What is a fatty liver disease

Simple fatty liver is also called nonalcoholic fatty liver (NAFL), alcoholic fatty liver disease, alcoholic steatohepatitis, nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis (NASH) ¹⁾.

Your liver is the largest organ inside your body and it is a vital organ that performs many essential functions. Your liver filters out harmful substances from your blood, makes bile to digest food, stores energy and nutrients, and manufactures hormones, proteins, and enzymes your body uses to function, remove poisons and ward off disease ²⁾.

Fatty liver disease is a condition in which fat builds up in your liver. Fatty liver or steatosis hepatitis, the accumulation of lipid within hepatocytes, is a common histological finding in human liver biopsy specimens and affects 10–24% of the general population ³⁾. There are two main types of fatty liver disease:

1. Nonalcoholic fatty liver disease (NAFLD).
2. Alcoholic fatty liver disease, also called alcoholic steatohepatitis.

Nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a condition in which fat builds up in your liver. This buildup of fat is not caused by heavy alcohol use. When heavy alcohol use causes fat to build up in the liver, this condition is called alcoholic liver disease ⁴⁾.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease in the United States. Most people with nonalcoholic fatty liver disease have simple fatty liver. Only a small number of people with nonalcoholic fatty liver disease have NASH. Experts estimate that about 20 percent of people with NAFLD have nonalcoholic steatohepatitis (NASH) ⁵⁾.

Between 30 and 40 percent of adults in the United States have nonalcoholic fatty liver disease (NAFLD). About 3 to 12 percent of adults in the United States have nonalcoholic steatohepatitis (NASH) ⁶⁾.

There are two types of nonalcoholic fatty liver disease (NAFLD):

1. Simple fatty liver: Simple fatty liver, also called nonalcoholic fatty liver (NAFL), is a form of nonalcoholic fatty liver disease (NAFLD) in which you have fat in your liver but little or no inflammation or liver cell damage. Simple fatty liver typically does not progress to cause liver damage or complications ⁷⁾.
2. Nonalcoholic steatohepatitis (NASH): Nonalcoholic steatohepatitis (NASH) is a form of nonalcoholic fatty liver disease (NAFLD) in which you have inflammation and liver cell damage, in addition to fat in your liver. This form of liver injury carries a 20%-50% risk for progressive liver fibrosis, 30% risk for cirrhosis, and 5% risk for hepato- cellular carcinoma (liver cancer) ⁸⁾. Nonalcoholic steatohepatitis (NASH) may lead to cirrhosis or liver cancer ⁹⁾.

Simple fatty liver and NASH are two separate conditions. Experts are not sure why some people with nonalcoholic fatty liver disease (NAFLD) have NASH while others have simple fatty liver. People typically develop one type of NAFLD or the other, although sometimes people with one form are later diagnosed with the other form of nonalcoholic fatty liver disease (NAFLD). Research suggests that certain health conditions make you more likely to develop NAFLD or NASH.

Who gets fatty liver disease ?

Researchers do not know the cause of nonalcoholic fatty liver (NAFLD). They do know that it is more common in people who ¹⁰⁾:

• Have type 2 diabetes and prediabetes
• Are obese
• Are middle aged or older (although children can also get it)
• Are Hispanic, followed by non-Hispanic whites. It is less common in African Americans.
• Have high levels of fats in the blood, such as cholesterol and triglycerides
• Have high blood pressure
• Take certain drugs, such as corticosteroids and some cancer drugs
• Have certain metabolic disorders, including metabolic syndrome
• Have rapid weight loss
• Have certain infections, such as hepatitis C
• Have been exposed to some toxins.

Nonalcoholic fatty liver disease (NAFLD) affects about 25 percent of people in the world. As the rates of obesity, type 2 diabetes, and high cholesterol are rising in the United States, so is the rate of nonalcoholic fatty liver disease (NAFLD). Nonalcoholic fatty liver disease is the most common chronic liver disorder in the United States ¹¹⁾.

