What Are the Three Alcoholic Liver Disease Stages?

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Alcohol is a toxin that, when consumed in large amounts, damages the liver, whose job is to filter toxins. This damage progresses through stages, starting with alcoholic fatty liver disease, followed by alcoholic hepatitis, and lastly, cirrhosis and liver failure.

Read ahead to learn in detail about the stages of alcoholic liver disease, the signs and symptoms of each stage, and what you can do to prevent permanent liver damage and loss of function.

What Is Alcohol Liver Disease?

Alcoholic liver disease, or alcohol-related liver disease (ALD), refers to a range of progressive liver conditions caused by long-term and excessive alcohol consumption. According to the National Institute on Alcohol Abuse and Alcoholism, 50.3% of liver cirrhosis deaths in 2019 were due to alcohol consumption.

Since the liver is the “poison control center” of the body, ALD occurs because alcohol goes through the liver to be metabolized. As the liver breaks it down, harmful toxins are created and released, damaging liver cells in the process.

Usually, the liver is able to repair itself after injury. However, if alcohol consumption in large amounts is a frequent behavior, the liver’s regenerative abilities get overwhelmed, leading to disease and a decline in function.

What Are the Stages of Alcohol Liver Disease?

There are three stages of ALD—alcoholic fatty liver, alcoholic hepatitis (jaundice), and cirrhosis.

Alcoholic Fatty Liver (Reversible)

This is the first stage of ALD, where fat molecules start depositing inside liver cells. It occurs because alcohol inhibits the breakdown of fat and as it starts building up inside liver cells, they begin dying.

A study by Yale University shows that almost 90% of habitual excessive drinkers have alcoholic fatty liver disease.

This stage usually has no symptoms, but might cause abdominal discomfort and generalized weakness. It’s reversible if you stop drinking and the liver is often able to make a full recovery with complete abstinence.

Alcoholic Hepatitis (Reversible if Mild)

This stage is characterized by inflammation of liver cells and cell death due to continued alcohol abuse. The damage here is more severe than fatty liver, so much so that clinical signs and symptoms begin to appear. These include:

  • Nausea
  • Vomiting
  • Long-term fatigue
  • Loss of appetite
  • Weight loss
  • Abdominal pain
  • Yellowing of the skin and whites of the eyes (alcoholic jaundice)

Alcoholic hepatitis might be reversible if detected early, although some loss of function is to be expected even with complete abstinence. Preventing irreversible damage requires quitting drinking alcohol and avoiding the overuse of any medication that causes liver injury.

That said, up to 40% of the cases of severe alcoholic hepatitis progress to the next stage—cirrhosis.

Alcohol-Related Cirrhosis (Irreversible)

This is the final stage of ALD. Once the liver’s regenerative abilities get overwhelmed, cells start dying and the body replaces them with scar tissue. Scar tissue can’t perform the normal functions of the liver, so signs of liver failure begin to show. These include:

  • Severe skin yellowing
  • Itching
  • Dark-colored urine
  • Clay-colored stool
  • Fat malabsorption, which is characterized by foul-smelling, greasy stool

As the condition progresses, more serious signs begin to appear, such as:

  • Abdominal swelling due to fluid accumulation (ascites)
  • Swelling of the hands and feet (edema)
  • Bloody vomit (hematemesis)
  • Bloody stool (hematochezia)
  • Low urine output due to kidney failure
  • Drowsiness due to high ammonia levels (hepatic encephalopathy)
  • Liver cancer

Prognosis of Alcohol-Related Cirrhosis

Doctors use the Child-Pugh score to classify how severe liver cirrhosis is and how likely patients are to succumb to it. The score is calculated by measuring the levels of liver metabolites and checking for important symptoms. The criteria include:

  • Bilirubin levels: the liver is supposed to help excrete this pigment from the body, so high levels mean more severe disease
  • Albumin levels: it’s normally produced by the liver, so low levels mean more severe disease
  • Prothrombin time: which measures how quickly the blood can clot. The liver normally produces clotting factors to help the blood clot, meaning a longer prothrombin time indicates a more severe disease
  • The presence or absence of abdominal swelling
  • The presence or absence of drowsiness

Doctors then classify patients into three Child-Pugh classes depending on their score. These include:

Child-Pugh Class

One-Year Survival Rate

A

100%

B

80%

C

45%

Stopping alcohol may improve the Child-Pugh class of patients but it can never restore liver function completely back to normal.

How Does Alcoholic Liver Disease Develop?

There are three ways the liver breaks down alcohol. The alcohol dehydrogenase

(ADH) pathway is the most significant and is what’s responsible for causing liver disease.

