Alcohol related liver disease (ALD) is the result of drinking more alcohol than the liver can process, which damages the organ. The liver, responsible for performing many functions in the body, processes what the body needs, discarding what it doesn’t. As the liver breaks down the alcohol, the chemical reaction releases a toxin, which damages liver cells. If too much alcohol is ingested repeatedly over time, even without getting drunk, liver damage can silently begin. When too much liver damage occurs, it impacts the whole body. ALD is both preventable and can be fatal.

More than 21,000 people die annually in the United States from ALD. Nearly 70 percent of those deaths are men, yet women develop the disease after less exposure to alcohol than men.

Types of Alcohol Related Liver Disease

• Alcholol Related Steatohepatitis (ASH): Fat accumulates inside liver cells, making it hard for the liver to work properly. This early stage of liver disease occurs fairly soon after repeated heavy drinking. Usually it is symptom free but upper abdominal pain on the right side from an enlarged liver may occur. Steatosis goes away with alcohol abstinence.
• Alcoholic Associated Hepatitis: This condition is marked by inflammation, swelling and the killing of liver cells. This scars the liver, which is known as fibrosis. Symptoms may occur over time or suddenly. They include fever, jaundice, nausea, vomiting and abdominal pain. Up to 35 percent of heavy drinkers develop alcohol associated hepatitis, which can be mild or severe. In many cases, stopping alcohol use can reverse it. But, 70% will go on to develop cirrhosis. Sometimes the damage does not reverse itself. Unfortunately, one of four people will return to alcohol use after an episode of alcohol associated hepatitis and this is associated with an increased risk of death.
• Alcohol related cirrhosis: Alcohol related cirrhosis and alcohol associated hepatitis are the most serious forms of ALD. Alcohol related cirrhosis occurs when the entire liver is scarred, causing the liver to shrink and harden. This can lead to liver failure. Usually, the damage cannot be reversed. Between 10 to 20 percent of heavy drinkers develop cirrhosis -- typically after 10 or more years of drinking.
• Metabolic ALD: Patients with unhealthy alcohol use who also have metabolic factors - such as type 2 DM, hypertension, or, hyperlipidemia - can develop a new defined condition of MetALD.Ìý

*Alcohol associated hepatitis and alcohol related cirrhosis were previously called alcohol steatohepatitis (ASH), a term that is still sometimes used.

Risk Factors for Alcohol Related Liver Disease

Not everyone who drinks heavily develops ALD. While the amount of alcohol and the length of time as a heavy drinker are the key risk factors, additional forces impact the outcome. They are:

• Obesity/Overweight: Carrying extra weight increases the risk of liver disease because fat builds up in the liver. The fat cells secrete acids which cause a reaction that destroys healthy cells in the liver, leading to scarring. Add alcohol to the mix and the combined effect adds additional liver damage.
• Malnutrition: Often people who drink heavily, eat poorly. They also may have trouble absorbing nutrients because alcohol’s toxic byproducts make it difficult to break down food. The lack of nutrients contributes to liver cell damage.
• Genetic component: How a body metabolizes alcohol is influenced by genetics. If certain enzymes are missing, that can affect the risk of developing ALD.
• Demographic influencers: Rates of ALD are higher in African-American and Hispanic males than in Caucasian males. Women are more susceptible than men to the impact of alcohol because they become more impaired than men after drinking equal amounts.
• Having viral hepatitis, especially hepatitis C virus: Adding alcohol to a liver already taxed by hepatitis increases the risk of developing liver disease, as well as liver cancer.

Symptoms of ALD

Most patients with ALD do not have symptoms until they develop symptoms of liver failure (alcohol associated hepatitis and/or decompensated ALD cirrhosis). Nearly all patients with early ALD will not have any symptoms at all, which is why it is important to take action if you are drinking heavily. By the time symptoms develop, ALD is usually very advanced.Ìý

As the disease progresses, the symptoms include:

• Jaundice (a yellow tint to the skin and the whites of the eyes)
• Swelling of the lower limbs (edema)
• Fluid buildup in the abdomen (ascites)
• Itchy skin
• Fever and shivering
• Fingernails that curve excessively
• Muscular weakness
• Blood in vomit or stools
• Bleeding and bruising more easily
• More sensitive reactions to alcohol or drugs
• High blood pressure in the liver (portal hypertension)
• Bleeding from veins in the esophagus (esophageal varices)
• Confusion and behavior changes
• Enlarged spleen
• Kidney failure

ALD Diagnosis

A hepatologist, a liver specialist, may suspect ALD after a physical examination and a conversation about a patient’s history of alcohol use. If further testing is needed, the doctor may order:

• Blood test
• Imaging tests: CT scan, MRI or ultrasound of the liver
• Endoscopy: To look for abnormal veins in the esophagus, stomach, and intestines
• Liver function test: Used to check for liver inflammation and liver damage.

ALD Treatment

Stop drinking alcohol: Abstinence is the most critical step to take following an ALD diagnosis. Even one drink is too many. Alcohol avoidance is the best way to possibly reverse liver damage or prevent liver disease from worsening. Those who find stopping alcohol use difficult may be diagnosed with alcohol use disorder (AUD) and should discuss treatment options with a doctor. Over 50% of people with AUD will have ALD. Getting help improves long-term abstinence and because a rapid reduction of alcohol in the body can lead to dangerous withdrawal symptoms including hallucinations and seizures, for which medicine may be prescribed.

AUD treatment is multifactorial - sobriety is much more than stopping drinking. It requires us to change how we think, socialize, and live. AUD is often co-occurring with depression, anxiety, or sleep disorders – all of which if un-recognized or under-treated present challenges to maintaining sobriety. Our ALD/AUD multidisciplinary program enlists the expertise in psychiatry, hepatology, and social work in order to:ÌýÌý

• Offer first-line and evidenced-based pharmacotherapies to target cravings/desires to drink and promote abstinenceÌý
• Develop AUD behavioral treatment plans that focus on increasing insight and motivation to avoid drugs and alcohol, promote an understanding of past consequences and future risks of use, focus on how to confront and manage cravings, develop healthy ways to recognize and manage stress, and strategize how to avoid high-risk situations that can lead to a return to hazardous drinkingÌý
• Provide comprehensive psychiatric diagnostic evaluations and treatment of co-morbid psychiatric disorders.ÌýÌý

For more information about Alcohol Use Disorder, symptoms and treatments visit:

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Nutrition and diet: Because nutritional deficiencies are common in patients with ALD, a special diet, vitamins and supplements may help. A nutritionist will educate patients on meal planning to combat malnutrition and help keep fluid buildup at bay through low-sodium suggestions. Similarly, a lifestyle change that includes eating right and losing weight may help decrease the toxic fat deposits in the liver.

Medications: A doctor may prescribe medicine depending on the severity of the ALD.Ìý Viral treatment is not a common part of ALD treatment, though it may be needed if someone has comorbid viral liver disease.ÌýÌýÌýÌýÌý

Liver transplantation: If the ALD is very advanced and does not improve with AUD treatment, a liver transplant will be needed. This surgery removes the diseased cirrhotic liver and replaces it with a healthy liver from a donor. Qualifying for one requires approval from a transplant center, as well as abstaining from alcohol both before and after surgery.

Other Information About Digestive and Liver Health

To see related medical services we offer, visit our Digestive and Liver Health overview page.

Make an Appointment

To make an appointment with University of Michigan Health Alcohol Liver Disease Clinic, call 1-800-333-9013.