Alcohol and Liver Disease
Many of us enjoy an occasional alcoholic drink, and our body can cope with drinking a small amount of alcohol - but it really is a small amount. People who drink 1-2 units a day are statistically at a slightly lower risk of heart attack than teetotallers, but drinking more than that increases your risk of several cancers and heart disease, as well as liver disease - that news seems to be taking longer to filter through.
How much alcohol is too much?
Drinking more than the recommended safe limits of alcohol can cause significant problems with your health, and the more alcohol you drink, the greater the risks.
The Chief Medical Officer recommends that men and women should stick to a maximum of 14 units a week. If you are drinking that much, you should spread it evenly over three or more days, ideally with several alcohol-free days a week. One unit of alcohol is equal to about half a pint of ordinary strength beer or cider, a small single measure of spirits or a standard pub measure of fortified wine such as sherry or port.
What are the symptoms?
The liver is in the upper right part of the tummy (abdomen), just below the ribs.
Drinking too much alcohol leads to three main conditions which can seriously threaten your health:
- Fatty liver.
- 'Scarring' of the liver (cirrhosis).
If you have early-stage liver disease (fatty liver or mild hepatitis), you may not get any symptoms. As the condition progresses, you may feel sick and generally unwell, feel tired all the time or get pain over your liver. You can also develop jaundice, where your skin and the whites of your eyes go yellow. In severe cases your liver may fail completely.
Learn more about symptoms associated with drinking too much alcohol.
Alcohol causing even more health havoc
In addition to the above main alcohol-related conditions, drinking too much alcohol can also cause many other medical problems. These include:
- High blood pressure (hypertension).
- Stomach and bowel conditions.
- Depression and anxiety.
- Sexual difficulties.
- Some cancers.
- Being overweight (obesity).
- Damage to an unborn baby.
- An increased risk of accidents.
- Addiction (alcohol dependence).
Read about the causes of alcohol-related conditions.
What tests will I need?
Alcoholic liver disease is diagnosed by a doctor taking a careful history of your drinking habits, a physical examination and tests such as blood tests and liver scans. Sometimes your doctor will recommend you have a liver biopsy, where a small sample of the liver is removed to look at under a microscope. Discover more about how liver problems associated with drinking too much alcohol are diagnosed.
What's the treatment?
If you have alcoholic liver disease then you must stop drinking completely. Fatty liver and mild alcoholic hepatitis usually recover if you can manage this. Also, mild cirrhosis will often not progress if alcohol is avoided for life. In severe cases, however, where liver scarring is extensive, a liver transplant may be the only possible treatment option.
If you feel that you are drinking more alcohol than you should, or that you cannot stop drinking, then treatment and support are available. Learn about treatment options for conditions caused by drinking too much alcohol. Remember that prevention is the best option.
What conditions do you risk developing by drinking too much alcohol?
The functions of your liver include:
- Storing glycogen, a chemical made from sugars. When required, glycogen is broken down into glucose which is released into the bloodstream.
- Helping to process fats and proteins from digested food.
- Making proteins that are essential for blood to clot (clotting factors).
- Processing many medicines which you may take.
- Helping to remove or process alcohol, poisons and toxins from the body.
- Making bile which passes from the liver to the gut and helps to digest fats.
There are three main stages of alcohol-related liver disease: fatty liver, hepatitis and cirrhosis. Any, or all, of these conditions can occur at the same time in the same person.
A build-up of fat occurs within liver cells in most people who regularly drink heavily. In itself, fatty liver is not usually serious and does not cause symptoms. Fatty liver will usually reverse if you stop drinking heavily. However, in some people the fatty liver progresses and develops into hepatitis.
Hepatitis means inflammation of the liver. The inflammation can range from mild to severe.
- Mild hepatitis may not cause any symptoms. The only indication of inflammation may be an abnormal level of liver chemicals (enzymes) in the blood, which can be detected by a blood test. However, in some cases the hepatitis becomes persistent (chronic), which can gradually damage the liver and eventually cause cirrhosis.
