Alcohol-related liver disease

(ARLD)

Alcohol-related liver disease is a condition where the liver has been damaged by alcohol. You don’t have to be addicted to alcohol to develop the condition, regularly drinking over the guideline amounts can put you at risk.

It’s sometimes referred to as alcoholic liver disease, and your doctor might use the abbreviations ALD or ARLD when they’re talking about it.

There are several stages of alcohol-related liver disease. Cirrhosis, the most serious stage of liver disease, usually takes many years to develop.

Symptoms such as weight loss, yellowing of the skin and eyes (jaundice) and swelling of the tummy (ascites) are usually only seen when the disease is at an advanced stage.

The information on this page is for:

Adults with alcohol related liver disease or suspected alcohol related liver disease
Family, friends, carers, and healthcare professionals.

On this page:

Key facts

Alcohol consumption is the most common cause of liver disease in the UK, accounting for 6 in 10 cases of liver disease. Up to 1 in 5 people in the UK drink alcohol in a way that could harm their liver.
You don’t have to show signs of addiction to be affected by alcohol-related liver disease. Having half a bottle of wine or a few pints most evenings can damage your liver.
Drinking alcohol increases the risk of 7 different types of cancer. Breast and bowel cancer are two of the most common types associated with drinking alcohol.
It’s estimated 3 to 5% of people with cirrhosis will develop liver cancer every year.

Find out more about alcohol related liver disease on this page.

What causes alcohol-related liver disease?

Generally, the more alcohol you drink above the recommended limits, the higher your risk of developing alcohol-related liver disease. It can make other types of liver disease worse too.

There are also other factors that can increase the risk of liver damage. If you drink too much alcohol on top of any of these, your chance of developing alcohol-related liver disease is greater. These include:

A weight in the overweight or obese range
Having diabetes (mainly type 2 diabetes)
Being female – women are more vulnerable to the harmful effects of alcohol than men
Having a pre-existing liver condition such as hepatitis C or haemochromatosis
Genetics – alcohol-related diseases and addiction often run in families.

Am I at risk?

It’s not only dependent or daily drinkers who develop liver disease. Heavy drinking even on a few days in the week can cause alcohol-related liver disease. It’s a lot easier to overdrink than many people realise, putting vast numbers of us in danger of alcohol-related illnesses.

The safer drinking limits are the same for men and women:

Drink no more than 14 units a week
Spread your drinking out over several days
Have 2 to 3 days without alcohol every week, it’s best if they’re next to each other.

If you’ve been regularly drinking over the guidelines for several months, it’s important to get your liver checked. Ask your doctor for a liver scan (called a VCTE, transient elastography, or FibroScan®) if you are:

a woman and have been drinking over 35 units a week
a man and have been drinking over 50 units a week.

It’s really important to be totally honest about how much and how often you drink alcohol and to find out whether your drinking has caused harm. Knowing about liver damage at an early stage allows you to make decisions that will help your liver to recover. Even if you are worried your liver may already be damaged, finding out for sure means you can get any help or treatment you need.

Find out more about your risk:

At risk checker

The 3 stages of alcohol-related liver disease

1. Alcohol-related fatty liver

Drinking over 4 units of alcohol per day will lead to some build-up of fat in the liver. Your liver breaks down alcohol, but some of the by-products are toxic and damage your liver. Among other problems, this makes fat build up in your liver. If you stop drinking alcohol completely for a period of time (months or years) your liver can recover.

2. Alcohol-related hepatitis

This stage of alcohol-related liver disease is very serious, and about a third of heavy drinkers with alcohol-related fatty liver will start to develop it. It normally occurs after years of drinking too much. But it can develop very suddenly and severely, even after you’ve stopped drinking. It usually follows weeks and months of heavy drinking, but can happen if you drink a lot of alcohol over a shorter period of time (binge drinking). This is called acute alcohol-related hepatitis and can result in liver failure and death.

