Alcoholic Liver Disease

Alcoholic liver disease

Excessive alcohol consumption over a long period of time leads to a wide range of liver damage. They range from fatty liver (steatosis hepatis) to the intermediate stage of liver inflammation (alcoholic steatohepatitis - ASH) to liver cirrhosis and life-threatening hepatic coma. Alcohol tolerance depends on many factors and is therefore individually different.

In healthy women, a daily consumption of twelve grams of alcohol - which corresponds to about an eighth of wine or a quarter of a liter of beer - is considered to be low-risk. Healthy men can usually tolerate double the amount. Most of the time, the liver-damaging effect of alcohol in women begins with frequent consumption of over 20 grams and in men over 40 grams per day. However, liver damage can also occur below this limit.

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What are the causes of alcoholic liver disease?

All alcohol-related diseases of the liver are caused by the toxic (poisonous) effects of alcohol (ethanol) and its breakdown products acetaldehyde and acetate on the liver tissue. At the beginning a fatty liver develops. More pronounced damage leads to alcoholic hepatitis and ultimately to liver cirrhosis.

In addition to the amount of alcohol consumed and the duration of alcohol consumption, other factors influence the severity of alcoholic liver damage:

• Diet (e.g. intake of large amounts of unsaturated fatty acids, fructose or a lack of protein);
• Potentially liver-damaging drugs (e.g. paracetamol, some antibiotics);
• Gender: Women are much more at risk than men because of the lower content of a special enzyme in their gastric mucosa and liver (alcohol dehydrogenase). Because of this relative enzyme deficiency, women cannot metabolize alcohol as quickly as men;
• Additional diseases: including heart failure, iron deposition in the liver (hemochromatosis or iron storage disease) and hepatitis B, C and D;
• various hereditary factors.

Alcoholic fatty liver (steatosis hepatis)

Fat droplets are deposited in the liver cells and the mitochondria (power plants of the cell) are damaged.

Alcoholic hepatitis (steatohepatitis)

It is a combination of fatty liver and liver inflammation. The liver swells, liver cells are destroyed and connective tissue begins to form (fibrosis). Alcoholic hepatitis can lead to a decrease in blood flow to the liver. This creates high pressure in the portal vein (portal hypertension).

Cirrhosis of the liver

In this advanced liver disease, the normal liver architecture is destroyed by pronounced connective tissue conversion of liver tissue into connective tissue (fibrosis). Nodules form and ultimately shrinkage of the liver.

In the advanced stage of liver cirrhosis, the liver can no longer compensate for the functional restrictions and can therefore no longer perform its tasks. So-called decompensated cirrhosis of the liver develops. This can be associated with serious complications. Portal hypertension develops very early in cirrhosis of the liver. In the further course, liver cell carcinoma can also develop.

What are the symptoms?

The symptoms depend heavily on the stage and severity of the disease. Most alcoholics do not suffer from liver damage until they are 30 years old. Severe liver damage is often found in this group of patients after the age of 40.

Liver size and tenderness

Even with fatty liver the size of the liver increases (hepatomegaly) and the liver becomes sensitive to pressure. Hepatitis is also characterized by enlargement and tenderness of the liver. In cirrhosis, the liver becomes smaller again and feels hard when you feel it over the abdominal wall. In the case of advanced liver cirrhosis, the liver can often no longer be felt due to the large size of the organ.

Alcohol hepatitis

A mild course of alcoholic hepatitis is characterized by increased fatigue, nausea and pain in the right upper abdomen. Jaundice (jaundice) and fever may also occur, and an enlarged spleen (splenomegaly) and weight loss may occur. If the disease is severe, jaundice, ascites, low blood sugar (hypoglycemia) and disorders of the electrolyte balance (sodium, potassium, chloride), blood coagulation and brain function (hepatic encephalopathy) occur. The mortality rate in severe cases is high.

Cirrhosis of the liver

Portal hypertension often occurs with the consequences of varicose veins in the esophagus (esophageal varices) and in the stomach, which can rupture and lead to life-threatening bleeding. Vomiting of red or coagulated black (coffee grounds-like) blood is just as possible as pitch-black stools (so-called tar stools caused by digested blood). Increased shimmering through of enlarged veins or varicose veins in the navel area (caput medusae) can also be seen on the abdominal wall. In addition, ascites and dysfunction of the central nervous system (hepatic encephalopathy) can occur. In addition, the body hair on the abdominal wall decreases. Small spider-shaped spider veins (Spider naevi) form on the skin and the skin on the palms of the hands is reddened. Among other things, there are also disorders of kidney function (hepatorenal syndrome) and lung function (hepatopulmonary syndrome).

How is the diagnosis made?