Here is how it goes:

  1. The liver converts alcohol into acetaldehyde using the ADH enzyme
  2. Acetaldehyde is converted into acetyl-CoA, which releases NADH (1,4-Dihydronicotinamide adenine dinucleotide) molecules
  3. High levels of NADH molecules cause fat to deposit inside liver cells

This causes gradual loss of liver function, leading to a higher rate of fat deposition and liver cell damage. If someone with the first stage of alcohol-related liver disease continues to drink alcohol, the damage gets compounded and the disease progresses.

How Are the Different Stages of Alcohol Liver Disease Diagnosed?

The different stages of ALD are diagnosed based on imaging and blood tests.

Diagnosing Alcoholic Fatty Liver

Abdominal ultrasound is the first imaging test used when suspecting alcoholic fatty liver. It shows:

  • Mild hepatomegaly, which means the liver is slightly enlarged due to fat deposition
  • Invisible blood vessels in the liver
  • Echogenicity, which means the liver shows up lighter than it should be in an ultrasound

If the ultrasound is unclear, your healthcare provider might order a CT scan, which is a more detailed imaging test.

You’ll also be asked to undergo a number of blood tests, which measure:

  • Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. The ratio of AST to ALT becomes 2:1 when liver damage is caused by alcohol
  • Gamma-glutamyl transpeptidase levels, which become elevated when there’s liver damage
  • Hemoglobin levels. These will be low because of low liver folic acid levels

Sometimes, your healthcare provider will also measure blood carbohydrate-deficient transferrin levels, which is the most specific marker of heavy drinking episodes.

Diagnosing Alcoholic Hepatitis

The recommended imaging test to diagnose alcoholic hepatitis is a Doppler ultrasound. It will show fat deposition and increased liver size.

The blood tests used in this case include:

  • White blood cell count, which becomes higher than 12,000/mm3
  • Total bilirubin, which is greater than 3 mg/dL
  • Albumin levels, which hover around 3 g/L due to decreased protein synthesis

There might also be a prolonged prothrombin time as the clotting factors produced by the liver start decreasing.

Diagnosing Alcohol-Related Cirrhosis

The gold standard for diagnosing alcohol-related cirrhosis is a biopsy, where a needle is passed through the abdomen to take out a small section of the liver tissue. This is examined under a microscope to detect the presence of scar tissue.

But a liver biopsy is invasive and painful, so it’s rarely performed. Instead, doctors use a long history of alcohol abuse and significantly out-of-range blood and imaging tests to diagnose this stage of ALD.

Important lab findings include:

  • Massive increase in ALT and AST (AST>ALT)
  • Decreased hemoglobin, platelets, and white blood cells
  • Significantly reduced albumin levels
  • Decreased total body protein
  • Significantly prolonged prothrombin time

Imaging in this stage will show a shrunken liver with a nodular surface due to scar deposition.

What Is the Treatment of Alcoholic Liver Disease?

The first line of treatment for ALD is a gradual reduction of alcohol intake (quitting cold turkey is discouraged because of withdrawal symptoms).

Alcoholic fatty liver disease and hepatitis might be reversible if appropriate nutritional requirements are met along with lifestyle modifications, like weight loss and increased exercise.

Patients might also be asked to increase multivitamin intake to support overall liver health and to make up for mineral deficiencies. Similarly, corticosteroids might be prescribed to reduce liver inflammation (although no medication has been approved yet by the FDA to treat ALD).

If someone develops liver cirrhosis, the goal of the treatment is to make up for the lost liver functions and prevent complications. Treatment includes:

  • A balanced diet with adequate protein intake
  • Fluid restriction to reduce abdominal swelling
  • Routine vaccinations because cirrhosis patients are at an increased risk of infection
  • Drugs like beta-blockers to prevent bleeding

The only curative treatment in the case of cirrhosis is a liver transplant.

Frequently Asked Questions

How Fast Does Alcoholic Liver Disease Progress?

It takes ten years on average for ALD to progress to liver cirrhosis. Your genetics, quantity, and quality of alcohol consumed can all affect this duration.

How Long Does It Take to Reverse Alcoholic Liver Damage?

Liver recovery begins as soon as a few days to weeks after you stop drinking. It might take a few months if the damage is more severe.

At What Point Is Liver Damage From Alcohol Irreversible?

Liver damage from alcohol is irreversible once patients develop cirrhosis.

Preventing ALD Through Alcohol Addiction Treatment

The most important prevention tactic against ALD is to stop drinking alcohol. It’s also the most challenging aspect of ALD treatment, but without it, all other treatments remain ineffective.

If you’re a heavy drinker, your first step towards better health should be to follow an alcohol addiction treatment plan, offered in-person or online through telehealth services like Curednation.

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