Alcohol related liver disease

Excess alcohol consumption can lead to a gradual scarring of the liver and eventually may lead to cirrhosis and abnormalities of liver function. It is a very common cause of liver disease in the UK and it usually progresses gradually over many years. The risk of developing alcohol related liver damage is directly proportional to the amount of alcohol consumed but can also be exacerbated by other factors such as obesity and diabetes. Susceptibility to alcohol related liver disease can also run in families.

Prevention of further damage, if possible, is the first step and we will encourage lifestyle changes if your liver disease is related to alcohol consumption to try to reduce the pressure on the liver. Most patients will be unaware that their liver is at risk as symptoms are usually only apparent at the advanced stages of liver damage. Symptoms at this time may include loss of muscle mass and body weight, lack of energy, mild confusion or the development of a swollen abdomen or legs. The onset of jaundice in someone who drinks alcohol to excess is a very worrying feature and necessitates urgent medical attention. We can provide patients with a tailored set of investigations to assess for liver damage and can support patients in their efforts to reduce their alcohol consumption.

Chronic alcohol related liver disease can be divided into 4 stages:

  • Most heavy drinkers will develop a fatty liver as a result of the breakdown of alcohol. This stage usually produces no symptoms and gets better if alcohol consumption is reduced.
  • The liver becomes inflamed. This is called steatohepatitis. In severe cases, jaundice may develop. A diagnosis of acute alcoholic hepatitis is made at this point.
  • Fibrosis – the laying down of scar tissue – begins. This cannot be picked up by routine blood tests or scans, and requires specific tests, such as a Fibroscan, to detect.
  • Liver cirrhosis is advanced fibrosis. The normally soft liver tissue is divided into thousands of pea-sized pockets, called nodules, and wrapped in extensive scar tissue. Blood supply through the liver can become impeded and normal liver function can be drastically reduced.

The cornerstone of the treatment of alcohol related liver disease is a sustained reduction in alcohol consumption. Dependent on the situation, a complete abstinence from alcohol may be required. Damage to the liver is often reversible in this situation, but recovery of normal liver function is harder to achieve the more advanced the stage of scarring. Once liver cirrhosis develops, the prognosis very much hinges on whether or not someone continues to drink.

We can assist patients to identify ways to reduce their alcohol consumption and if necessary make recommendations and onward referrals to allied specialists in this field to help. Patients who drink alcohol to excess may have a poor overall diet or specific nutritional deficiencies, and this is an area we will focus on. Patients with advanced liver disease can be at risk of future complications and an aspect of the care we provide here will involve intermittent screening tests to manage complications pre-emptively. Alcohol hepatitis requires urgent medical therapy to prevent acute deterioration in liver function.

Fatty liver disease

Fatty liver disease is common liver disorder and is increasing in prevalence year by year. It can be associated with being overweight and is more common in patients who also have diabetes or high cholesterol. 

Only a proportion of patients with NAFLD will progress to advanced stages of liver disease, and simple tests are available to help determine who those patients are. There are no specific treatments yet for NAFLD, though lifestyle changes can have a beneficial impact on the condition and there are many new drugs in advanced stages of clinic trials.

Hepatitis B (HBV)

Chronic Hepatitis B affects several hundred million people worldwide and one of the most common causes of cirrhosis and primary liver cancer. 

Infection is often acquired in early childhood and usually manifests no symptoms. Screening for this condition is important if there is a family history of HBV or if the patient is from a part of the world with high rates of infection. Though there is no cure, very effective treatments exist to control the infection and prevent liver disease. Many other patients will only require monitoring of

Hepatitis C (HCV)

Chronic Hepatitis C is the most common transmissible cause of liver disease in the UK and is a very important cause of end stage liver disease and primary liver cancer. 

Infection can remain undetected for many years and is usually asymptomatic. Routes of transmission include through transfusion of infected blood products before discovery of the virus in 1991. There are now several new highly effective and well tolerated medicines available to cure hepatitis C infection.

Hepatocellular carcinoma (HCC)

This is a primary liver cell cancer that usually occurs only in the context of cirrhosis, though not always. Regular screening with blood tests and scans can pick up HCC at an early stage, making it more likely that curative treatment can be given.

Cirrhosis

Cirrhosis refers to extensive scarring of the liver and can occur after many years of liver disease. It can cause long-term irreversible damage to the liver. Any form of chronic liver injury can lead to cirrhosis but the most common causes are excess alcohol, chronic viral hepatitis, and non-alcohol fatty liver disease (NAFLD). Other causes include auto-immune diseases of the liver and bile ducts, and inherited metabolic disorders such as haemachromatosis (iron overload). Medications and chemicals may rarely cause an acute liver injury but are very unlikely to cause cirrhosis.

Chronic liver disease typically causes few, if any, symptoms, and indeed patients may even have cirrhosis and be unaware of it. After a patient has developed cirrhosis, they may go onto develop symptoms as part of their disease progression. Symptoms occur due to loss of liver function, but cirrhosis of the liver can be quite advanced before there are any complaints at all. Patients may ultimately develop liver failure, which is a life-threatening condition.