Nonalcoholic fatty liver disease (NAFLD) is more common in people who have certain conditions, including obesity and conditions that may be related to obesity, such as type 2 diabetes. Researchers have found nonalcoholic fatty liver disease (NAFLD) in 40 to 80 percent of people who have type 2 diabetes and in 30 to 90 percent of people who are obese ¹²⁾. In research that tested for NAFLD in people who were severely obese and undergoing bariatric surgery, more than 90 percent of the people studied had NAFLD ¹³⁾.

Alcoholic fatty liver disease only happens in people who are heavy drinkers, especially those who have been drinking for a long period of time. The risk is higher for heavy drinkers who are women, are obese, or have certain genetic mutations ¹⁴⁾.

Causes of Nonalcoholic fatty liver disease (NAFLD)

You are more likely to develop nonalcoholic fatty liver disease (NAFLD)—either simple fatty liver or NASH—if you:

• are overweight or obese
• have insulin resistance
• have abnormal levels of fats in your blood, which may include high levels of triglycerides, abnormal levels of cholesterol—high total cholesterol, high LDL cholesterol, or low HDL cholesterol
• have metabolic syndrome or one or more traits of metabolic syndrome. Metabolic syndrome is a group of traits and medical conditions linked to overweight and obesity. People with metabolic syndrome are more likely to develop type 2 diabetes and heart disease. Experts think NAFLD may be closely linked to metabolic syndrome. Doctors define metabolic syndrome as the presence of any three of the following: large waist size, high levels of triglycerides in your blood, low levels of HDL cholesterol in your blood, high blood pressure, higher than normal blood glucose levels.
• have type 2 diabetes.

Human studies and animal models suggest that dietary factors can affect fatty infiltration and lipid peroxidation in various types of liver disease including nonalcoholic fatty liver disease (NAFLD) ¹⁵⁾. More recently, increased ingestion of sugar sweetened beverages (e.g. soft drinks, fruit drinks, plus major sources of high fructose corn syrup) was found to be linked to nonalcoholic fatty liver disease (NAFLD) ¹⁶⁾ independent of metabolic syndrome, with NAFLD patients consuming 5 times the amount of carbohydrates from sugar sweetened beverages as compared to healthy persons ¹⁷⁾. Individuals consuming more than 1 sugar sweetened beverage daily showed a higher prevalence of metabolic syndrome than those consuming < 1 soft drink per day ¹⁸⁾.

Caramel is made by the carefully controlled heat treatment of carbohydrates, generally in the presence of acids and alkalis, in a process called caramelization. Soft drinks contain caramel coloring and sweetener, which is rich in advanced glycation end products which increase insulin resistance and inflammation ¹⁹⁾, ²⁰⁾. The FDA has established 200 mg of caramel per kg body weight as an acceptable daily intake.

High fructose diets have induced fatty liver in rats and ducks ²¹⁾. Such diets have also caused increases in hepatic lipid peroxidation and activation of inflammatory pathways in the liver of rats ²²⁾. The inborn error of metabolism known as hereditary fructose intolerance, a rare disease which results from a deficiency in the fructose metabolizing enzyme, aldolase B, has demonstrated that fructose consumption can cause progressive liver disease in humans ²³⁾.

Recently, Stanphone demonstrated that consuming fructose-sweetened beverages, not glucose-sweetened beverages increases hepatic de-novo lipogenesis (fat production by the liver production), promotes dyslipidemia (abnormal blood cholesterol), decreases insulin sensitivity and increases visceral adiposity in overweight and obese adults ²⁴⁾. One study of lean women found that 4 days of over feeding with a sucrose-sweetened (glucose + fructose) drink increased de-novo lipogenesis by 200%-300% ²⁵⁾. Another feeding study showed that 2 day of high fructose intake (30% of kcal/d, consumed as sweetened beverage at every meal) resulted in decreased postprandial glucose concentration and insulin response and prolonged alimentary lipemia in women ²⁶⁾. A recent clinical study indicates that NAFLD patients have a higher intake of soft drink and meat and a tendency towards a lower intake of fish rich in omega-3 ²⁷⁾.

The extent to which excessive fructose might contribute to the high prevalence of NAFLD in Western societies has not been systematically investigated. It has been shown that consumption of sugar sweetened beverages is linked to obesity and results in an increased risk of metabolic syndrome. Individuals consuming > 1 soft drink per day had a higher prevalence of metabolic syndrome than those consuming < 1 drink per day ²⁸⁾.