- A more severe hepatitis tends to cause symptoms such as:
- Feeling sick (nausea).
- Yellowing of the skin and the whites of the eyes (jaundice), caused by a high level of bilirubin - a chemical normally metabolised in the liver.
- Generally feeling unwell.
- Sometimes, pain over the liver.
- A very severe bout of alcoholic hepatitis can quickly lead to liver failure. This can cause deep jaundice, blood clotting problems, confusion, coma and bleeding into the guts. It is often fatal.
- The main treatment for alcoholic hepatitis is to provide adequate nutrition (this sometimes involves passing liquid feeds through a tube in the stomach) and steroids.
Cirrhosis is a condition where normal liver tissue is replaced by scar tissue (fibrosis). The scarring tends to be a gradual process. The scar tissue affects the normal structure and regrowth of liver cells. Liver cells become damaged and die as scar tissue gradually develops. So, the liver gradually loses its ability to function well. The scar tissue can also affect the blood flow through the liver which can cause back pressure in the blood vessels which bring blood to the liver.
About 1 in 10 heavy drinkers will eventually develop cirrhosis. It tends to occur after 10 or more years of heavy drinking. Note: cirrhosis can develop in people who have never had alcoholic hepatitis.
Cirrhosis can happen from many causes other than alcohol. If you have another persistent liver disease and drink heavily, you are likely to increase your risk of developing cirrhosis.
Cirrhosis can lead to end-stage liver disease. However, in the early stages of the condition, often there are no symptoms. You can get by with a reduced number of working liver cells. But, as more and more liver cells die and more and more scar tissue builds up, symptoms start to appear. The eventual symptoms and complications are similar to a severe episode of hepatitis (listed above). However, unlike a bout of severe hepatitis, the symptoms and complications tend to develop slowly. See separate leaflet called Cirrhosis for more details.
It is not clear why some people are more prone to damage of their liver cells by alcohol and to developing hepatitis and/or cirrhosis. But, as a rule, the more heavily and the more regularly you drink, the greater your risk of developing hepatitis and/or cirrhosis.
The scarring and damage of cirrhosis is usually permanent and cannot be reversed. However, recent research has led to a greater understanding of cirrhosis. Research suggests that it may be possible to develop medicines in the future which can reverse the scarring process of cirrhosis.
What happens when you drink alcohol?
When you drink alcohol, it is absorbed into the bloodstream from the stomach and intestines. All blood from the stomach and intestines first goes through the liver before circulating around the whole body. So, the highest concentration of alcohol is in the blood flowing through the liver.
Liver cells contain chemicals (enzymes) which process (metabolise) alcohol. The enzymes break down alcohol into other chemicals which in turn are then broken down into water and carbon dioxide. These are then passed out in the urine and from the lungs. The liver cells can process only a certain amount of alcohol per hour. So, if you drink alcohol faster than your liver can deal with it, the level of alcohol in your bloodstream rises.
What are the problems of drinking too much alcohol?
Your liver and body can usually cope with drinking a small amount of alcohol. Indeed, drinking a small amount of alcohol (1-2 units per day) may help to prevent heart disease and stroke.
However, drinking over the recommended limits (detailed below) can be harmful. If you drink heavily you have an increased risk of developing:
- Serious liver problems (alcoholic liver disease).
- Some stomach disorders.
- Severe inflammation of the pancreas (pancreatitis).
- Mental health problems, including depression and anxiety.
- Sexual difficulties such as impotence.
- Muscle and heart muscle disease.
- High blood pressure.
- Damage to nervous tissue.
- Accidents - drinking alcohol is associated with a much increased risk of accidents. In particular, injury and death from fire and car crashes. About 1 in 7 road deaths are caused by drinking alcohol.
- Some cancers (mouth, gullet, liver, colon and breast).
- Obesity (alcohol has many calories).
- Damage to an unborn baby in pregnant women.
