Alcohol Related Liver Disease

Alcohol is the most widely consumed mood-altering substance in the United States. It is a causal factor in more than 200 disease and injury conditions.[1] Heavy drinking has many potential health consequences including liver disease. In the United States, it is the leading cause of liver disease.[2] Alcohol related liver disease [ARLD] is a result of heavy, prolonged drinking that results in liver swelling and inflammation. Over time this can lead to cirrhosis, the final stage of liver disease. The symptoms of ARLD depend on the stage of the disease.

There are three stages^[3]:

1. Fatty liver disease: This is the first stage of ARLD, where fat starts to accumulate around the liver. It can be cured by not drinking alcohol anymore.
2. Alcoholic hepatitis: Alcohol abuse causes inflammation (swelling) of the liver in this stage. The outcome depends on the severity of damage. In some cases, treatment can reverse the damage, while more severe cases of alcoholic hepatitis can lead to liver failure.
3. Alcoholic cirrhosis: This is the most severe form of ARLD. At this point, the liver is scarred from alcohol abuse, and the damage cannot be undone. Cirrhosis may eventually lead to liver failure.

The signs of liver disease can vary.  In the first stage of liver disease termed alcoholic fatty liver disease there are no physical symptoms. The findings on examination of an enlarged liver and unexplained elevation of liver function tests can be a clue. Occasionally a fatty liver is discovered incidentally during an ultrasound of the abdomen or with a CT/MRI scan for another medical issue. Remember. At this stage the patient has no symptoms related to alcoholic fatty liver disease.

Acute alcoholic hepatitis, the second stage of ARLD, can present with nausea, loss of appetite, weight loss, swelling of the abdomen or legs, confusion, vomiting, fever, malaise, and jaundice [yellowing of the skin]. Patients at risk for more severe ARLD include persons that do not eat well, binge drinkers, and persons with a family history of liver disease.

Alcoholic cirrhosis is the most severe stage of alcohol related liver disease. Cirrhosis occurs in 30% of individuals with long-standing consumption of more than 3 drinks a day.[4]  Cirrhosis implies that scar tissue has replaced the normal liver cells after the liver cells die. Cirrhosis is marked by degeneration of cells, inflammation, and fibrous thickening of tissue.  Once cirrhosis has developed, the liver damage is irreversible. The prognosis is improved with abstinence, but complications (e.g., gastrointestinal bleeding) often occur. Medications are available to assist in the management of more advanced liver disease including cirrhosis. Liver transplantation may be considered in patients with severe complications.[5]

Making the diagnosis of alcoholic liver disease requires a detailed patient history with supportive laboratory and imaging studies. A liver biopsy may be useful to confirm the diagnosis, and to rule out other diseases. [6] By far the most important recommendation to the patient diagnosed with alcohol related liver abnormalities is to openly discuss their drinking habits. Lying to your doctor may result in numerous extraneous and unnecessary tests and can ultimately delay the diagnosis.

Treatment and management of alcohol liver disease depend on the extent of the disease. In general recommendations include:

• Alcohol abstinence, enrollment to detoxification programs and treatment to support long term recovery
• Nutritional support
• Screening for hepatocellular carcinoma with ultrasonography every six months and screening for esophageal varices in those with cirrhosis
• Chronic alcoholics are more prone to develop hepatotoxicity from acetaminophen, so dosing should not exceed more than 2000 mg per day. An average person can tolerate up to 4000 mg of acetaminophen per day.
• Treatment of co-existing liver diseases such as Hepatitis B and C viral infections[7]

In summary the diagnosis of alcohol related liver disease at any stage can be treated once the diagnosis is established. The first step is to discuss openly your drinking behaviors with your physician. The second step is to be willing to address the drinking that got you there.

