Alcohol-related liver disease is liver damage caused by drinking too much alcohol for a long time.
In general, the amount of alcohol consumed (how much, how often, and for how long) determines the risk and severity of liver damage.
Symptoms range from none at first to fever, jaundice, fatigue, and a tender, painful, and enlarged liver, then to more serious problems such as bleeding in the digestive tract and deterioration of brain function.
To help identify whether drinking is a problem, doctors may give the person a questionnaire, test for biomarkers that indicate a person’s alcohol intake, and ask family members how much the person drinks.
If people who have been drinking in excess have symptoms of liver disease, doctors do blood tests to evaluate the liver and occasionally do a liver biopsy.
The best treatment is to stop drinking alcohol, but doing so is very difficult and requires help, often in rehabilitation programs.
Approximately 11.3% of people age 18 and older are estimated to have had alcohol use disorder in the preceding year (see National Institute on Alcohol Abuse and Alcoholism: Alcohol Use Disorder (AUD) in the United States).
Most alcohol, after being absorbed in the digestive tract, is processed (metabolized) in the liver. As alcohol is processed, substances that can damage the liver are produced. The more alcohol a person drinks, the greater the damage to the liver. When alcohol damages the liver, the liver can continue to function for a while because the liver can sometimes recover from mild damage. Also, the liver can function normally even when about 80% of it is damaged. However, if people continue to drink alcohol, liver damage progresses and may eventually result in death. If people stop drinking, some damage may be reversed. Such people are likely to live longer.
Alcohol use disorder may cause three types of liver damage, which often develop in the following order (although a person can have more than one at the same time):
Accumulation of fat (fatty liver, or alcohol-associated hepatic steatosis): This type is the least serious and can sometimes be reversed. It occurs in more than 90% of people who drink too much alcohol.
Inflammation (alcoholic hepatitis): The liver becomes inflamed in about 10 to 35% of people.
Alcohol-associated cirrhosis: About 10 to 20% of people develop cirrhosis. In cirrhosis, a large amount of normal liver tissue is permanently replaced with scar tissue (called fibrosis), which performs no function. As a result, the internal structure of the liver is disrupted, and the liver can no longer function normally. Eventually, the liver usually shrinks. People may have a few symptoms or the same symptoms as those due to alcoholic hepatitis. Cirrhosis usually cannot be reversed.
Cirrhosis can cause the following serious complications:
Ascites: Fluid may accumulate in the abdomen, causing swelling.
Hepatic (portosystemic) encephalopathy: Brain function may deteriorate because the damaged liver is less able to remove toxic waste products from the blood. People may become drowsy and confused.
Portal hypertension: The vein that brings blood to the liver may be narrowed or blocked, increasing blood pressure in that vein. Portal hypertension causes or contributes to ascites, bleeding in the digestive tract, an enlarged spleen (splenomegaly), and sometimes portosystemic encephalopathy.
Bleeding in the digestive tract: Veins in the esophagus and stomach may enlarge and begin to bleed because of portal hypertension. People may vomit blood or have bloody or dark, tarry stools.
Liver failure: The liver becomes less and less able to function, resulting in many complications and generally failing health. Liver failure can eventually lead to kidney failure.
Bleeding disorder: People tend to bleed and bruise more easily because the damaged liver does not produce enough of the substances that make blood clot (coagulate). Also, alcohol can reduce the number or activity of platelets, which also help blood clot. Portal hypertension leads to an enlarged spleen, which also decreases the number of platelets.
Enlarged spleen: Portal hypertension causes the spleen to enlarge (a condition called splenomegaly). The enlarged spleen traps and destroys more white blood cells and platelets than it normally does. As a result, the risk of infections and bleeding is increased.
Risk Factors for Alcohol-Related Liver Disease
Alcohol-related liver disease is more likely to develop if people
Drink large amounts of alcohol
Have been drinking a long time
Are women
Have a genetic makeup that makes them susceptible to alcohol-related liver disease
Have obesity
Alcohol consumption
People can understand their risk of alcohol-related liver disease more precisely if they know how much alcohol they are drinking. To determine how much they are drinking, they need to know the alcohol content of alcoholic beverages. Different types of beverages contain different percentages of alcohol.
Beers: 2 to 7% in most
Wines: 10 to 15% in most
Hard liquors: 40 to 45% in most
However, in typical servings of these different types of beverages, the amount of alcohol is similar even though the amount of liquid is very different.
A 12-ounce can of beer: About 1/7 to 4/5 ounce
A 5-ounce glass of wine: About ⅔ to 1 ounce
A 1½-ounce shot (or typical mixed drink) of hard liquor: About ½ ounce
In hard liquor, the alcohol concentration is often described as proof. The proof is about twice the percentage of alcohol. For example, an 80-proof hard liquor contains 40% alcohol.