- Alcohol dependence (addiction).
In the UK, deaths due to alcohol-related diseases (particularly liver disease) have risen considerably over a period of 20 years.
What tests will I need?
A doctor may suspect that you have liver problems from your symptoms and from a physical examination. (For example, they may detect that your liver is enlarged, or that you are retaining fluid.) They may especially think of liver problems as a cause of your symptoms if you have a history of heavy alcohol drinking. Some tests may be done:
- Blood tests may show abnormal liver function. There are a number of liver function tests (LFT's) that look at levels of various chemicals in the liver. If the liver is damaged or becomes inflamed then the levels of these rise and can be detected on a blood test as they are released into the bloodstream. Even though a number of different LFTs are tested, you only need to give one blood sample for all of them.
- A blood test to check how well your blood clots. Helping your blood to clot is one of the functions of the liver, and you may be at higher risk of bleeding if your liver is damaged.
- A blood test for anaemia. People with alcohol problems can be deficient in a vitamin called vitamin B12, which can lead to anaemia
- An ultrasound scan may show that you have a damaged liver. This painless test is the same type as pregnant women have when their baby is being checked. Some lubricating jelly is placed on the skin of the tummy over the liver, and a handheld ultrasound scanner is moved across the skin. This shows an image of the liver on a monitor and liver damage or enlargement can be seen.
- To confirm the diagnosis, a small sample (biopsy) of the liver may be taken to be looked at under the microscope. The 'scarring' of the liver caused by liver damage (cirrhosis), or the typical features of liver cells with alcoholic hepatitis can be seen on a biopsy sample. This is usually done by a liver specialist and involves freezing an area of the skin with a local anaesthetic above the liver and pushing a small needle into the liver to obtain a sample.
What should I do if I have alcohol-related liver disease?
For all types of liver disease caused by alcohol, you should stop drinking alcohol completely. Also, you may be referred to a dietician to review your diet. This is because many people who drink heavily do not eat properly and need advice on getting back into eating a healthy diet. Vitamin supplements may be prescribed for a while.
- If you have fatty liver, or alcoholic hepatitis which is not severe, you should fully recover from these conditions if you stop drinking alcohol.
- If you have severe hepatitis and require hospital admission, you may require intensive care treatment. Some people with severe hepatitis will die.
- If you have 'scarring' of the liver (cirrhosis), stopping drinking alcohol can improve your outlook. It depends on how severe the cirrhosis has become. If cirrhosis is diagnosed when it is not too advanced and you stop drinking alcohol, the cirrhosis is unlikely to progress. However, the cirrhosis and symptoms will almost certainly get worse if you continue to drink alcohol. In severe cases where the scarring is extensive and the liver can barely function, a liver transplant may be the only option.
You are very unlikely to develop liver problems caused by alcohol if you drink within the recommended safe limits. That is:
- Men and women should drink no more than 14 units of alcohol per week, spread evenly over several days and with at least two alcohol-free days a week.
- Pregnant women. The Chief Medical Officer's latest guideline for women is that if you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk. The risk of harm to the baby is likely to be low if a woman drank only small amounts of alcohol before she knew she was pregnant or during pregnancy. Women who find out they are pregnant after already having drunk during early pregnancy, should avoid further drinking, but should be aware that it is unlikely in most cases that their baby has been affected. If you are worried about how much you have been drinking when pregnant, talk to your doctor or midwife.
Where do these recommendations come from?
- New guidelines from the UK Chief Medical Officer for both men and women state that you are safest not to drink regularly more than 14 units per week, to keep health risks from drinking alcohol to a low level. If you do drink as much as 14 units per week, it is best to spread this evenly over three days or more - if you have one or two heavy drinking sessions, you increase your risks of death from long-term illnesses and from accidents and injuries. The risk of developing a range of illnesses (including, for example, cancers of the mouth, throat and breast) increases with any amount you drink on a regular basis. If you wish to cut down the amount you're drinking, a good way to help achieve this is to have several drink-free days each week.
