Alcoholic Hepatitis: What you need to Know
The liver is a 3-Pound work horse of an organ, processing much of what we take into our bodies. That includes medications, alcohol fatty foods and other toxins. But the liver has its limits. The routine insult and injury caused, for example, by excessive alcohol consumption can lead to fat buildup and scarring of the liver. And as a result, a person can develop a potentially deadly condition: alcoholic hepatitis, which is characterized by inflammation of the organ.
“The majority of people who get alcoholic hepatitis have underlying injury to begin with,” explains Dr. Gyongyi Szabo, a physician scientist and chief academic officer at Beth Israel Deaconess Medical Center in Boston. “The liver’s a resilient organ. It’ll heal itself. It’s one of the few types of tissues of the body that can heal itself. But if somebody has an ongoing daily insult for many years, and usually it’s decades, the pattern of scar that’s laid down is what subsequently leads to problems.”
Alcoholic hepatitis can lead to liver cirrhosis, extensive scarring of the organ that can cause liver failure.
The Damage Done By Drinking
Although there’s no exact threshold of alcohol consumption that leads to alcoholic hepatitis, having even a few drinks per day may be enough to put a person at risk for developing the condition. “Three standard drinks – so 45 grams of alcohol per day is generally what’s required. It may be a little more than that for men and maybe a little less than that for women,” explains Dr. Shehzad Merwat, medical director of liver transplantation at the University of Texas Medical Branch. “What happens is that the hepatocytes, the liver cells themselves, become swollen from inflammation and toxic injury of the alcohol.”
While alcoholic hepatitis is usually associated with excessive drinking, not all who drink heavily develop the condition. In fact, some who drink in moderation may also develop alcoholic hepatitis. Along with alcohol consumption, it’s thought that genetics play a role in predisposing a person to this form of hepatitis. “There is no absolutely safe level of alcohol consumption,” Szabo says. So based on predisposition, some people could potentially drink a lot and not have liver disease, she notes, while others may drink less, relatively speaking, and develop liver disease.
The more extensive the damage to the liver, the more likely symptoms of alcoholic hepatitis are noticeable. The condition is most often diagnosed around middle age, in people 40 to 60 years old.
“When the symptoms come on, and they tend to come on somewhat abruptly, it’s quite late in the disease,” Merwat says. “Picking up subtle symptoms and signs is challenging. Oftentimes they’re not present,” he says. Even if early signs of liver disease were present, it would require the trained eye of a health professional to notice them.
Symptoms of alcoholic hepatitis – ranging from the more pronounced to subtle – include:
- Jaundice, or yellowing of the eyes and skin.
- Low-grade fever.
- Discomfort in the abdomen (especially the upper right side, where the liver is located).
- Swelling or distention of the abdomen from ascites, accumulation of fluid in the peritoneal cavity, the space that contains the liver, as well as the stomach and intestines.
- Vomiting blood.
- Loss of appetite and malnutrition.
- Weight loss.
- Confusion due to hepatitis encephalopathy, a condition in which the liver can no longer adequately remove toxins from the bloodstream, impairing brain function.
- Spider angioma, when small blood vessels extend, like spider legs, from a larger blood vessel in the skin.
Spider angiomas, also called nevus araneus, may appear for reasons that aren’t clear on different parts of the body, like the face, check, back and arms; and people who are healthy people often have these. But sometimes they’re also associated with liver disease.
“The most subtle symptoms of advanced scarring in the liver might be things like spider angiomas,” Merwat says. But because they’re subtle, “oftentimes people don’t notice them.”
When alcoholic hepatitis is mild, symptoms may be nonexistent or very subtle. “The clinical symptoms that patients have may be very vague,” Szabo says. “Like coming down with the flu or having some diarrhea – not having very good energy. In people who regularly drink, it also could be like hangover kind of symptoms.”
Before You Even Have Symptoms
Given that symptoms can be difficult to spot until alcoholic hepatitis is severe, experts stress the importance of being proactive. That includes limiting alcohol consumption. Additionally, seek help if you drink in excess, as well as a medical evaluation to determine if heavy drinking has your impacted liver function.