Moderate drinking is defined as one standard drink per day for women and two standard drinks per day for men (see Dietary Guidelines for Americans, 2020-2025). However, the World Health Organization (WHO) states that, when it comes to alcohol consumption, there is no safe amount that does not affect health (see WHO: No level of alcohol consumption is safe for our health).
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines heavy ("at-risk") drinking in males as more than 14 standard drinks per week, or more than 4 drinks per day, and in females as more than 7 standard drinks per week, or more than 3 drinks per day (see NIAAA: Drinking Levels Defined).
Generally, the more and the longer people drink, the greater their risk of alcohol-related liver disease. However, liver disease does not develop in every person who drinks heavily for a long time. Thus, other factors are involved.
Binge drinking may also increase the risk of alcohol-related liver disease. The NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration levels to 0.08 g/dL, which typically occurs after 4 drinks for women and 5 drinks for men, in about 2 hours (see NIAAA: Drinking Levels Defined). Each such drink is considered to be 12 ounces of 5% beer, 5 ounces of wine, or 1.5 ounces of hard (80-proof) liquor.
Sex
Women are more vulnerable to liver damage by alcohol, even after adjustments are made for smaller body size. Women are at risk of liver damage if they drink about half as much alcohol as men. That is, drinking more than ¾ to 1½ ounces of alcohol a day puts women at risk. Risk may be increased in women because their digestive system may be less able to process alcohol, thus increasing the amount of alcohol reaching the liver.
Genetic makeup
Genetic makeup is thought to be involved because alcohol-related liver disease often runs in families. Family members may share genes that make them less able to process alcohol.
Obesity
Obesity makes people more vulnerable to liver damage by alcohol.
Other factors
Accumulation of iron in the liver and hepatitis C also increase the risk of liver damage by alcohol.
Iron may accumulate when people have hemochromatosis (a hereditary disorder that results in absorption of too much iron) or when they drink fortified wines that contain iron. However, iron accumulation is not necessarily related to how much iron is consumed.
More than 25% of heavy drinkers also have hepatitis C, and the combination of heavy drinking and hepatitis C greatly increases the risk of cirrhosis.
If iron has accumulated in the liver or if people have had hepatitis C for more than 6 months, the risk of liver cancer (hepatocellular carcinoma) is increased.
Symptoms of Alcohol-Related Liver Disease
Heavy drinkers usually first develop symptoms during their 30s or 40s and tend to develop severe problems about 10 years after symptoms first appear.
Fatty liver often causes no symptoms. In one third of people, the liver is enlarged and smooth but is not usually tender.
As alcohol-related liver disease progresses to alcoholic hepatitis, symptoms may range from mild to life-threatening. People may have a fever, jaundice, and a tender, painful, enlarged liver. They may feel tired.
Heavy drinking can make the bands of fibrous tissue in the palms tighten, causing the fingers to curl (called Dupuytren contracture), and make the palms look red (called palmar erythema). Small spiderlike blood vessels (spider angiomas) may appear in the skin of the upper body. Salivary glands in the cheeks may enlarge, and muscles may waste away. Peripheral nerves (nerves outside the brain and spinal cord) may be damaged, causing loss of sensation and strength. The feet and hands are affected more than the upper legs and arms.
DR P. MARAZZI/SCIENCE PHOTO LIBRARY
Men who drink heavily may develop female characteristics, such as smooth skin, enlarged breasts, and decreased body hair. Their testes may shrink.
The pancreas may become inflamed (called pancreatitis), causing severe abdominal pain and vomiting.
People may become undernourished because drinking too much alcohol, which has calories but little nutritional value, decreases the appetite. Also, the damage caused by alcohol can interfere with the absorption and processing of nutrients. People may have deficiencies of folate, thiamin, other vitamins, or minerals. Deficiencies of certain minerals can cause weakness and shaking. Also, nutritional deficiencies probably cause or contribute to peripheral nerve damage.
In heavy drinkers, thiamin deficiency can lead to Wernicke encephalopathy, which can cause confusion, difficulty walking, and eye problems. If not promptly treated, Wernicke encephalopathy may result in Korsakoff syndrome, coma, or even death. Korsakoff syndrome causes memory loss and confusion.
Anemia may develop because bleeding occurs in the digestive tract or because people develop deficiencies of a nutrient needed to make red blood cells (certain vitamins or iron).
Symptoms may also result from the complications of cirrhosis (see Introduction, above).
After cirrhosis develops, the liver usually shrinks.
Liver cancer develops in 10 to 15% of people with cirrhosis due to alcohol abuse.
Diagnosis of Alcohol-Related Liver Disease
A doctor's evaluation of symptoms
History of heavy alcohol use
Alcohol biomarkers
Liver tests and complete blood count (CBC)
Sometimes liver biopsy
Doctors suspect alcohol-related liver disease in people who have symptoms of liver disease and who drink a substantial amount of alcohol.