- The Royal College of Physicians (RCP) advises no more than 14 units per week for men and 14 units per week for women. They also recommend having 2-3 alcohol-free days a week to allow the liver time to recover after drinking anything but the smallest amount of alcohol. A quote from the RCP: "In addition to quantity, safe alcohol limits must also take into account frequency. There is an increased risk of liver disease for those who drink daily or near daily compared with those who drink periodically or intermittently."
- The House of Commons Science and Technology Committee advises that people should have at least two alcohol-free days a week.
- Some would argue that the upper limits of the recommendations are too high. For example, one study found that drinking more than two units a day for men and more than one unit a day for women significantly increases the risk of developing certain cancers.
In general, the more you drink above the upper recommended limits, the more harmful alcohol is likely to be.
And remember, binge drinking can be harmful even though the weekly total may not seem too high. For example, if you only drink alcohol once or twice a week but when you do you drink 4-5 pints of beer each time, or a bottle of wine each time, this is a risk to your health.
One unit of alcohol is 10 ml (1 cl) by volume, or 8 g by weight, of pure alcohol. For example:
- One unit of alcohol is about equal to:
- Half a pint of ordinary strength beer or cider (3-4% alcohol by volume); or
- A small pub measure (25 ml) of spirits (40% alcohol by volume); or
- A standard pub measure (50 ml) of fortified wine such as sherry or port (20% alcohol by volume).
- There are one and a half units of alcohol in:
- A small glass (125 ml) of ordinary strength wine (12% alcohol by volume); or
- A standard pub measure (35 ml) of spirits (40% alcohol by volume).
But remember, many wines and beers are stronger than the more traditional ordinary strengths. A more accurate way of calculating units is as follows. The percentage alcohol by volume (% abv) of a drink equals the number of units in one litre of that drink. For example:
- Strong beer at 6% alcohol by volume (abv) has six units in one litre. If you drink half a litre (500 ml) - just under a pint - then you have had three units.
- Wine at 14% abv has 14 units in one litre. If you drink a quarter of a litre (250 ml) - two small glasses - then you have had three and a half units.
Some other examples
Three pints of beer, three times per week, is at least 18-20 units per week. A drinking session of three pints is at least six units, which is more than the safe limit advised for any one day. Another example: a 750 ml bottle of 12% wine contains nine units. If you drink two bottles of 12% wine over a week, that is 18 units. These are above the upper safe limits for men and women.
However, you should not drink alcohol at all if:
- You have already developed early 'scarring' of the liver (cirrhosis).
- You have chronic hepatitis or certain other liver problems. Your doctor will advise for each specific condition.
Do you need help to stop drinking?
Help and treatment are available if you find that you cannot stop drinking alcohol. Counselling and support from a doctor, nurse, or counsellor are often all that is needed. A detoxification treatment may be advised if you are alcohol-dependent. Referral for specialist help may be best for some people. If you feel that you need, or a relative or friend needs, help about alcohol then speak with your doctor.
Further reading & references
- House of Commons Science and Technology Committee - Alcohol Guidelines (Eleventh Report); UK Parliament, December 2011
- Schutze M, Boeing H, Pischon T, et al; Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study. BMJ. 2011 Apr 7;342:d1584. doi: 10.1136/bmj.d1584.
- I J Beckingham and S D Ryder; ABC of diseases of liver, pancreas, and biliary system: Investigation of liver and biliary disease. BMJ 2001;322:33-36.
- The Government's Alcohol Strategy (proposals to cut 'binge drinking', alcohol-fuelled violence, and number of people drinking to damaging levels); HM Government, 2012
- Antenatal care for uncomplicated pregnancies; NICE Clinical Guideline (March 2008, updated 2017)
- UK Chief Medical Officers' Alcohol Guidelines Review, Summary of the proposed new guidelines; Dept of Health, January 2016
- Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence; NICE Clinical Guideline (February 2011)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Roger Henderson
Dr Laurence Knott