Marc Whitsett MD

DABIM, ABAM, FASAM

[1] https://www.who.int/news-room/fact-sheets/detail/alcohol

[2] https://www.ncbi.nlm.nih.gov/books/NBK546632/

[3] https://www.healthline.com/health/alcoholism/liver-disease#types-and-symptoms

[4] https://www.ncbi.nlm.nih.gov/books/NBK546632/

[5] https://pubmed.ncbi.nlm.nih.gov/9553600/

[6] http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/alcoholic-liver-disease/#:~:text=The%20diagnosis%20of%20alcoholic%20liver,for%20enrollment%20in%20clinical%20trials

[7] https://www.ncbi.nlm.nih.gov/books/NBK546632/

Studies continue to show that a healthy, balanced diet is an effective tool that can be used to prevent disease, slow aging, and heal the body and mind. When an individual enters recovery, they need to be prepared to work not just on overcoming the urge to use drugs or drink, but also to heal their mind, body, and spirit. This is done through an integrated treatment plan that uses a variety of means, including therapy, exercise, meditation, adequate sleep, and a healthy diet. In fact, researchers emphasize that one of the main pillars of total health and wellness is proper nutrition, and more and more treatment centers are helping clients realize the benefits of nutrition during and after treatment.

There has been much research in recent years on the benefits and importance of good nutrition. We now know that eating a variety of healthy foods that are packed with vitamins and minerals will not only make us look and feel great but will help us combat certain diseases and prevent others. What we eat impacts our entire body – it affects our health, our mood, our energy level, and our brain functioning.

Addiction and Malnutrition

People often eat poorly because of emotions, stress, and other factors, and those struggling with drug or alcohol addiction are no exception. At times, an addict will binge eat unhealthy foods because of cravings brought on by substance use. Other times, they might not eat at all because their substance masks their hunger or fills them up with empty calories. Many addicts are deficient in essential nutrients, including zinc and vitamin B. Low zinc levels can lead to poor vision, sores on the skin, confusion, depression, and intestinal problems. A shortage of vitamin B in the body can slow the production of dopamine, which leads to increased cravings, severe mood swings, and depression. Likewise, individuals with severe fluctuations in blood sugar levels, such as often occur among addicts, are more likely to experience cravings, GI upset, and mood swings.

Food is Fuel

Alternatively, when people eat well, they remain healthier in the long run and are in better control of their own health. Some would even say food is like medication for certain health issues. Geisinger Health System, located in Pennsylvania, has recently begun incorporating the Fresh Food Farmacy among its hospitals. This program provides healthy foods including fruits, vegetables, lean meats, and low-sodium options to patients, and they are already seeing positive results. “We are far away from prescribing diets categorically to fight disease,” Dr. William Li, a heart expert and author of Eat to Beat Disease, told TIME Magazine. “And we may never get there. But we are looking to fill in the gaps that have long existed in this field with real science. This is the beginning of a better tomorrow.”

To reverse the effects of a poor diet, experts recommend fruits and vegetables, which are high in necessary vitamins and antioxidants and help provide energy and healing to bodies in recovery that need it. Foods high in protein help the body produce dopamine, which is especially important to those going through withdrawal from drugs that inhibit the body’s normal production of this feel-good chemical.

Benefits of eating healthy foods:

• Reduces risk of chronic diseases such as diabetes, heart disease, and stroke
• Promotes healthy metabolism and increased energy
• Slows the progression of cognitive decline
• Improves emotional health
• Decreases depression and reduces stress

Different foods produce different benefits, and researchers and treatment providers all have their own beliefs and findings of what foods are best to eat. In general, most experts agree about the following classifications of food:

Good foods for health and brain function:

• Fish
• Legumes
• Nuts
• Seeds
• Vegetables
• Fruit
• Wholegrains

Foods to avoid:

• Sugar
• Simple carbohydrates
• Trans fats
• Processed foods

A Holistic Treatment Plan that Works

Along with nutrition, experts say that adequate sleep, positive social activities, spiritual growth, and physical exercise are all important during the recovery process. Various lifestyle modifications help the entire individual heal, build strength, and become better prepared to face the challenges of rehab. A wide focus on whole health is one of the best ways to facilitate lasting recovery.