Table 1. Calories and sugar content in different soft drinks

Soft drinks: calorie content (number of calories)				Soft drinks: sugar content (numbers of teaspoons of sugar)
	12- oz. Can	20 oz. Bottle	64 oz. Big cup		12- oz. Can	20 oz. Bottle	64 oz. Big cup
Sunkist	190	325	1040	Orange slice	11.9	19.8	63.5
Mountain dew	165	275	880	Mint maid orange soda	11.2	18.7	59.7
Dr. Pepper	160	250	800	Mountain dew	11.0	18.3	58.7
Pepsi	150	250	800	Barq’s root beer	10.7	17.8	57.1
Coke classic	140	250	800	Pepsi	9.8	16.3	52.3
Sprite	140	250	800	Squirt	9.5	15.8	50.7
7-Up	140	250	800	Dr. Pepper	9.5	15.8	50.7
				7-Up	9.3	15.5	49.6
				Coke classic	9.3	15.5	49.6
				Sprite	9.0	15.0	48.0

[Source ²⁹⁾]

Research also suggests that certain genes may make you more likely to develop NAFLD. Experts are still studying the genes that may play a role in NAFLD ³⁰⁾.

In NAFLD, people have a buildup of fat in the liver that is not caused by alcohol use. If you have a history of heavy alcohol use and fat in your liver, your doctor may determine that you have alcoholic liver disease instead of NAFLD.

Causes of Nonalcoholic steatohepatitis (NASH)

Experts are not sure why some people with nonalcoholic fatty liver disease have NASH and others have simple fatty liver. Research suggests that certain genes may play a role.

People with nonalcoholic fatty liver disease are more likely to have NASH if they have one or more of the following conditions:

• obesity, especially with a large waist size
• high blood pressure
• high levels of triglycerides or abnormal levels of cholesterol in their blood
• type 2 diabetes
• metabolic syndrome.

Less common causes of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis (NASH)

Less common causes of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis (NASH) include

• disorders that cause your body to use or store fat improperly
• rapid weight loss
• certain infections, such as hepatitis C
• certain medicines, such as amiodarone (Cordarone, Pacerone), diltiazem, glucocorticoids, highly active antiretroviral therapy, methotrexate (Rheumatrex, Trexall), synthetic estrogens, tamoxifen (Nolvadex, Soltamox), valproic acid
• exposure to some toxins.

A study funded by the National Institute of Diabetes and Digestive and Kidney Diseases found that people who had surgery to remove their gallbladder were more likely to develop nonalcoholic fatty liver disease. More research is needed on the link between gallbladder removal and nonalcoholic fatty liver disease.

How you can prevent nonalcoholic fatty liver disease and NASH

You may be able to prevent nonalcoholic fatty liver disease and NASH by eating a healthy diet, limiting your portion sizes, and maintaining a healthy weight.

If you don’t have nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH), you may be able to prevent these conditions by eating a healthy diet, limiting your portion sizes, and maintaining a healthy weight.

If you have nonalcoholic fatty liver disease or nonalcoholic steatohepatitis (NASH), your doctor may recommend gradually losing weight if you are overweight or obese.

Your doctor may suggest limiting your intake of fats to help prevent or treat nonalcoholic fatty liver disease or NASH. Fats are high in calories and increase your chance of becoming obese. Four types of fats are

1. Saturated fats, found in meat, poultry skin, butter, lard, shortening, and all milk and dairy products except fat-free versions.
2. Trans fats, found in foods that list hydrogenated or partially hydrogenated oil on the label, such as crackers and snack foods, commercially baked goods such as cookies and cakes, and fried foods such as doughnuts and french fries.
3. Monounsaturated fats, found in olive, peanut, and canola oils.
4. Polyunsaturated fats, found in greatest amounts in corn, soybean, and safflower oils, and many types of nuts. Omega-3 fatty acids are a type of polyunsaturated fat. Sources include oily fish such as salmon, walnuts, and flaxseed oil.