If there are indications of liver damage (e.g. increased liver function parameters in the blood), the doctor asks the patient about his / her drinking habits. Often this question is not answered sincerely by those affected, partly out of shame. From a consumption of over 20 grams (women) or 40 grams (men) of alcohol, this can be considered as a cause or at least as an additional burden in another liver disease. In patients with a daily consumption of more than 80 grams of pure alcohol, this alcohol is assumed to be the cause of the liver disease. However, other possible causes are always checked. If there is a known abuse of alcohol, the function of the liver is checked regularly.

The blood findings can show increases in transaminases (GOT, GPT) and γ-GT, but also decreases in vitamin B1, vitamin B6 and folic acid. The blood count may show reductions in white and red blood cells and platelets. The coagulation parameters (Quick value, INR) can be changed. An increase in the so-called CDT (R) - Carbohydrate Deficient Transferrin rel. - speaks in favor of long-term excessive alcohol consumption. However, this value can sometimes be within the normal range despite heavy alcohol consumption.

Radiological findings such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) of the upper abdomen can indicate fatty liver, lump formation, or ascites. A special examination of the elasticity of the liver tissue using ultrasound (elastography) can be used to check whether there is cirrhosis of the liver. A tissue sample can be taken from the liver (biopsy) for an accurate assessment of the liver tissue.

A gastroscopy can identify esophageal and gastric varices. In addition, stool samples can be used to search for invisible blood from bleeding in the gastrointestinal tract (haemoccult).

How is alcoholic liver disease treated?

The main pillar in the treatment is the renouncement of alcohol (alcohol abstinence). As a result, fatty liver disease can completely regress within a few weeks in the case of alcoholic liver disease. Alcoholic fatty liver hepatitis and the onset of cirrhosis can sometimes also regress. In advanced cirrhosis of the liver, abstaining from alcohol can often delay further connective tissue transformation of liver tissue. It may also lead to a partial regression of the connective tissue remodeling. This can lead to an improvement in the symptoms or an extension of the lifespan.

Supportive measures include, for example, a healthy diet, an adequate supply of vitamins and trace elements and, in the case of withdrawal symptoms, the administration of medication to calm down and relieve mental stress.

A clear therapeutic success could not be proven for the antioxidants silymarin (milk thistle), vitamin A, vitamin E, S-adenosyl-l-methionine.

Corticosteroids may have beneficial effects in severe alcoholic hepatitis. The circulation-enhancing drug pentoxyphylline may lower the risk of a fatal course of alcoholic hepatitis.

For more information, see Treatment of Liver Cirrhosis.

A liver transplant may be necessary in the advanced stages of alcoholic hepatitis and liver cirrhosis. Organ transplants are very valuable. Therefore, preference is given to those affected who are likely to be able to maintain a permanent abstinence from alcohol to protect the transplanted liver. In some transplant centers, a six-month period of abstinence is required before a transplant. In other centers there is no stipulation of the duration of alcohol abstinence (abstinence from alcohol) before the transplant. Instead, the procedure is decided by doctors together with psychologists, who examine and care for affected patients in detail.

Whom can I ask?

If you have symptoms of liver disease, you should seek medical help immediately. You can contact a doctor for general medicine or a specialist for internal medicine (internist). Internists specializing in gastroenterology and hepatology specialize in liver diseases.

If you want to reduce your alcohol consumption, a consultation with your general practitioner can help you. If necessary, he or she can refer you to a specialist in psychiatry or a psychotherapist or a clinical psychologist.

Support groups such as Alcoholics Anonymous can have a significant influence on the motivation to abstain from alcohol.

Note vomiting blood (red or black) is an emergency! Life-threatening blood loss can quickly occur. An emergency doctor must therefore be called immediately (EU: 112, Austria: 144). Blood in the stool (red or black stool) should also be checked by a doctor immediately.

How are the costs going to be covered?

All necessary and appropriate diagnostic and therapeutic measures are taken over by the health insurance carriers. Your doctor will generally settle accounts directly with your health insurance provider. With certain health insurance providers, however, you may have to pay a deductible (treatment contribution) (e.g. BVAEB, SVS, SVS, BVAEB). However, you can also use a doctor of your choice (ie doctor without a health insurance contract). For more information, see Costs and Deductibles.

For certain examinations, approval from the responsible health insurance company (medical service - "chief physician") may be required, as well as for certain medicinal or non-medicinal treatments, in some cases only when the disease has reached a certain extent. In the case of certain services (e.g. inpatient stays, medical aids and medical aids) - depending on the health insurance provider - patient co-payments are provided. Most health insurance providers provide for a permit, sometimes depending on the type of medical aid. The prescription fee has to be paid for medication on a “cash prescription”. For more information about the respective provisions, please contact your health insurance provider, which you can find on the website of your social insurance, for example.