Decompensated Alcoholic Liver Disease

What is Alcoholic Liver Disease?

Alcoholic Liver Disease (ALD) is a liver condition in which overconsumption of alcohol results in the development of fatty liver, cirrhosis, and alcoholic hepatitis. It is one of the leading causes of liver disease associated with mortality.¹ Chronic alcohol abuse is the main cause of ALD, as the liver is the primary site of alcohol metabolism. Excessive alcohol consumption leads to hepatic lesions, fat accumulation, and hepatitis (inflammation of the liver) which advance liver fibrosis or cirrhosis development.¹  According to the NHS, the liver is the second most complex organ in the human body – its complexity also makes it susceptible to tissue damage.¹  Excessive alcohol consumption over several years reduces the liver’s ability to perform its functions such as blood filtering, blood sugar and cholesterol regulation, and immunity. ALD is unique as, unlike other liver conditions, the only risk factor is excessive alcohol consumption. Consuming a large volume of alcohol in a short period and exceeding the recommended limits of alcohol over long periods can lead to the development of ALD. The NHS recommends adults not exceed more than 14 units of alcohol a week and spread alcohol consumption over 3 days or more if one drinks close to 14 units of alcohol a week.¹ 

What is Liver Cirrhosis?

Liver cirrhosis, also known as end-stage liver disease, is the most advanced stage of several chronic liver diseases.²  It is characterised by the degeneration and death of hepatocytes, the main cell type of the liver. The hepatocytes are replaced by collagenous or fibrous tissue growth in the liver. The dual actions of the degeneration of liver tissue and collagenous growth in the liver results in partial or total loss of liver function (liver failure) and scarred appearance of the liver.² Accumulation of liver scar tissues blocks blood circulation through the liver and thus slows the liver’s ability to filter the blood of toxins and produce liver proteins and other substances required for digestion. If left untreated, liver cirrhosis is life-threatening. However, liver cirrhosis is typically caught early as it is the final stage of most liver diseases.² When caught early, medical intervention can slow or stop the further progression of liver cirrhosis.

There are two main types of liver cirrhosis: decompensated cirrhosis and compensated cirrhosis. In decompensated cirrhosis, the liver is unable to perform its functions to full efficiency. Patients with this type typically exhibit several severe symptoms. In compensated cirrhosis, the liver is able to perform its functions and these patients typically do not display symptoms. It is commonly referred to as the asymptomatic stage.²   

Who is at Risk?

Liver cirrhosis is the final disease stage of several hepatitis conditions and modifiable risk factors that lead to chronic liver failure.

Individuals with chronic viral hepatitis disease (hepatitis B, C, and D) are at an increased risk of liver cirrhosis.³ As viral hepatitis is a chronic inflammatory disease of the liver, over time, this inflammation causes substantial liver degeneration and cell death leading to cirrhosis development.³  

Chronic alcohol abuse also increases an individual’s risk of liver cirrhosis. Alcohol is primarily metabolised in the liver and, incidentally, the liver is the most severely impacted organ of alcohol abuse. Alcohol misuse can lead to the development of alcoholic cirrhosis.³

There are several genetic diseases that may cause damage to the liver.³ These genetic diseases include:

• Haemochromatosis: Haemochromatosis is a genetic disorder that causes excessive accumulation of iron in the organs. Iron accumulation progressively damages organ tissue, which can lead to cirrhosis.
• Alpha-1 antitrypsin deficiency: Alpha 1-trypsin is a hepatic protein that protects the body tissue from damage by infection-fighting agents. Reduced alpha-1-antitrypsin due to inherited genetic mutations causes the liver to be susceptible to cirrhosis.
• Cystic fibrosis: Cystic fibrosis is a genetic disorder that causes thicker-than-normal mucus and sweat secretions throughout the body. These thick mucus secretions can lead to liver cirrhosis development as the thick mucus secretions may block the liver’s ducts. This blockage can lead to scar tissue formation (fibrosis) which may lead to cirrhosis.

Causes of Alcoholic Liver Disease

Chronic Alcohol Abuse

Chronic alcohol abuse is the main cause of the alcoholic liver disease (ALD). Several years of exceeding the recommended alcohol intake limits can lead to ALD.¹ Alcoholic drinks are primarily metabolised in the liver’s parenchymal cells that make up 70% of the liver tissue composition.² Consuming large amounts of alcohol causes the parenchymal cells to become more susceptible to cell death and degeneration as they reduce alcohol’s toxicity. Over time, alcohol abuse causes a wide range of liver lesions including fatty liver (steatosis), and hepatitis (inflammation), leading to fibrosis or cirrhosis formation. It is recommended that one should not exceed over 14 units of alcohol per week.