Replacing saturated fats and trans fats in your diet with monounsaturated fats and polyunsaturated fats, especially omega-3 fatty acids, may reduce your chance of heart disease if you have nonalcoholic fatty liver disease ³¹⁾.

Your doctor may suggest other dietary changes to help treat nonalcoholic fatty liver disease and NASH:

• Eat more low-glycemic index foods—such as most fruits, vegetables, and whole grains. These foods affect your blood glucose less than high-glycemic index foods, such as white bread, white rice, and potatoes.
• Avoid foods and drinks that contain large amounts of simple sugars, especially fructose. Fructose is found in sweetened soft drinks, sports drinks, sweetened tea, and juices.
• Avoid heavy alcohol use, which can damage your liver. For men, experts define heavy alcohol use as more than 4 drinks per day or more than 14 drinks per week. For women, heavy alcohol use is more than 3 drinks per day or more than 7 drinks per week ³²⁾.

Signs and symptoms of fatty liver disease

Both nonalcoholic fatty liver disease (NAFLD) and alcoholic fatty liver disease are usually silent diseases with few or no symptoms ³³⁾. If you do have symptoms, you may feel tired or have discomfort in the upper right side of your abdomen.

Because there are often no symptoms, it is not easy to find fatty liver disease. Your doctor may suspect that you have it if you get abnormal results on liver tests that you had for other reasons. To make a diagnosis, your doctor will use

• Your medical history
• A physical exam
• Various tests, including blood and imaging tests, and sometimes a biopsy

As part of the medical history, your doctor will ask if you have a history of health conditions that make you more likely to develop nonalcoholic fatty liver disease and NASH, such as

• overweight or obesity
• insulin resistance
• high levels of triglycerides or abnormal levels of cholesterol in your blood
• metabolic syndrome
• type 2 diabetes

Your doctor will ask about diet and lifestyle factors that may make you more likely to develop nonalcoholic fatty liver disease and NASH, such as a lack of physical activity or a habit of drinking beverages with added sugar.

Medical tests can’t show whether alcohol is the cause of fat in your liver. Your doctor will ask about your alcohol intake to find out whether fat in your liver is a sign of alcoholic liver disease or nonalcoholic fatty liver disease.

He or she will also ask which medicines you take, to try to determine whether a medicine is causing your nonalcoholic fatty liver disease.

During the physical exam, your doctor will examine your body and check your weight and height to calculate your body mass index (BMI). Your doctor will look for signs of fatty liver disease, such as

• An enlarged liver
• signs of insulin resistance such as darkened skin patches over your knuckles, elbows, and knees
• Signs of cirrhosis, such as jaundice, a condition that causes your skin and whites of your eyes to turn yellow

You will likely have blood tests, including liver function tests and blood count tests. In some cases you may also have imaging tests, like those that check for fat in the liver and the stiffness of your liver. Liver stiffness can mean fibrosis, which is scarring of the liver. In some cases you may also need a liver biopsy to confirm the diagnosis, and to check how bad the liver damage is.

What tests do doctors use to diagnose nonalcoholic fatty liver disease and NASH ?

Doctors use blood tests, imaging tests, and sometimes liver biopsy to diagnose nonalcoholic fatty liver disease and NASH.

• Blood tests

A health care professional may take a blood sample from you and send the sample to a lab. Your doctor may suspect you have nonalcoholic fatty liver disease or NASH if your blood test shows increased levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Your doctor may perform additional blood tests to find out if you have other health conditions that may increase your liver enzyme levels.

• Imaging tests

Your doctor may use the following imaging tests to help diagnose nonalcoholic fatty liver disease:

Ultrasound. Ultrasound uses a device called a transducer, which bounces safe, painless sound waves off your organs to create an image of their structure.

Computerized tomography (CT) scans. CT scans use a combination of x-rays and computer technology to create images of your liver. For a CT scan, a health care professional may give you a solution to drink and an injection of a special dye, called contrast medium. Contrast medium makes the structures inside your body easier to see during the procedure. You’ll lie on a table that slides into a tunnel-shaped device that takes the x-rays.

Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed images of your organs and soft tissues without using x-rays. A health care professional may give you an injection of contrast medium. With most MRI machines, you’ll lie on a table that slides into a tunnel-shaped device. Some machines allow you to lie in a more open space; examining the liver can be more difficult with these machines.

A technician performs these tests in an outpatient center or a hospital. A technician can perform an ultrasound in a doctor’s office as well. A radiologist reads and reports on the images. You don’t need anesthesia , although you may receive light sedation during an MRI if you have a fear of confined spaces.

Imaging tests can show fat in your liver. These tests can’t show inflammation or fibrosis, so your doctor can’t use these tests to find out whether you have simple fatty liver or NASH. If you have cirrhosis, imaging tests may show nodules, or lumps, on your liver.

• Liver biopsy

During a liver biopsy, a doctor will take a piece of tissue from your liver. A pathologist will examine the tissue under a microscope to look for signs of damage or disease.

A doctor performs a liver biopsy at a hospital or an outpatient center. A health care professional will tell you how to prepare for a liver biopsy. You may need to stop taking certain medicines to prepare. You may be asked not to eat or drink anything for 8 hours before the procedure. During the procedure, you may receive a local anesthetic, sedatives, and pain medicine.

During the biopsy, you’ll lie on a table with your right hand resting above your head. The doctor will numb the area where he or she will insert the biopsy needle with a local anesthetic and then use the needle to take a small piece of liver tissue.

A liver biopsy is the only way to detect liver inflammation and damage to diagnose NASH. Doctors don’t recommend this test for everyone with nonalcoholic fatty liver disease. Your doctor may recommend a liver biopsy if you are more likely to have NASH or if your other tests show signs of advanced liver disease or cirrhosis.

What are the treatments for fatty liver disease ?

Doctors recommend weight loss to treat nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). Weight loss can reduce fat in the liver; inflammation; and fibrosis, or scarring ³⁴⁾. If you are overweight or obese, losing weight by making healthy food choices, limiting portion sizes, and being physically active can improve nonalcoholic fatty liver disease and NASH. Losing at least 3 to 5 percent of your body weight can reduce fat in the liver. You may need to lose up to 10 percent of your body weight to reduce liver inflammation ³⁵⁾.

Doctors recommend gradually losing 7 percent of your body weight or more over the course of 1 year ³⁶⁾. Rapid weight loss through very low calorie diets or fasting—eating and drinking nothing except water—can make nonalcoholic fatty liver disease worse ³⁷⁾.

If your doctor thinks that a certain medicine is the cause of your nonalcoholic fatty liver disease, you should stop taking that medicine. But check with your doctor before stopping the medicine. You may need to get off the medicine gradually, and you might need to switch to another medicine instead.

There are no medicines that have been approved to treat NAFLD. Studies are investigating whether a certain diabetes medicine or Vitamin E can help, but more studies are needed.

The most important part of treating alcohol-related fatty liver disease is to stop drinking alcohol. If you need help doing that, you may want to see a therapist or participate in an alcohol recovery program. There are also medicines that can help, either by reducing your cravings or making you feel sick if you drink alcohol.

Both alcoholic fatty liver disease and one type of nonalcoholic fatty liver disease (nonalcoholic steatohepatitis) can lead to cirrhosis. Doctors can treat the health problems caused by cirrhosis with medicines, operations, and other medical procedures. If the cirrhosis leads to liver failure, you may need a liver transplant.

What are some lifestyle changes that can help with fatty liver disease ?

If you have any of the types of fatty liver disease, there are some lifestyle changes that can help:

• Eat a healthy diet, limiting salt and sugar, plus eating lots of fruits, vegetables, and whole grains
• Get vaccinations for hepatitis A and B, the flu and pneumococcal disease. If you get hepatitis A or B along with fatty liver, it is more likely to lead to liver failure. People with chronic liver disease are more likely to get infections, so the other two vaccinations are also important.
• Get regular exercise, which can help you lose weight and reduce fat in the liver
• Talk with your doctor before using dietary supplements, such as vitamins, or any complementary or alternative medicines or medical practices. Some herbal remedies can damage your liver.

Medicines

No medicines have been approved to treat nonalcoholic fatty liver disease and nonalcoholic steatohepatitis (NASH). However, researchers are studying medicines that may improve these conditions.

