver transplant is currently the only way to cure irreversible liver failure. It may be considered if liver failure keeps progressing despite not drinking, you are otherwise well enough for the operation, and you commit to not drinking for the rest of your life.

NHS inform says malnutrition is common in people with ARLD, so a balanced diet is important. Avoiding salty food and not adding salt can reduce the risk of fluid swelling in the legs, feet and tummy. Because a damaged liver cannot store energy well, the body may break down muscle between meals, so some people need extra energy and protein, including healthy snacks and 3 or 4 small meals a day rather than 1 or 2 large ones.

Your GP can advise on a suitable diet or refer you to a dietitian. In the most serious cases, NHS inform says nutrients may need to be given through a feeding tube.

See a GP or an alcohol addiction support service if you have symptoms of liver disease, or you are worried about your drinking or want help to stop. The NHS says not to wait for symptoms to get worse.

Call 999 or go to A&E if you are worried alcohol may be affecting your liver and you vomit blood or your poo is black and looks sticky, you have pain in your tummy, you have difficulty breathing or shortness of breath, or you feel suddenly confused, dizzy or have difficulty staying awake. The NHS says not to drive yourself to A&E.

In the NHS, the usual first contact is your GP or a local alcohol support service, with referral to hepatology or gastroenterology teams for scans, biopsy, endoscopy and cirrhosis care. Alcohol services and charities such as Alcoholics Anonymous, Alcohol Change UK and SMART Recovery offer support, and the NHS lists Liver UK for information and support for people affected by liver disease.

Some people also choose a private hepatology or gastroenterology appointment for faster access to scans or specialist opinion. Whichever route you use, the tests, treatment principles and advice to stop drinking are the same, and results should be shared with your GP.