Chronic alcohol abuse also affects the liver’s ability to metabolise other drugs and medications. Chronic alcohol abuse causes specific liver enzyme levels to increase: these enzymes cause drugs (such as acetaminophen) to be metabolised and converted into a more toxic intermediate. This increases an individual’s risk of developing liver disease and later causes liver failure.²

Gender, Age and Ethnicity

Gender, age, and ethnicity also affect one’s risk of alcoholic liver disease (ALD). Women have been proven to be more susceptible to alcohol-induced tissue damage. This may be due to women having higher blood alcohol concentrations than men when both sexes ingest the same amount of alcohol (2). It is not completely understood how age affects ALD; however, older age is attributed to greater susceptibility to the disease. The relationship between ethnicity and age is still being explored, however, there is increasing evidence of its existence.³

Stages of Alcoholic Liver Disease

The progression of alcoholic liver disease (ALD) is described by 3 main stages presented below. 

• Fatty Liver (Steatosis)

Overconsumption of alcohol leads to the development of a fatty liver. This is characterised by the accumulation of fat deposits within the liver – starting with the liver cells surrounding the central vein of the liver and gradually progressing to the liver cells surrounding the portal vein. Alcohol increases fat accumulation in the liver because the liver’s energy source, fatty acids, is replaced by ethanol from alcoholic beverages. Chronic steatosis causes increased susceptibility to fibrosis and cirrhosis development as the excessive fat in the liver can cause extensive tissue damage. Fatty liver development can be reversed if the individual permanently stops consuming alcohol. 

• Alcoholic Hepatitis

Alcoholic hepatitis follows fatty liver development. It is a more aggressive form of liver damage that is characterised by inflamed liver tissues, dying liver cells, immune system intervention, and protein accumulation. Alcoholic hepatitis is unrelated to the hepatitis disease subgroup as it is entirely caused by chronic alcohol abuse. At this stage, an individual may become aware that their liver is becoming increasingly damaged from excessive alcohol intake. In mild cases, permanently stopping the consumption of alcohol can reverse the condition. However, in severe cases, alcoholic hepatitis may be life-threatening.

• Fibrosis and Cirrhosis

Fibrosis and end-stage cirrhosis result in the deposition of excessive amounts of extracellular matrix proteins in the liver. The liver becomes increasingly scarred and fibrotic as the liver cells continue to degenerate and die to be replaced with scarred and fibrous tissue. Most patients still exhibit some degree of hepatitis while the fat from the fatty liver stage is no longer as prominent. According to the World Health Organization’s report, an estimate of 50% of all cirrhosis-related deaths can be linked to alcohol abuse.

Symptoms of Alcoholic Liver Disease

Individuals with alcoholic liver disease (ALD) do not usually exhibit symptoms until liver damage becomes severe (decompensated alcoholic liver disease), typically in the alcoholic hepatitis stage of ALD progression.^1-3 These symptoms include⁴:

• Weight loss
• Loss of appetite
• Drowsiness
• Vomiting blood
• Bloody stools
• Jaundice (yellowing of the eyes and skin)
• Fever
• Weakness
• Abdominal fluid accumulation
• Easily bruising
• Varices (swollen veins of the oesophagus and stomach) 

Diagnosis of Alcoholic Liver Disease

As alcoholic liver disease (ALD) typically does not exhibit symptoms until it progresses into its severe forms, self-diagnosis can be quite difficult. However, if a medical provider suspects that a patient has ALD, there is a wide range of diagnostic methods that may be used to confirm the disease’s presence. These include blood tests, medical scanning tests, liver biopsy, and endoscopy.