Cirrhosis and Liver Function

The liver is the largest individual organ in the body and is responsible for hundreds of different chemical and physiological functions which, overall, play a central role in keeping conditions constant within the body.

Liver functions include:

  • Metabolism of fats and carbohydrates
  • Removal and breakdown of toxins.
  • Breakdown and disposal of old red blood cells.
  • Production of bile, a fluid that helps with digestion.
  • Storage of minerals, vitamins and glycogen.
  • Production of a majority of blood proteins including those that make a blood clot.
  • Regulation of the immune system

The liver has an impressive ability to keep renewing often despite repeated or long- term injury, so a patient’s liver function may be preserved even in the setting of chronic liver disease. There may come a time, however, after the onset of cirrhosis when the capacity for regeneration is exhausted. At this point a patient may start to exhibit the signs and symptoms of liver dysfunction. These can include:

  • Fluid retention in the abdomen (ascites) or legs
  • Recurrent infections
  • Loss of weight and muscle wasting or weakness
  • Internal bleeding in the gut from portal hypertension 
  • Confusion or excessive drowsiness (encephalopathy)

Diagnosing liver cirrhosis

Your doctor would initially perform blood tests of liver function, an ultrasound scan of the liver anatomy and Fibroscan. A fibroscan is a completely painless test that measures the amount of scarring (fibrosis) and fat (steatosis) in the liver and very reliably determine whether a patient has cirrhosis. Fibroscan can be performed in 5-10mins and does not require sedation. If cirrhosis is confirmed, further investigations may be advised to determine the cause and assess for complications.

Looking after a patient with cirrhosis

The mainstay of management is to identify and treat or remove the underlying cause. Part of the care of a patient with cirrhosis will also include screening for potential complications, and the treatment of these as and when they occur.

Portal hypertension

Blood flow through a cirrhotic liver is impeded causing backpressure in the veins that drain into it from the gut and spleen. This is termed portal hypertension and can lead to the development of dilated blood vessels in the gut called varices.

Varices may burst and cause severe or life-threatening internal bleeding. Treatment can be given to reduce the risk of this occurring. Screening for cirrhosis is safely performed with an endoscopic examination of the oesophagus and stomach.

Cholangiopathy

These are a group of diseases that primarily affect the bile ducts draining the liver. 

By impeding the free flow of bile, these diseases may cause progressive damage to the liver over time and can directly cause complications in the bile ducts themselves such as obstructive jaundice, bile infection, stones and bile duct cancer.

Abnormal Liver Function Tests (LFTs)

Liver function tests (LFTs) are frequently performed to detect early signs of liver injury or inflammation and to directly measure liver function. 

They may be performed in patients at risk of liver disease or sometimes as a part of a general screen in patients who are non-specifically unwell.  Transient derangements of LFTs can sometimes occur with general viral infections or as part of a reaction to a new medication. A patient with an LFT abnormality should be further investigated to exclude significant liver disease.

Liver transplantation

Liver transplantation involves the replacement of the whole of a patient’s liver with that from a donor. Most donations occur from people who have an acute terminal illness and who had expressed an intention to donate their organs after death, a process called cadaveric donation. A healthy person may also donate a part of their liver to a relative in a process called Live Related Liver Donation (LRLD).

A majority of liver transplantation in the UK is carried out within the NHS from cadaveric donors. Patients from overseas, who are ineligible for NHS care, will usually require a living related donor to be able to undergo liver transplantation in the UK.

Patients will normally spend 2-4 weeks in hospital to recover after transplant surgery, and a full recovery can take up to six months. They will have to take a number of new medications to help look after their new liver. In particular, they will need to be on life-long immunosuppression medication to prevent rejection.

A patient’s general health and physical condition needs to be sufficiently robust to successfully undergo transplant surgery, so it is important to consider the potential need for transplantation earlier rather than later in patients with advanced liver disease, whilst they are still relatively well.

Why might I need a liver transplant?

The most common reason for needing a liver transplant is when a patient’s own liver has extensive and irreversible damage and is starting to fail. This is called end-stage liver disease or decompensated cirrhosis. A liver specialist can use liver disease severity scoring systems to predict when a patient may need a transplant, though good clinical judgement and experience are also vital. Liver transplantation is also sometimes performed as an operation to treat some forms of primary liver cancer, called hepatocellular carcinoma (HCC).

This operation is carried out with the intent of curing the cancer. Rarely, liver transplantation is used a life-saving procedure in patients with acute liver failure, a condition that can deteriorate rapidly over a number of days, and which if untreated can lead to multi-organ failure and death.

Liver specialists at the London Liver Group have extensive expertise in the management of liver transplant patients, and some also work in major UK liver transplant centers. Transplant surgery itself is not currently performed at the London Clinic, but we are able to assess and advise patients as to their need and suitability for liver transplantation, and similarly review any potential living related donors.

We are able to care for patients who have had liver transplantation elsewhere and who now require a specialist to look after their new liver and manage their long-term immunosuppression.