Focusing on whole body healing is important during recovery, but it is also vital to life and success after treatment. The newly sober individual who has learned the importance of eating healthy foods, exercising regularly, remaining socially active, and caring for their own spiritual wellbeing will find they are better prepared to face each new day. Maintaining a sober lifestyle long after recovery can be difficult, but with a stronger body and mind, it is achievable.

Even though researchers are finding vast benefits to nutrition, exercise, and mediation to those in recovery, it is important to remember that these alone are not enough to heal an addiction. Instead, they fill a supportive role in the recovery process. Therapy, counseling, and even medications at times are necessary to the individual’s recovery, and there really is no substitute to hard work and proper healing with the help of a trained professional. With the help of therapy, skills development, and a focus on emotional and physical healing, an individual can rebuild their health and prepare themselves for a sober life.

Nutrition and Recovery at The Ridge

The Ridge is a state-of-the-art treatment facility that offers the very best therapy and counseling available. Our experienced staff members are compassionate, professional, and will help you or your loved one learn how to overcome addiction.

The Ridge is a drug and alcohol treatment facility located near Cincinnati in Batavia, Ohio. Our program focuses on full body health, and we understand the importance of proper nutrition during rehab. Our private chef prepares nutritional meals for our clients that are rich in nutrients, whole grains, and amino acids, and are specially designed to promote healing and reduce cravings. We also incorporate physical exercise, meditation, social activities, and time spent outdoors in our program, which help create balance in our clients’ everyday lives.

Dr. Whitsett is Board Certified in Internal Medicine and Addiction Medicine. He is the Medical Director for The Ridge Treatment Center. You can read his full bio here.

I Drink A Lot. Can I Just Quit Drinking Safely?

Some people drink a lot. They often ask can I quit drinking safely? Some people decide they should quit drinking, as they understand that excessive drinking is not healthy. For people who drink to excess, one of the most difficult things to do is to make that decision to quit.

However, before someone decides to just quit drinking, it is important for them to understand that for some people, this can be dangerous, even life threatening.

So how do you know if it is safe to just quit?

Well, it depends.

Most people that drink too much are not physically dependent upon alcohol. Alcohol-dependent individuals must drink every day. When they stop drinking for even 1 day, they suffer symptoms of alcohol withdrawal.

Symptoms of alcohol withdrawal include, but are not limited to:

• hand tremors
• a lot of anxiety
• sweating
• nervousness
• a racing heart
• body twitches
• seizures

Rarely symptoms of alcohol withdrawal escalate, leading to “DTs”, or delirium tremens, a life-threatening syndrome that can cause cardiovascular and respiratory failure. Other symptoms of DTs might include confusion, fever, and hallucinations.

In addition, someone who stops drinking abruptly can also suffer seizures, with or without DTs.

If a person is able to stop drinking for 24 hours and they have no withdrawal symptoms such as hand tremors, feeling a lot of anxiety, sweating, nervousness, a racing heart, and body twitches, generally there is no danger of continuing not to drink and medical care with medication is not required.

However, if a person experiences the above mentioned withdrawal symptoms:

1. While they are actively cutting down on their drinking, or
2. Within 24 hours of quitting drinking

then it is important to seek medical attention.

In general, people at high risk of medical complications coming off alcohol are:

1. Those that have a history of DTs.
2. Those with a history of seizures.
3. Those people with a history of chronic, heavy, daily drinking (usually for weeks or months without a day off).
4. Those that have to drink to start the day because of hand tremors or feeling ill.

It is difficult to quantify if there is a specific amount of alcohol consumed that places someone at risk for alcohol withdrawal syndrome and/ or DTs. 

While some people can drink large amounts (say a case of beer a day), not everyone that drinks this much has alcohol withdrawal since the ability to withstand alcohol’s physical effects can vary from person to person.