Blood Tests

Blood tests that examine the liver’s functioning can diagnose ALD. As the condition slowly leads to reduced liver function, these tests detect the low concentration of liver-produced proteins within the blood. Serum albumin, a protein produced in the liver, is commonly tested as low serum albumin levels indicate reduced liver function.¹

Medical Scanning Tests

Medical scans of the liver produce high-resolution images of the liver that medical practitioners can use to diagnose liver conditions. These include ultrasound scans, CT scans, and MRI scans. Scans can also detect the liver scar tissue to estimate what stage of ALD a patient may have.¹

Liver Biopsy

A liver biopsy is a medical procedure in which a needle is inserted into the body via the ribs to collect a small liver cell sample. The sample is sent to a lab for microscopic examination to examine for liver damage and to identify what stage of ALD a patient may be at.¹

Endoscopy

An endoscopy is a medical procedure in which a medical instrument passes through the oesophagus and stomach to display imaging of both organs so that medical practitioners can examine for cirrhosis signs such as swollen blood vessels.¹

Treatments for Alcoholic Liver Disease 

The main treatment for alcoholic liver disease (ALD) is abstinence. As ALD is caused by chronic alcohol abuse, permanently stopping the consumption of alcohol can potentially slow or stop the progression of the disease. During the fatty liver disease stage, liver damage is reversible if the patient abstains from alcohol for at least a two-week period.¹ According to NHS guidelines, in some cases, it may be safe to start alcohol consumption again if the individual remains within the recommended alcohol intake. However, this is not recommended for individuals struggling with alcoholism and other types of substance abuse.

Patients in the advanced stages of ALD are recommended to abstain from alcohol for life. This is because in alcoholic hepatitis and fibrosis/cirrhosis stages, the liver tissues are degenerating and dying off and the condition is no longer reversible.² Continued alcohol consumption will only cause severe damage and worsen the condition further. There are currently no medical interventions that can prevent the eventual liver failure that follows the ALD’s advanced stages.¹ 

In very serious cases of ALD, the liver loses its full functioning abilities – which leads to liver failure. As there are no medical treatments for liver failure, the patient must undergo a liver transplant. In a liver transplant, the patient’s liver is replaced with a healthy liver from a healthy donor.  Patients must commit to permanently abstaining from alcohol and be physically fit enough to be considered and to survive the transplant operation. However, there are several risks of a liver transplant: the body may reject the new healthy liver, and it may not function well within the body.⁵

Complications

There are several complications that may arise from alcoholic liver disease (ALD) that affect the liver and other organs of the body. Some of these complications are listed below.

Portal Hypertension

Portal hypertension is a common condition that is associated with cirrhosis. It is less common in patients in the alcoholic hepatitis stage of alcoholic liver disease. As scar tissue formation occurs in the liver, the blood pressure within the liver’s blood vessel supply increases, leading to portal hypertension. If the blood pressure of these vessels continues to increase, after a certain point, the blood pressure causes the vessel walls to burst and bleed out. Portal hypertension can also lead to fluid accumulation in the stomach and surrounding area known as ascites. ¹ 

Hepatic Encephalopathy

Hepatic encephalopathy is one of the most severe complications resulting from ALD.¹ As the ALD progresses, the liver’s ability to filter the blood of toxins reduces. High blood toxin levels can affect the nervous system to cause symptoms such as agitation, anxiety, mood swings, inability to concentrate, and potentially even coma. Hepatic encephalopathy requires hospital admission as it can be potentially fatal.^1,7

Liver Cancer

Long-term alcohol abuse can also increase a patient’s risk of liver cancer. There is a significant correlation between liver cancer and alcohol abuse. Up to 5% of cirrhosis patients have been diagnosed with liver cancer.¹ 

How does decompensated alcoholic liver disease affect Life Expectancy?

On average, patients diagnosed with decompensated alcoholic liver disease (DALD) have a life expectancy of between 1-3 years.⁶ A patient’s life expectancy is dependent on their age, health, and potential complications that may arise from the condition. DALD is life-threatening as the liver is no longer able to functionally meet its physiological demands.^1-4 However, if medical intervention is sought early, one’s life expectancy may increase. According to the MayoClinic, approximately 75% of patients who undergo liver transplant operation live for a minimum of 5 years.⁵ A patient’s life expectancy can also be increased by maintaining a healthy lifestyle before and after a liver transplant operation and abstaining from alcohol for life.^5,6

Summary

Alcoholic liver disease (ALD) is a condition that is attributed to acute and chronic alcohol abuse. As it progresses, it leads to gradual loss of liver function. In the early stages of the condition, associated liver damage can be reduced if the individual abstains from alcohol.² However, as ALD advances to its severe forms, the damage is irreversible. Patients often do not exhibit any symptoms until the disease progresses to its later stage at which point the disease becomes increasingly harder to treat medically.⁵ For prevention, it is recommended that adults remain within the recommended alcohol limits of 14 alcohol units a week.¹