Some studies suggest that pioglitazone (Actos), a medicine for type 2 diabetes, improves NASH in people who don’t have diabetes. Researchers need more information to find out whether this medicine is safe and effective for long-term use in people with NASH ³⁸⁾.

A study by the National Institute of Diabetes and Digestive and Kidney Diseases’ NASH Clinical Research Network found that treatment with vitamin E or pioglitazone improved NASH in about half of the people treated ³⁹⁾. Doctors may recommend vitamin E for people who have NASH and don’t have diabetes or cirrhosis ⁴⁰⁾. Talk with your doctor before taking vitamin E or pioglitazone.

For safety reasons, talk with your doctor before using dietary supplements , such as vitamins, or any complementary or alternative medicines or medical practices. Some herbal remedies can actually damage your liver.

How do doctors treat the complications of NASH ?

If NASH leads to cirrhosis, doctors can treat the health problems caused by cirrhosis with medicines, operations, and other medical procedures. If cirrhosis leads to liver failure, you may need a liver transplant.

What is a liver transplant ?

Your liver is the largest organ inside your body. It helps your body digest food, store energy, and remove poisons. You cannot live without a liver that works. If your liver fails, your doctor may put you on a waiting list for a liver transplant. Doctors do liver transplants when other treatment cannot keep a damaged liver working.

During a liver transplantation, the surgeon removes the diseased liver and replaces it with a healthy one. Most transplant livers come from a donor who has died ⁴¹⁾. Sometimes there is a living donor. This is when a healthy person donates part of his or her liver for a specific patient.

The most common reason for a transplant in adults is cirrhosis ⁴²⁾. This is scarring of the liver, caused by injury or long-term disease. The most common reason in children is biliary atresia, a disease of the bile ducts.

If you have a transplant, you must take drugs the rest of your life to help keep your body from rejecting the new liver ⁴³⁾.

What is alcoholic liver disease ?

Alcoholic liver disease is damage to the liver and its function due to alcohol abuse ⁴⁴⁾. Your liver breaks down most of the alcohol you drink, so it can be removed from your body. But the process of breaking it down can generate harmful substances. These substances can damage liver cells, promote inflammation, and weaken your body’s natural defenses. The more alcohol that you drink, the more you damage your liver. Alcoholic fatty liver disease is the earliest stage of alcohol-related liver disease. The next stages are alcoholic hepatitis and cirrhosis.

Causes of alcoholic liver disease

Drinking too much alcohol, either on a single occasion – known as binge drinking – or drinking a lot over time, can take a serious toll on your health and well-being. In addition to injuring the liver, alcohol has many effects on your body including:

• Lessening your ability to think clearly and move with coordination; it can change your mood and behavior.
• Disrupting the processes involved in digestion, leading to malnutrition and weight loss.
• Weakening your immune system and the ability to fight infections. Increasing your risk of developing certain cancers including cancers of the colon, liver, esophagus, mouth, and breast (for women).

Alcoholic liver disease occurs after years of heavy drinking. Over time, scarring and cirrhosis of the liver can occur. Cirrhosis is scarring of the liver and poor liver function. It is the last stage of chronic liver disease including alcoholic liver disease ⁴⁵⁾.

Alcoholic liver disease does not occur in all heavy drinkers. The chances of getting liver disease go up the longer you have been drinking and more alcohol you consume. You do not have to get drunk for the disease to happen ⁴⁶⁾.

Alcoholic liver disease seems to be more common in some families ⁴⁷⁾. Women may be more likely to have this problem than men ⁴⁸⁾.

What factors increase your risk for alcohol-related liver disease ?

The amount of alcohol you consume is the most important risk factor for developing alcohol-related liver disease ⁴⁹⁾. The risk increases with the length of time and amount of alcohol you drink. However, because many people who drink heavily or binge drink do not develop alcohol-related liver disease, we know there are other factors that affect a person’s susceptibility.