As a general rule (no medical studies to confirm), if a person drinks 13 standard drinks a day for a month, then they have about a 50% chance of having major life-threatening withdrawals.[1] 

In instances where a person develops alcohol withdrawal, it is recommended that the person seeks medical attention to assess and advise treatment. Alcohol withdrawal can be lethal. When alcohol withdrawal is medically managed, however, the fatality rate is extremely low.

When we assess a patient with alcohol withdrawal, we check vital signs, a breathalyzer, obtain a brief history and physical and do an assessment called a “CIWA-Ar”, or Clinical Assessment for Alcohol Withdrawal, Revised.[2] This 5-10 step assessment is simple, and can predict if someone is at risk for a mild, moderate or severe alcohol withdrawal syndrome.

When we identify a patient with alcohol withdrawal symptoms, we determine the severity of the withdrawal risk and then place the patient in a level of care appropriate for that particular patient. Most of the time, a patient can be treated with medication as an outpatient; rarely, the patient requires hospitalization.

So, my advice is that if a person is experiencing symptoms that suggest alcohol withdrawal, they should consult with a health care professional and obtain a medical evaluation to determine if they are at risk.

If the person is not at risk, no harm, no foul. But I guarantee that if they are at risk, they will be glad they sought medical attention to manage their withdrawal from alcohol in the safest manner possible.

[1] http://hams.cc/odds/; a standard drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor

[2] https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal

ALCOHOL WITHDRAWAL PROTOCOL

At The Ridge, we’ve spoken about the dangers of alcohol withdrawal. Of all substances, alcohol withdrawal is the most likely to be deadly in extreme cases without proper treatment. Even heroin withdrawal, as difficult as it is, isn’t as dangerous as withdrawal from alcohol. That’s why it’s so essential that alcohol withdrawal protocol is managed by expert physicians who are knowledgeable in the process.

When doctors manage alcohol withdrawal, the danger of lethal complications dramatically decreases. One way that withdrawal is managed is by the use of prescription benzodiazepines. These drugs are powerful tranquilizers that affect the brain in a way similar to alcohol. Since the worst alcohol withdrawal symptoms—delirium tremens, hallucinations, seizures—come from a hyperactive brain, using a tranquilizer to calm the brain down understandably mitigates the worst effects. We have patients visit us as far as Columbus, Ohio for alcohol treatment.

However, using benzos during alcohol withdrawal carries its own risks that you need a skilled doctor to avoid. Benzos are extremely addictive themselves and have their own difficult withdrawal period. The best way to prevent addiction or withdrawal is for your doctor to prescribe a series of ever-decreasing doses over a set period of time. By weaning off of benzos, you avoid withdrawing from them, and using them only temporarily makes addiction very unlikely.

The Ridge is a physician managed facility with a staff of addictionologists and treatment experts. Learn more about The Ridge.

It’s important to be aware that withdrawal from continued, high amounts of alcohol should be managed by a physician. However, there are situations where one might be forced to withdraw from alcohol without that kind of preparation.

If an alcoholic suffers a serious accident and is taken to the hospital, they will be unable to drink while being treated, forcing them to undergo withdrawal. We’ve heard stories of people detoxing from alcohol while in the hospital, with the doctors treating them not familiar enough with addiction to realize what’s happening to their patients. Some doctors who are ignorant of what addiction is or how harmful withdrawal can be will not treat the withdrawal process in a misguided attempt to punish the addict and teach them a lesson about the consequences of their actions. While this isn’t sure to happen—there are thousands of great doctors who can provide effective, proper treatment—it’s worth knowing there’s a possibility.

The best way to be sure that an alcoholic’s withdrawal process is safely managed according to proper alcohol withdrawal protocol is to get them into a treatment center. The Ridge’s staff physicians can safely oversee alcohol withdrawal, both at The Ridge and at local Cincinnati hospitals. Our residential treatment program will give alcoholics the tools they need to get into recovery and maintain long-term health, happiness, and sobriety.