3. Cirrhosis

This is the most serious stage of alcohol-related liver damage, when the liver has a lot of severe scarring (fibrosis). Up to 1 in every 5 heavy drinkers will develop cirrhosis.

It’s really important that you are referred to a liver specialist if you have one of the more serious forms of liver damage. These conditions are more difficult to treat and need specialist care.

Where to find support if you need help to stop drinking alcohol

Cutting down on drinking alcohol or stopping drinking altogether can be very difficult and lots of people need some help. Useful contacts, websites and apps include:

Alcoholics Anonymous (AA) support to stop drinking available UK-wide. Call free on 0800 9177 650 or visit www.alcoholics-anonymous.org.uk
Drinkline a national alcohol helpline. Calls are free and completely confidential. Call 0300 123 1110
Smart Recovery a charity that promotes addiction recovery through meetings and online resources, including online meetings. Visit www.smartrecovery.org
Drink Free Days App get help with cutting back on alcohol, improving your health, boosting your energy, losing weight and saving money. Visit www.nhs.uk/live-well/alcohol-support

Support for families and friends:

Al-anon offers support for anyone whose life has been affected by someone else’s drinking. Call free on 0800 0086 811 or find a support group by visiting www.al-anonuk.org.uk
AdFam has information and support to help you cope with your loved one’s alcohol or drug use. Visit www.adfam.org.uk

What are the symptoms of alcohol-related liver disease?

The early stages of alcohol-related liver disease usually do not cause any symptoms. It’s often diagnosed during tests for other conditions. Many people aren’t diagnosed until their disease has become serious.

Early symptoms can include:

An aching feeling or discomfort on the upper right side of your tummy (where your liver is)
Little or no appetite
An overwhelming sense of tiredness (fatigue)
Feeling sick (nausea)
Diarrhoea
Feeling generally unwell
Trouble sleeping (insomnia)

As the liver struggles to work more serious symptoms can develop. If you have any of these symptoms, tell a doctor straight away:

Yellowing of the skin and whites of the eyes (jaundice), this can be harder to see if you have black or brown skin
Tummy (abdominal) pains over the liver area
Itching
Losing a lot of weight for no reason
Weakness and wasting of your muscles
Swelling in the legs, ankles and feet caused by a build-up of fluid (oedema)
Swelling in your tummy caused by a build-up of fluid (ascites)
A tendency to bleed and bruise more easily, such as frequent nosebleeds and bleeding gums
Periods of confusion, forgetting things, mood changes or poor judgement (encephalopathy or brain fog)

Even if you have no symptoms, if you are at risk and are worried, tell your doctor.

Read more about the symptoms of liver disease here.

How is alcohol-related liver disease diagnosed?

You might only find out you have alcohol-related liver disease during tests for other health problems.

If your doctor thinks you have any form of liver disease they will try to find out what is causing it and how damaged your liver is. This will include special blood tests and scans which are usually carried out at a hospital.

If your symptoms or blood tests suggest alcohol-related liver disease you might need further tests to measure how scarred your liver has become. It’s important to give your doctor as much information as you can. This will help them to diagnose your condition correctly and give you the right care.

Many people are only diagnosed with alcohol-related liver disease after going to A&E with symptoms of serious liver disease or liver failure. At this stage, it’s unlikely that your liver disease can be fully reversed. But there is still a lot that can be done to stop your condition getting worse and even repair some of the damage.

Tests that you might have include:

blood tests
scans such as transient elastography (eg FibroScan), ultrasound, MRI, CT
endoscopy
biopsy

Fibrosis (scarring) tests and scores

It’s very important that the amount of scarring in your liver is measured as part of your alcohol-related liver disease diagnosis. It is an important piece of information that doctors use when they’re assessing liver damage, and whether it can be reversed.

Fibrosis is the medical term for scarring. It is usually measured on a scale of 0 to 4. The higher the number, the more severe it is.

