Alcoholic Liver Disease (ALD)

Content of This Page

1- Introduction

2- Pathophysiology

3- Symptoms

4- Stages of The Disease

5- Treatment

6- What Should You Avoid

Introduction

Alcoholic Liver Disease (ALD) refers to a range of liver conditions caused by chronic and excessive alcohol consumption. It represents a major cause of chronic liver disease globally and contributes significantly to liver-related morbidity and mortality. The disease spectrum includes:

 

  • Alcohol-related fatty liver (steatosis)

  • Alcoholic hepatitis

  • Alcoholic cirrhosis

© image from Wikimedia Commons

Pathophysiology

1-Ethanol metabolism in the liver generates acetaldehyde and reactive oxygen species (ROS).These damage hepatocytes by disrupting proteins, lipids, and DNA.

2-Fatty liver (steatosis) develops as alcohol:

  • Inhibits fat breakdown (β-oxidation) and promotes fat synthesis.
  • Causes triglyceride accumulation in hepatocytes.

3-Alcoholic hepatitis arises from:

  • Inflammatory cytokines (e.g. TNF-α) and immune cell infiltration.

  • Hepatocyte ballooning and formation of Mallory-Denk bodies.

4-Fibrosis and cirrhosis result from:

  • Activation of hepatic stellate cells → collagen deposition.
  • Architectural distortion of the liver with loss of function.

5-Modifying factors include:

  • Genetics (e.g. PNPLA3 variants), obesity, viral hepatitis, and malnutrition.

© image from librepathology

Symptoms

  1. Fatty Liver:

  • Often asymptomatic

  • May have fatigue or mild right upper abdominal discomfort

  1. Alcoholic Hepatitis:

  • Jaundice, fever, nausea, RUQ pain

  • Anorexia, weight loss, fatigue

  • Severe cases: confusion (encephalopathy), bleeding, renal issues

  1. Alcoholic Cirrhosis:

  • Abdominal swelling (ascites), leg oedema

  • Vomiting blood (variceal bleeding), confusion

  • Hormonal signs: spider naevi, gynaecomastia, testicular atrophy

  • Chronic signs: muscle wasting, Dupuytren’s contracture, parotid swelling

Stages of The Disease

1-Fatty Liver (Steatosis):

  • Fat builds up in liver cells
  • Usually silent and fully reversible with alcohol abstinence

2-Alcoholic Hepatitis:

  • Inflammatory liver injury with jaundice, fever, and RUQ pain
  • Can be severe and life-threatening, but partially reversible

3-Alcoholic Cirrhosis:

  • Permanent liver scarring and dysfunction
  • Features: ascites, encephalopathy, bleeding
  • Irreversible, but abstinence may slow progression

Treatment

1-Alcohol Abstinence:

  • Most important intervention
  • Improves outcomes at all stages
  • Requires counselling and rehabilitation support

2-Nutritional Support:

  • High-protein, high-calorie diet
  • Supplement vitamins (e.g. thiamine, folate, zinc)

3-Alcoholic Hepatitis (Severe Cases):

  • Corticosteroids (e.g. prednisolone) if DF >32
  • N-acetylcysteine (NAC) may be added
  • Stop steroids if no response at 7 days

4-Cirrhosis Management:

  • Standard treatment for ascites, varices, and encephalopathy
  • Monitor for complications

5-Liver Transplantation:

  • Consider in end-stage disease
  • Requires sustained abstinence and psychosocial assessment

What Should You Avoid

1-Alcohol – Absolute avoidance is essential at all stages.

2-Liver-toxic drugs – Avoid high-dose paracetamol, NSAIDs, and certain antibiotics.

3-Sedatives (e.g. benzodiazepines) – Can worsen hepatic encephalopathy.

4-High-salt diet – Exacerbates ascites and oedema.

5-Herbal or unregulated supplements – May be toxic to the liver.

6-Smoking – Accelerates liver damage and fibrosis.

7-Raw shellfish or contaminated food – Increases infection risk in cirrhotic patients.

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