Alcohol-Related Liver Disease

Key points

• Drinking alcohol is a common cause of liver disease in Australia 

• Any alcohol makes your liver work harder than normal 

• You don’t have to be getting drunk to cause liver damage 

• Regular heavy drinking can lead to alcohol-associated hepatitis, liver cirrhosis, and liver cancer 

• If you have liver cirrhosis, even if it isn’t caused by alcohol, you shouldn’t drink any alcohol at all 

• It doesn’t matter which type of alcohol you drink – any alcohol can cause damage 

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What is alcohol–related liver disease? 

Alcohol-related liver disease happens when your liver has been damaged by alcohol. When you drink alcohol, most of it is broken down and processed by the liver. As the liver breaks down alcohol, it releases a toxin called acetaldehyde which damages liver cells and leads to inflammation.  

A healthy liver can only process about 1 standard drink per hour, so as soon as you are drinking more than that the liver can’t keep up and damage will start to happen.  

There are 3 stages of alcohol-related liver disease: 

1. Alcohol-related fatty liver: When you have too much alcohol, fat builds up inside the liver cells, making it hard for the liver to keep working properly. This is the most common form of liver disease caused by alcohol and can happen early. Fat can start to build up in your liver even after just a few days of heavy drinking.  Even though you might not have any symptoms, if you keep drinking the damage will continue to get worse. Stopping drinking can reverse fatty liver that has been caused by alcohol. Alcohol related fatty liver is also called steatohepatitis. 

1. Alcohol-related hepatitis: Hepatitis means ‘inflammation’. This happens when your liver becomes swollen and inflamed, and healthy cells die. This inflammation can occur suddenly after binge drinking (acute alcohol-related hepatitis), or after a long time of regular heavy drinking (chronic alcoholic hepatitis). As with alcohol related fatty liver, this can lead to worsening disease and cirrhosis if you continue to drink alcohol. If you have alcohol-related hepatitis that has not progressed to cirrhosis, you can still stabilise and even reverse the damage that has been caused if you stop drinking. 
2. Alcohol-related cirrhosis: This is the most severe form of alcohol-related liver disease. It happens when the liver has become so scarred that it shrinks and becomes hard and lumpy. Once this happens, the liver can’t work properly anymore. This can lead to advanced liver disease and liver cancer (hepatocellular carcinoma, or HCC). Cirrhosis usually can’t be reversed. If you have cirrhosis, it is extremely important to stop drinking alcohol to try and prevent your liver disease getting worse. At this stage, your treatment will focus on preventing or managing complications of your cirrhosis. 

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What are the symptoms of alcohol–related liver disease? 

In the early stages, when you have alcohol-related fatty liver, you may have no symptoms or just feel a little more tired and unwell than normal. Often by the time you get severe symptoms, the disease has progressed to the point of hepatitis or cirrhosis. 

Symptoms can include: 

• Jaundice (yellow skin and whites of your eyes) 

• Oedema (swelling of the lower limbs) 

• Ascites (swelling in your belly because of extra fluid) 

• Itchy skin 

• Clubbing of the fingernails (where they curve excessively) 

• Spider naevi – small, red, spider-like marks that appear on the skin, especially on the face, neck, upper chest and arms 

• Muscle weakness 

• Fatigue (feeling very tired) 

• Nausea and vomiting 

• Vomiting blood, or blood in your stools (poo) 

• Bruising easily 

• Confusion and changes in behaviour 

• More infections and fevers 

A lot of these symptoms can be mild or caused by something else. 

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How is alcohol–related liver disease diagnosed? 

Alcohol-related liver disease may be first diagnosed when you have a blood test or visit your doctor for some of the symptoms listed above. Because you might not have symptoms yet, you might not even know that your alcohol intake is a problem. 

You will also have other blood tests to check how well your blood can clot (stop bleeding) as this is another indication of liver health or liver disease. 

You will probably have scans of your liver such as a Fibroscan and ultrasound. This will show if you have a fatty or scarred liver or if your liver looks even more damaged (cirrhosis). 

A liver biopsy may be done to get a definite diagnosis and to see exactly how damaged your liver is. 

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Why did I get alcohol–related liver disease? 

The major risk factor for developing alcohol-related liver disease is drinking too much alcohol. The more you regularly drink, or the more often you binge drink, the higher your risk of developing alcohol-related liver disease.  

Drinking anything above the Australian guidelines puts you at risk. That means no more than 10 standard drinks a week, and no more than 4 standard drinks on any one day. A standard drink varies depending on the type of alcohol – check the guidelines for more information. 

There are some other risk factors that can increase your chance of developing alcohol-related liver disease: 

• Being overweight or having obesity – if you are overweight or have obesity, your liver will already be storing extra fat which can lead to scarring. Heavy drinking on top of this will increase the amount of damage in your liver. 

• Poor eating (malnutrition) – if you are drinking a lot of alcohol, you might not be eating properly. Your body might also have trouble absorbing the nutrients it needs because your liver is having to work harder to process alcohol. The combination of alcohol and poor nutrition can speed up liver damage. 

• Genetics – not everyone who drinks heavily will develop alcohol-related liver disease. And some people who inherit certain genes may get liver disease at a lower level of drinking. How your body metabolises (breaks down) alcohol is influenced by your genes. If your body is missing certain enzymes (a type of protein), you may be at a higher risk of developing alcohol-related liver disease. 

• Demographics (where you live) – people who live in remote and very remote outer regional areas of Australia are more likely to drink above the recommended guidelines compared to people in major cities. People who live in lower socio-economic areas are also at risk of drinking above the recommended guidelines. 