Doctors may give the person a questionnaire to help identify whether drinking is a problem (see Screening for alcohol abuse). When the person's alcohol consumption is in doubt, it can be confirmed by family members or use of alcohol biomarkers.
There is no definitive test for alcohol-related liver disease. But if doctors suspect the diagnosis, they do blood tests to evaluate the liver (liver tests). A complete blood count to check for a low platelet count and anemia is also done.
Liver imaging tests are not routinely done. If ultrasonography or computed tomography is done for other reasons, doctors may see evidence of fatty liver or portal hypertension, an enlarged spleen, or accumulation of fluid in the abdomen.
A technique called ultrasound elastrography may be done to determine how stiff the liver is. A stiff liver indicates fibrosis. For this test, ultrasonography is done while pressure or vibration is applied to the liver. This test often makes a biopsy unnecessary.
Even if examination and test results suggest alcohol-related liver disease, doctors periodically check for other forms of liver disease that can be treated, especially viral hepatitis. Other causes of liver problems may coexist and, if present, must be treated.
Liver biopsy is sometimes done when the diagnosis is uncertain or when liver disease appears to have more than one cause. Liver biopsy can confirm liver disease, provide evidence that alcohol is the likely cause, and determine the type of liver damage present. It can also identity whether iron has accumulated in the liver. Such accumulation may indicate hemochromatosis.
If people have cirrhosis, tests for liver cancer are done periodically. They include ultrasonography and blood tests to measure levels of alpha-fetoprotein, which are high in about half the people with liver cancer.
Treatment of Alcohol-Related Liver Disease
Stopping drinking (abstinence) and assistance in doing so
Treatment of symptoms and complications
Treatments for liver damage
Stopping drinking (abstinence)
Abstinence is usually the best treatment. Other than liver transplantation, abstinence is the only treatment that can slow or reverse alcohol-related liver disease. In addition, it is available to all and has no side effects.
Because abstinence is difficult, several strategies are used to help motivate people and to help them change their behavior. Strategies include behavioral therapy and psychotherapy (talk therapy)—often as part of a formal rehabilitation program—as well as self-help and support groups (such as Alcoholics Anonymous) and counseling sessions with the primary care doctor. Therapies that explore and help people clarify why they want to abstain from alcohol (called motivational enhancement therapy) may also be used.
Medications
Medications are sometimes used but only to supplement behavioral and psychosocial therapies (see Detoxification and rehabilitation
Treatment of symptoms and complications
Doctors treat the problems caused by alcohol-related liver disease and the withdrawal symptoms that develop after people stop drinking.
A nutritious diet and vitamin supplements (especially B vitamins) are important during the first few days of abstinence. They can help correct nutritional deficiencies that can cause complications such as weakness, shaking, loss of sensation and strength, anemia, and Wernicke encephalopathy. Supplements can also improve general health. Often, if inflammation is severe, people are hospitalized and may need to be fed through a tube to receive adequate nutrition.
Benzodiazepines (sedatives) are used to treat withdrawal symptoms (see Emergency treatment). However, if alcohol-related liver disease is advanced, sedatives are used in small doses or avoided because they can trigger portosystemic encephalopathy.
Treatments for liver damage
Corticosteroids can help relieve severe liver inflammation and are safe to use if people do not have an infection, bleeding in the digestive tract, kidney failure, or pancreatitis.
Liver transplantation may be done if the damage is severe. Transplantation enables people to live longer. However, because about half the people start drinking again after transplantation, most transplantation programs require that people be abstinent for a period of time to qualify.
Prognosis for Alcohol-Related Liver Disease
The prognosis depends on how much fibrosis and inflammation are present.
If people stop drinking and no fibrosis is present, fatty liver and inflammation can be reversed. Fatty liver may completely resolve within 6 weeks. Fibrosis and cirrhosis often cannot be reversed.
Certain biopsy and blood test results can help doctors predict a person's prognosis better. Doctors can also use formulas and models (which combine various test results) to help predict prognosis.
Once cirrhosis and its complications (such as fluid accumulation in the abdomen and bleeding in the digestive tract) develop, the prognosis is worse. Only about half the people with these complications are still alive after 5 years. People who stop drinking tend to live longer than those who do not stop drinking.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Alcoholics Anonymous: An international fellowship of people with a drinking problem who rely on a 12-step program to support each other in overcoming the obsession to drink.
American Liver Foundation: Hosts community education programs that give an overview of all aspects of liver disease and wellness. Also provides support groups, information on finding a physician, and opportunities to participate in clinical trials.
Hazelden Betty Ford Foundation: Provider of outpatient and residential substance use and addiction recovery programs.