Liver specialists can use routine blood tests to see how scarred your liver is, but there are more accurate ways to check if you have liver fibrosis without doing a biopsy. These include:

Fibrosis blood tests, such as an Enhanced Liver Fibrosis (ELF) test, FIB-4 test, or FibroTest
Tests of liver stiffness, such as transient elastography eg FibroScan®.

You could get one of 3 possible results:

A low-risk score means advanced fibrosis can be safely ruled out. This means you don’t have advanced fibrosis or cirrhosis. Your doctor will do a fibrosis test every 2 years to check your condition hasn’t got worse.
An inconclusive-risk, meaning it doesn’t say for sure if you have advanced fibrosis. You should be offered further tests to find out and this might include an ultrasound scan or a liver biopsy. You might also be referred to a specialist.

A high-risk score means that you probably have advanced fibrosis or cirrhosis. You should be referred to a liver specialist (hepatologist or gastroenterologist) who will do further tests and manage your care from then on.

It’s really important that the scarring in your liver is checked regularly because there are often no symptoms to tell you or your doctor if your condition is getting worse.

Treating alcohol-related liver disease

Your liver is the only internal organ that can repair itself. If you can stop drinking alcohol and eat healthily, you’ll reduce the risk of further damaging your liver and give it the best chance of recovering.

Once you have been diagnosed your treatment plan will depend on which stage of alcohol-related liver disease you have.

If your liver disease is at an early to moderate stage the aim will be to cure your condition, by:

giving your liver a chance to repair itself
preventing further damage.

If it’s more advanced, your treatment will aim to stabilise your liver disease and stop it from getting worse. You will be treated for any complications, such as bloating (ascites) or bleeding (varices). Read more about cirrhosis, its complications and how they are treated.

Monitoring your condition

It’s important to have regular appointments with your doctor or specialist so they can monitor your condition. They will be able to provide you with more information on how often these should be, who with and what to expect. If you have cirrhosis, you’ll need monitoring every six months for the rest of your life, which will include checking (surveillance) for a type of liver cancer called hepatocellular carcinoma.

You should also have fibrosis tests to check the scarring in your liver every 2 years. This is important because there are often no symptoms to alert you or your doctor if your disease getting worse.

Stop drinking alcohol

If you have alcohol-related fatty liver, the damage may be reversed if you stop for a period of time (months or years). After this, it’s usually safe to start drinking again if you stick to the recommended government guidelines. Speak to your doctor if you are thinking of starting drinking again, if you have a dependence on alcohol it may not be safe to start again.

If you have a more serious form of alcohol-related liver disease, such as alcohol-related hepatitis or cirrhosis, your doctor will advise you to stop drinking completely (lifelong abstinence) to prevent further damage.

Lots of people find it hard to stop drinking or cut down, so ask your doctor for help if you need it. They can refer you to specialist advice and support from alcohol services. If you have consumed a lot of alcohol over a long period of time, you may need medical assistance (a medical detox) to help your body cope without alcohol to start with.

If you’re dependent on alcohol, you can experience alcohol withdrawal symptoms if you suddenly stop drinking, so your doctor might recommend cutting down your alcohol intake slowly rather than stopping straight away. Reducing the amount of alcohol you drink can still lead to a significant improvement in your condition.

You might be offered medication and psychological therapy, such as cognitive behavioural therapy (CBT), to help you through the withdrawal process. Some people need to stay in hospital or a specialist rehabilitation clinic during the initial withdrawal phases so their progress can be closely monitored. If you’re at home, you’ll need to regularly see a nurse or another health professional. This could be at home, at your GP surgery or at a specialist NHS service.

Once you have stopped drinking, you might need further medical treatment to help ensure you do not start drinking again.

Diet and nutrition

A lot of people with alcohol-related liver disease are malnourished. Not getting the right nutrients from your diet makes it harder for your liver to recover, so eating well is key to treating your condition.

For earlier stage alcohol-related liver disease, focus on eating a well-balanced diet that includes lots of vegetables, fruit, wholegrain carbohydrates (such as wholemeal bread or brown rice) and lean protein (such as chicken, fish or tofu). Cut down on highly processed foods and snacks, especially those that are high in fat, sugar, or salt.