Additional risk factors that play a role in someone developing alcohol-related liver disease include:

• Obesity: Obesity is a contributing factor to fatty liver disease. The combined effect of obesity and alcohol together is worse than the effect of either one of them alone.
• Malnutrition: Many people who drink heavily are malnourished, either because they eat poorly due to loss of appetite and nausea or because alcohol and its toxic byproducts prevent the body from breaking down and absorbing nutrients. In both cases, the lack of nutrients contributes to liver cell damage.
• Genetic factors: Genetics can influence how the body processes alcohol and may predispose someone to alcoholism and alcohol-related liver disease. Race and ethnicity: A higher risk of liver injury appears to be associated with one’s racial and ethnic heritage. For example, rates of alcoholic cirrhosis are higher in African-American and Hispanic males compared with Caucasian males.
• Your sex: Women are more susceptible than men to the adverse effects of alcohol.
• Pattern of drinking: It’s worse to drink outside of meal times and binge drink, defined as five drinks for men and four drinks for women in one sitting.
• Chronic viral hepatitis, particularly hepatitis C: The combined effect of alcohol and viral hepatitis on the liver results in more advanced disease than either of them alone.

There are three main types of alcohol-related liver disease:

Fatty liver

Also called steatosis, this is the earliest stage of alcohol-related liver disease and the most common alcohol-related liver disorder ⁵⁰⁾. It is characterized by an excessive accumulation of fat inside liver cells, which makes it harder for the liver to function. Usually there are no symptoms, although the liver can be enlarged and you may experience upper abdominal discomfort on the right side. Fatty liver occurs fairly soon in almost all people who drink heavily. The condition will usually go away if you stop drinking.

Alcoholic hepatitis

This is an inflammation, or swelling, of the liver accompanied by the destruction of liver cells. Up to 35 percent of heavy drinkers develop alcoholic hepatitis, which can be mild or severe ⁵¹⁾. Symptoms may include fever, jaundice, nausea, vomiting, abdominal pain and tenderness. In its mild form, alcoholic hepatitis can last for years and will cause progressive liver damage, although the damage may be reversible over time if you stop drinking. In its severe, acute form the disease may occur suddenly – after binge drinking for instance – and can quickly lead to life-threatening complications. Alcoholic cirrhosis: This is the most serious type of alcohol-related liver disease.

Cirrhosis

Cirrhosis refers to the replacement of normal liver tissue with nonliving scar tissue. Between 10 and 20 percent of heavy drinkers develop cirrhosis, usually after 10 or more years of drinking ⁵²⁾. Anything that damages the liver over many years can lead the liver to form scar tissue. Fibrosis is the first stage of liver scarring. When scar tissue builds up and takes over most of the liver, it’s referred to as cirrhosis. Research has shown that cirrhosis can be reversed, although this may not occur for all patients. Cirrhosis caused by alcohol can be a life-threatening disease ⁵³⁾.

How does alcohol-related liver disease progress ?

Many heavy drinkers will progress from fatty liver disease to alcoholic hepatitis to alcoholic cirrhosis over time. However, some heavy drinkers may develop cirrhosis without first having alcoholic hepatitis first ⁵⁴⁾. Others may have alcoholic hepatitis but never have symptoms. Additionally, alcohol consumption may worsen liver injury caused by non-alcoholic liver diseases such as chronic hepatitis C.

Since an individual’s susceptibility to the toxic effects of alcohol may vary by many factors including age, gender, genetics and coexistent medical conditions, it is reasonable for you to review alcohol use with your physician.

Symptoms of alcoholic liver disease

There may be no symptoms, or symptoms may come on slowly, depending on how well the liver is working. Symptoms tend to be worse after a period of heavy drinking.

Early symptoms include:

• Fatigue and loss of energy
• Poor appetite and weight loss
• Nausea or belly pain
• Small, red spider-like blood vessels on the skin.