Drinking in moderation is generally defined as having no more than one standard alcoholic drink daily for women or two for men. That’s the equivalent of a 12-ounce 5% beer, one 5-ounce glass of wine (12% alcohol) or 1 1.5-ounce shot of liquor (40% alcohol, or 80 proof). “So it’s important to keep in mind that a pint of craft brew – beer that’s 8% alcohol – is not one drink; that might actually be two drinks,” Merwat says.
Anyone who’s drinking excessively should stop to consider whether they may have a significant liver problem that they’re not aware of, says Dr. Rohit Loomba, director of hepatology and a professor of medicine in the division of gastroenterology at the University of California, San Diego. “Anyone drinking more than three to four drinks per day on regular basis is in trouble, and they should be evaluated,” he says.
Diagnosing Alcoholic Hepatitis
Your primary care doctor will assess your overall health. That includes discussing your medical history and drinking habits. While the stigma of substance abuse may lead many to hide alcoholism, clinicians say it’s imperative to be forthright in discussing alcohol consumption with your physician. Avoiding the conversation could lead to further liver damage.
Frequently, liver function tests are performed to check just that. These blood tests check levels of enzymes, such as alkaline phosphatase, alanine transaminase and aspartate aminotransferase, or other substances produced by the liver, like bilirubin, a waste product produced by the liver. Too much can lead to the yellowing of the skin and eyes seen with jaundice.
Lung function tests can be helpful in detecting to problems even before symptoms arise. However, a lung function test that comes back normal doesn’t preclude the possibility that a person could still have liver damage.
As necessary, a patient may be referred to a specialist who works with liver disease patients, such as a gastroenterologist or hepatologist. In some patients, a liver biopsy – or small sample from the organ taken by inserting a small needle into the liver – is analyzed to help with diagnosing liver diseases and disorders. This can be used to confirm if you have a diagnosis of alcoholic hepatitis.
An ultrasound, CT scan or MRI may also be done to look more closely at the liver and assess damage.
Limited Treatment Options for Severe Alcoholic Hepatitis
As damage becomes more extensive, and especially for people who have developed cirrhosis, the prognosis becomes increasingly bleak. Many die within months of their diagnosis.
But if alcoholic hepatitis is caught early, when damage to the liver is still mild, it may be possible to see significant improvement. Clinicians stress that a person needs to stop drinking alcohol immediately to avoid further damage. For that reason, counseling, support groups and other treatment programs aimed at helping a person quit drinking for the long term are advised.
There’s no cure for alcoholic hepatitis – and permanent, extensive scarring can’t be reversed. Instead, treatment aims to prevent further damage.
“Treatment of acute alcoholic hepatitis is quite difficult,” Merwat says. Steroids may be prescribed to limit inflammation, but research is mixed on their usefulness and impact on survival rates. “The most recent studies show that short-term mortality is improved,” he notes. “However, mortality at one year is no different between patients who received steroids and who didn’t receive steroids.”
In some patients with life-threatening alcoholic hepatitis, liver transplant may be an option. This involves replacing the damaged organ with a healthy liver – or part of one – from a donor.
But experts reiterate that given the deadly nature of alcoholic hepatitis, prevention – namely drinking in moderation or stopping altogether – remains the most effective strategy. That starts with following alcohol consumption recommendations – and getting help as needed .
Experts say getting people to follow recommendations starts with education around the dangers of excessive alcohol consumption. Loomba says ideally that would involve starting at the high school level to raise awareness of the problem. “Because that’s where some of the drinking behaviors could set in,” he says: “so education at the school level about the harmful effects of alcohol, avoiding binge drinking.”
Frequently, people develop drinking habits early in life. And experts say that can make it harder to overcome alcohol dependence and decrease the risk of permanent liver damage. So education that leads young adults to avoid or curb excessive drinking is critical. That can help prevent liver problems like alcoholic hepatitis, which can be deadly if it isn’t addressed before symptoms arise.
Rohit Loomba, MD; Shehzad Merwat, MD; Gyongyi Szabo, MD, PhD, Hon. ScD