• Being female – even though men drink at dangerous levels more than women, women are more at risk of developing alcohol related liver disease. 

• Having another liver disease – if you already have damage to your liver from another disease (such as hepatitis C), having alcohol will speed up the damage and make you sicker a lot more quickly. 
• Having a mental-health problem such as depression, anxiety or post-traumatic stress disorder may be associated with drinking too much alcohol and other health problems that predispose to liver disease. 

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How is alcohol–related liver disease treated? 

Depending on the stage of your disease, treatment is aimed at reversing the damage, stabilising your current liver health, or managing the complications of cirrhosis. 

• Stop drinking: The first and most important treatment for alcohol related liver disease is to stop drinking alcohol (alcohol abstinence).  Stopping all alcohol will reverse early damage. If you already have cirrhosis, stopping all alcohol will help to keep your health as stable as possible. Stopping drinking may be really difficult and you may need specialised support.
  

  If you have been diagnosed with alcohol related liver disease, even one drink is too much. 

• Improve nutrition: People with alcohol-related liver disease will often have poor nutrition. They might need a special diet and some vitamins and supplements may be required. In the early stage (fatty liver), your focus should be on a healthy, balanced diet like the Fatty Liver Diet, avoiding processed foods and avoiding extra sugars, salts and unhealthy fats as much as possible. If you have alcohol-related hepatitis or cirrhosis, your nutrition needs will change, as your body will need much more protein and energy as it works hard to process and use nutrients. You may need to have supplement drinks to make sure you are getting all the nutrition you need. You may see a specialised dietician to help you manage your diet. 
• Medications: You may need to take medications to help manage the symptoms of alcohol-related liver disease. Which medications you need depends how severe your disease is. Some medications are used to treat withdrawal from alcohol and to control cravings to help you stop drinking alcohol. Others are needed for acute alcohol-associated hepatitis or the complications of cirrhosis. If you have acute alcohol-related hepatitis, you will likely be admitted to hospital as you will be very unwell. You may be given steroid medications to try to reduce the inflammation in your liver. There can be side effects associated with steroids which your doctor would discuss with you.  
• Counselling: Having counselling to help you stop drinking, remain abstinent and adjust to your new lifestyle and health concerns is a critical part of treatment for alcohol-related liver disease. This may be done through a formal drug and alcohol service at a hospital, with your GP or through community-based support groups. 
• Liver transplant: If you have cirrhosis due to your alcohol use, and you have complications that can’t be managed with medications and other treatments anymore, you may be referred for consideration of a liver transplant. An extensive evaluation process is undertaken for anyone being considered for transplant and not all people who are referred will proceed to transplant for a range of reasons. There are strict guidelines about who is eligible for liver transplant. To be eligible, you will have a thorough addiction assessment and will need to be assessed as low risk of returning to alcohol use after liver transplant. Most people will be followed for a period of time (not less than six months) to see if the liver function recovers just by stopping drinking and with good nutritional support.  Referral to a drug and alcohol support service is recommended. You may have random alcohol tests while you are waiting for a liver transplant. This is usually a regular blood test, that is done to ensure that you haven’t started drinking again.  

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Living with alcohol–related liver disease 

If you have been diagnosed with alcohol-related liver disease, you can still live well and have a healthy lifestyle by following the advice of your medical team. 

• Vaccinations: If your liver is not working properly, you are at increased risk of infection. You should be vaccinated against hepatitis B and hepatitis A, have a flu shot every year, and keep up to date with COVID vaccines. 

• Diet: Good nutrition is key to helping your body stay healthy and your liver recover if you have early stage disease.  

• Exercise: Exercise is good for everyone, but especially if you have liver disease. Exercise can help to maintain muscle mass, which can be decreased in liver disease. It can also help you to lose weight if you are overweight or obese, which will help to decrease the amount of fat being stored in your liver. Exercise can also have benefits to your mental health and is a great thing to do with family and friends to keep up your social supports.  

• Remain alcohol free: Even if you have early stage alcohol-related liver disease, not drinking alcohol again is the safest way to make sure that you don’t do any more damage to your liver. There are many non-alcoholic alternatives available in social situations. Involving your support network in helping you to remain alcohol free can be really helpful. 

• Monitoring: if you have cirrhosis caused by alcohol-related liver disease, it’s important you are having regular surveillance to assess for liver failure and liver cancer. You should be having a review, bloods and ultrasound every 6 months, to assess for any other complications associated with cirrhosis. 

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More information and support 

There are many support networks in Australia if you are trying to stop drinking or remain alcohol free. 

• Liver Foundation Nurse Led Support Line 1800 841 118 
• Alcoholics Anonymous 1300 222 222
• Alcohol and Drug Foundation 
• National Alcohol and Other Drug Hotline 1800 250 015 
• Hello Sunday Morning (a website aimed to help with decreasing alcohol intake and remaining sober. With tips, personal stories and programs to follow this is a great website for you and your support network to delve into. There is an app available through Hello Sunday Morning called Daybreak. This has been developed to help you track and change your relationship with alcohol. This Australian built app offers non-judgemental peer support, personal improvement activities and is completely anonymous)
• Sober in the Country (a national charity supporting rural communities to decrease or stop alcohol use)
• SMART Recovery (an evidence based recovery method grounded in Cognitive Behavioural Therapy that supports people with substance dependencies to live a balanced life)
• Lifeline Australia (24-hour crisis counselling, support groups and suicide prevention services) 13 11 14 or text 0477 13 11 14