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Alcoholic Liver Disease (ALD

Overview

Alcoholic liver disease (ALD) or alcohol-related liver disease is an umbrella term for a group of liver diseases caused due to excessive alcohol consumption over time. ALD is a progressive condition and individuals with early ALD may be asymptomatic (not outwardly show any symptoms), with simple steatosis (fat accumulation in liver also known as alcoholic fatty liver disease) or alcoholic steatohepatitis (an advanced stage of alcoholic steatosis associated with inflammation and cell damage) and early-stage fibrosis (reversible accumulation of collagen in the liver), while patients with advanced ALD may have advanced fibrosis (irreversible, widespread fibrosis), which can cause cirrhosis and associated complications (hepatocellular carcinoma), alcohol-associated hepatitis with jaundice, portal hypertension, and/or acute-on-chronic liver failure. Thus, ALD includes a range of conditions, including alcoholic fatty liver disease (alcoholic steatosis), alcoholic steatohepatitis, fibrosis, portal vein hypertension, alcohol-associated hepatitis, cirrhosis, liver failure, and hepatocellular carcinoma.

Excess and prolonged consumption of alcohol is the primary cause of ALD. The liver breaks down alcohol into smaller molecules, leading to detoxification but drinking too much alcohol over a prolonged duration can overwhelm this ability, leading to the development of ALD.

  • Heavy drinking
  • Genetic factors  
  • Nutritional deficiencies: Alcohol interferes with the absorption of essential nutrients, a phenomenon that can contribute to liver disease.
  • Coexisting conditions: Pre-existing conditions, like metabolic syndrome, viral hepatitis, or obesity, can increase the risk of developing ALD.

Symptoms may vary depending on disease severity. Common symptoms have been enumerated below:

  • Fatty liver (alcoholic steatosis)  
  • Slight discomfort in the upper abdomen.
  • Jaundice
  • Swelling of the lower limbs (oedema)
  • Fluid buildup in the abdomen (ascites)
  • Itchy skin
  • Fever and shivering
  • Excessively curved fingernails
  • Muscle weakness
  • Blood in vomit or stools
  • Easy bleeding and bruising  
  • More sensitive reactions to alcohol or drugs
  • High blood pressure in the liver (portal hypertension)
  • Bleeding from veins in the oesophagus (oesophageal varices)
  • Confusion and behavioural changes (hepatic encephalopathy)
  • Enlarged spleen

One of the first steps in the diagnosis of ALD involves going through an individual’s medical history (alcohol consumption patterns, including the quantity and frequency of drinking). The other steps include:

  • Physical examination
  • Laboratory tests: Several blood tests help assess liver function and detect ALD-associated damage.
    • Liver function tests (LFTs):
      1. ALT and AST: High ALT and AST values indicate liver damage. Further, in case of liver damage, AST values are generally higher than ALT values.
      2. ALP and GGT: Increased ALP and GGT values can indicate liver damage or biliary obstruction.
      3. Bilirubin: High levels of bilirubin may indicate liver dysfunction that can lead to jaundice.
      4. CBC: A low platelet count or anaemia in a complete blood count test can suggest liver damage.
      5. Coagulation studies (PT, INR): The liver produces clotting factors, so a longer blood clotting time (i.e., prolonged PT (prothrombin time) or elevated INR (international normalized ratio)) indicates liver dysfunction.
      6. Serum albumin: Low albumin levels can be a sign of chronic liver disease.
      7. Ammonia level: Elevated levels of ammonia may indicate hepatic encephalopathy, a severe complication of advanced liver disease.
  • Imaging studies:
    • Ultrasound
    • CT and MRI
    • Elastography (FibroScan)
    • Magnetic resonance elastography (MRE)
  • Liver biopsy: In some cases, a liver biopsy—removing a small piece of liver tissue for examination under a microscope—may be used to assess the degree of liver damage. It helps determine the extent of liver inflammation, presence of fat in the liver (steatosis), the degree of fibrosis or scarring (cirrhosis), and whether alcohol is responsible for the damage observed.
  • Exclusion of other liver diseases: As the symptoms of ALD can overlap with those of liver disease arising from other causes (e.g., viral hepatitis, fatty liver disease unrelated to alcohol, or autoimmune liver diseases), doctors may conduct additional tests to rule out other conditions:
    • Hepatitis B and C tests: To rule out viral hepatitis as the cause of liver disease.
    • Autoimmune markers: To rule out autoimmune hepatitis.
    • Iron tests: To exclude hemochromatosis (excess iron accumulation in the liver).
    • Alpha-1 antitrypsin deficiency test: To rule out genetic liver diseases.

Once ALD is diagnosed, the severity of liver damage is assessed. This is typically done through:

  • MELD score: Used to determine the severity of cirrhosis and predict survival by considering bilirubin levels, creatinine levels, and INR.
  • Child‒Pugh score: Used to determine the prognosis of liver disease (prediction of the likely disease course, including the probability of recovery/recurrence), particularly cirrhosis, by looking at factors, like serum albumin and bilirubin levels, encephalopathy, and ascites.

The most important step in managing ALD is to completely stop drinking alcohol (abstinence), which may stop the progression of liver damage and, in some cases, allow the liver to heal; however, a drastic decrease in alcohol consumption can result in severe withdrawal symptoms, for which medicine may be prescribed. Other strategies include:

  • Nutritional support: Individuals with ALD often suffer from malnutrition and deficiencies. A balanced diet with vitamin supplementation (especially B vitamins) is therefore crucial for recovery.
  • Liver transplantation: A liver transplant may be necessary in cases of advanced ALD. However, it is generally only considered for people who have stopped drinking for at least six months.
  • Management of complications: This may include:
    • Diuretics: To counter fluid buildup.
    • Lactulose: To prevent encephalopathy.
    • Endoscopic treatments: For variceal bleeding.
    • Medications: For managing complications, like infections, bleeding, or ascites (fluid accumulation).

Preventing ALD involves reducing or eliminating alcohol consumption and taking steps to protect liver health. 

  • Limiting the alcohol intake: Adhering to recommended guidelines for alcohol consumption can significantly reduce the risk of developing ALD.
  • Maintaining a healthy diet: A balanced diet and regular exercise are necessary for maintaining liver health and prevent malnutrition, which is common in ALD.
  • Early intervention: Regular check-ups and liver function tests for high-risk individuals (e.g., individuals with heavy drinking habits) can help detect liver damage early, thereby improving the chances of recovery.
  • Vaccinations: For individuals with ALD, vaccination against hepatitis A and B is recommended as infections can further harm the liver.
  • Avoiding other liver toxins: Limiting the use of over-the-counter medications like acetaminophen (which can be toxic to the liver) and avoiding exposure to harmful chemicals can help protect the liver.
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