As liver function worsens, symptoms may include:

• Fluid buildup of the legs (edema) and in the abdomen (ascites)
• Yellow color in the skin, mucous membranes, or eyes (jaundice)
• Redness on the palms of the hands
• In men, impotence, shrinking of the testicles, and breast swelling
• Easy bruising and abnormal bleeding
• Behavior changes and confusion or problems thinking
• Pale or clay-colored stools

Exams and Tests for alcoholic liver disease

Your health care provider will do a physical exam to look for:

• An enlarged liver or spleen
• Excess breast tissue
• Swollen abdomen, as a result of too much fluid
• Reddened palms
• Red spider-like blood vessels on the skin
• Small testicles
• Widened veins in the abdomen wall
• Yellow eyes or skin (jaundice)

Tests you may have include:

• Complete blood count (CBC)
• Liver biopsy
• Liver function tests
• Coagulation studies

Tests to rule out other diseases include:

• Abdominal CT scan
• Blood tests for other causes of liver disease
• Ultrasound of the abdomen

Treatment of alcoholic liver disease

Lifestyle Changes

Some things you can do to help take care of your liver disease are:

• Abstinence: If you’ve been diagnosed with alcohol-related liver disease, the single most important thing you can do for yourself is to stop drinking. Abstinence is the only way of possibly reversing liver damage, or in more advanced cases, preventing it from becoming worse. Discuss treatment options with your healthcare provider; these can include counseling, medications, an outpatient treatment program or a residential inpatient stay. If you are physically addicted to alcohol, medical supervision in a detoxification (or detox) program may be required to safely reduce your alcohol levels. It can be dangerous to stop drinking very suddenly. A rapid reduction in alcohol can lead to withdrawal symptoms including anxiety, agitation, hallucinations and seizures. Your doctor can recommend a program that best meets your needs.
• Nutrition therapy: Nutritional deficiencies are very common in people with alcohol-related liver disease. Your doctor will likely recommend a special diet, as well as vitamin and nutritional supplements, to combat the effects of malnutrition and help you gain weight if needed. You may be referred to a nutritionist who can assist you with meal planning. If you have trouble eating enough to get the vitamins and nutrients you need, your doctor may recommend giving you a special nutrient-rich liquid intravenously or via tube feeding. Eat a healthy diet that is low in salt.
• Get vaccinated for diseases such as influenza, hepatitis A and hepatitis B, and pneumococcal pneumonia.
• Talk to your doctor about all medicines you take, including herbs and supplements and over-the-counter medicines.

Medicines from your doctor

• “Water pills” (diuretics) to get rid of fluid build-up
• Vitamin K or blood products to prevent excess bleeding
• Medicines for mental confusion
• Antibiotics for infections
• Depending on the severity of your disease, your doctor may recommend medications to help reduce liver inflammation. These drugs have shown some short-term benefit in increasing survival. Steroid treatment with prednisolone is usually the first-line medication, followed by pentoxifylline, if steroid therapy doesn’t work. No alternative medicine treatments have been found to cure alcoholic hepatitis.

Other Treatments

• Endoscopic treatments for enlarged veins in the throat (bleeding varices)
• Removal of fluid from the abdomen (paracentesis)
• Placement of a transjugular intrahepatic portosystemic shunt (TIPS) to repair blood flow in the liver

When cirrhosis progresses to end-stage liver disease, a liver transplant may be needed.

Outlook (Prognosis) for alcoholic liver disease

Anyone with alcohol-related liver disease will improve their health and life expectancy if they stop drinking. People with fatty liver may be able to use alcohol moderately after their liver recovers. People with alcoholic hepatitis or alcoholic cirrhosis should stop drink completely.

For alcohol-related liver disease 10 people who do not stop drinking the outlook is poor. Continued excessive drinking can shorten your lifespan. Your risk for complications such as bleeding, brain changes, and severe liver damage go up. The outcome will likely be poor if you keep drinking.

Cirrhosis is caused by scarring of the liver. In most cases, the liver cannot heal or return to normal function once the damage is severe. Cirrhosis can lead to serious complications.

Possible Complications of alcoholic liver disease

Complications may include:

• Bleeding disorders (coagulopathy)
• Buildup of fluid in the abdomen (ascites) and infection of the fluid (bacterial peritonitis)
• Enlarged veins in the esophagus, stomach, or intestines that bleed easily (esophageal varices)
• Increased pressure in the blood vessels of the liver (portal hypertension)
• Kidney failure (hepatorenal syndrome)
• Liver cancer (hepatocellular carcinoma)
• Mental confusion, change in the level of consciousness, or coma (hepatic encephalopathy).