If you have alcohol-related hepatitis or cirrhosis, as well as eating a healthy balanced diet you may need to follow special advice to make sure you get enough energy (calories) and protein, and not too much salt. This will help prevent muscle wasting and weakness. Read detailed information about eating well with cirrhosis.

In some serious cases of malnutrition, you may need to be fed through a tube (enteral nutrition). The tube is very thin, it goes up your nose and then through your food pipe and into your stomach. This is often lifesaving, but requires very specialist expertise and care to avoid harm. Many patients can be taught to use the tube feeding system at home and isn’t uncomfortable to use.

It’s important to keep your weight healthy, as this helps stop more damage to your liver. Carrying extra bodyweight can cause liver damage too. And if you are underweight it could be a sign that you are malnourished. If you need to lose or gain weight ask your doctor for advice on diet tailored to you.

Doing regular physical activity or exercise can help keep you strong and prevent muscle wasting. Do what you can manage each day – doing something, even something small, is much better than nothing. Find out more about being active.

Talk to your clinical team before making any changes to your diet, they know you best and can give you personalised advice. Your diet and nutrition should be regularly reviewed by a liver specialist or dietitian with experience in advising liver disease patients, to ensure you are given the right advice based on your individual needs.

Medicines

The use of medication to directly treat alcohol-related liver disease is complex and there’s generally a lack of good evidence to support its effectiveness. As there’s no one-size-fits-all approach it’s important you have a specialist co-ordinating your care and that you understand the plan they have put in place for you.

If you have severe alcohol-related hepatitis, you may need to be treated in hospital. Specialists may use anti-inflammatory medication in some patients to reduce liver damage, such as steroids (corticosteroids).

Corticosteroid treatment:

Has been shown to improve survival in the short term (1 month)
Has not been shown to improve survival over a longer term (3 months to 1 year)
Increases the risk of serious infections within the first 3 months of starting treatment.

Other medicines that can be used to treat liver disease and its complications include antibiotics and heart medicines, like beta blockers. These are classed as off-label or unlicensed medicines, meaning that the medicine isn’t licensed for treatment of your condition. But the medicine will have a licence to treat another condition and will have undergone clinical trials for this. Your doctor may recommend these if they think it will treat your condition effectively and the benefits are greater than any risks.

If you have been admitted to hospital with alcohol-related liver disease, it’s really important that before you are discharged you ask about aftercare. If you don’t get the information you need about managing your condition at home, speak to your doctor.

Liver transplants

If your liver is very badly damaged, a liver transplant could be life-saving. It’s usually only recommended if other treatments are no longer helpful, and your life is threatened by end stage liver disease.

There’s a general assumption that if you have later stage alcohol-related liver disease you can’t have a liver transplant, but this isn’t true. Things have changed, which means you can be eligible if it’s the right treatment for you. To be eligible you must have stopped drinking completely. Your liver specialist will try to treat your liver disease for a couple of months before considering referring you to a transplant specialist.

Anyone with liver disease can have a transplant assessment if they meet certain conditions. This will be carried out at a liver transplant unit, and the process usually takes about a week. You may need to stay in hospital during this time, or you may be able to go home at the end of each day.

The assessment involves talking to liver transplant specialists and having tests to check your liver and general health, including the strength of your heart and lungs.

As surgery is very technical, people who have a transplant will need to spend some time in the Intensive Care Unit (ICU) after their operation.

Liver transplants are very successful. They are a major operation so it can take up to a year to recover, most people are able to leave hospital around 10 days after surgery.

Once you’ve had a transplant you’ll need lifelong treatment with medication to control your immune system. This is managed by your transplant specialist or hepatologist.

If you have later stage liver disease it’s really important to ask your liver specialist about having a transplant. There are 7 transplant units in the UK and they will tell you which one they usually refer to. Read or download more information about liver transplants here.

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