Alcoholic hepatitis

Alcoholic hepatitis is inflammation of the liver caused by drinking alcohol.

Alcoholic hepatitis is most likely to occur in people who drink heavily over many years. However, the relationship between drinking and alcoholic hepatitis is complex. Not all heavy drinkers develop alcoholic hepatitis, and the disease can occur in people who drink only moderately.

If you're diagnosed with alcoholic hepatitis, you must stop drinking alcohol. People who continue to drink alcohol face a high risk of serious liver damage and death.

Symptoms

The most common sign of alcoholic hepatitis is yellowing of the skin and whites of the eyes (jaundice).

Other signs and symptoms include:

• Loss of appetite
• Nausea and vomiting
• Abdominal tenderness
• Fever, often low grade
• Fatigue and weakness

Malnutrition is common in people with alcoholic hepatitis. Drinking large amounts of alcohol suppresses the appetite, and heavy drinkers get most of their calories from alcohol.

Additional signs and symptoms that occur with severe alcoholic hepatitis include:

• Fluid accumulation in your abdomen (ascites)
• Confusion and behavior changes due to a buildup of toxins normally broken down and eliminated by the liver
• Kidney and liver failure

When to see a doctor

Alcoholic hepatitis is a serious, often deadly disease.

See your doctor if you:

• Have signs or symptoms of alcoholic hepatitis
• Can't control your drinking
• Would like help cutting back on your drinking

Causes

Alcoholic hepatitis develops when the alcohol you drink damages your liver. Just how alcohol damages the liver — and why it does so only in some heavy drinkers — isn't clear.

These factors are known to play a role in alcoholic hepatitis:

• The body's process for breaking down alcohol produces highly toxic chemicals.
• These chemicals trigger inflammation that destroys liver cells.
• Over time, scars replace healthy liver tissue, interfering with liver function.
• This irreversible scarring (cirrhosis) is the final stage of alcoholic liver disease.

Other factors that can contribute to alcoholic hepatitis include:

• Other types of hepatitis. If you have hepatitis C and also drink — even moderately — you're more likely to develop cirrhosis than if you don't drink.
• Malnutrition. Many people who drink heavily are malnourished because they eat poorly or because alcohol and its byproducts prevent the body from properly absorbing nutrients. Lack of nutrients contributes to liver cell damage.

Risk factors

The major risk factor for alcoholic hepatitis is the amount of alcohol you consume. How much alcohol it takes to put you at risk of alcoholic hepatitis isn't known. But most people with the condition have a history of drinking more than 3.5 ounces (100 grams) — equivalent to seven glasses of wine, seven beers or seven shots of spirits — daily for at least 20 years.

However, alcoholic hepatitis can occur among those who drink less and have other risk factors.

Other risk factors include:

• Your sex. Women seem to have a higher risk of developing alcoholic hepatitis possibly because of differences in the way alcohol is processed in women.
• Obesity. Heavy drinkers who are overweight might be likelier to develop alcoholic hepatitis and to progress from that condition to cirrhosis.
• Genetic factors. Studies suggest there may be a genetic component in alcohol-induced liver disease although it's difficult to separate genetic and environmental factors.
• Race and ethnicity. Blacks and Hispanics might be at higher risk of alcoholic hepatitis.
• Binge drinking. Having five or more drinks within two hours for men and four or more for women might increase your risk of alcoholic hepatitis.

Complications

Complications of alcoholic hepatitis, which result from severe liver damage, relate to scar tissue. Scar tissue can slow blood flow through your liver, increasing pressure in a major blood vessel (portal vein), and the buildup of toxins. Complications include:

• Enlarged veins (varices). Blood that can't flow freely through the portal vein can back up into other blood vessels in the stomach and esophagus. These blood vessels have thin walls and are likely to bleed if filled with too much blood. Heavy bleeding in the upper stomach or esophagus is life-threatening and requires immediate medical care.
• Ascites. Fluid that accumulates in the abdomen might become infected and require treatment with antibiotics. Ascites isn't life-threatening but are usually a sign of advanced alcoholic hepatitis or cirrhosis.
• Confusion, drowsiness and slurred speech (hepatic encephalopathy). A damaged liver has trouble removing toxins from your body. The buildup of toxins can damage your brain. Severe hepatic encephalopathy can result in coma.
• Kidney failure. A damaged liver can affect blood flow to the kidneys, resulting in damage to those organs.
• Cirrhosis. This scarring of the liver can lead to liver failure.

Prevention

You might reduce your risk of alcoholic hepatitis if you:

• Drink alcohol in moderation, if at all. For healthy adults, moderate drinking means up to one drink a day for women of all ages and men older than 65, and up to two drinks a day for men age 65 and younger. The only certain way to prevent alcoholic hepatitis is to avoid all alcohol.
• Protect yourself from hepatitis C. Hepatitis C is an infectious liver disease caused by a virus. Untreated, it can lead to cirrhosis. If you have hepatitis C and drink alcohol, you're far more likely to develop cirrhosis than if you didn't drink.
• Check before mixing medications and alcohol. Ask your doctor if it's safe to drink alcohol when taking your prescription medications. Read the warning labels on over-the-counter medications. Don't drink alcohol when taking medications that warn of complications when combined with alcohol — especially pain relievers such as acetaminophen (Tylenol, others).

Diagnosis

Your doctor will conduct a physical examination and ask about your current and past alcohol use. It's important to be honest about your drinking habits. Your doctor might ask your permission to interview family members about your drinking.

To test for liver disease, your doctor might recommend:

• Liver function tests
• Blood tests
• An ultrasound, CT or MRI scan of the liver
• A liver biopsy, if other tests and imaging don't provide a clear diagnosis or if you are at risk of other causes of hepatitis

Treatment

Treatment for alcoholic hepatitis involves quitting drinking and therapies to ease the signs and symptoms of liver damage.

Quitting drinking

If you've been diagnosed with alcoholic hepatitis, you must stop drinking alcohol and never drink alcohol again. It's the only way to possibly reverse liver damage or prevent the disease from worsening. People who don't stop drinking are likely to develop a variety of life-threatening health problems.

If you are dependent on alcohol and want to stop drinking, your doctor can recommend a therapy that's tailored for your needs. It can be dangerous to stop drinking suddenly so if you're dependent, be sure to discuss a plan with your doctor.

Treatment might include:

• Medications
• Counseling
• Alcoholics Anonymous or other support groups
• Outpatient or residential treatment program

Treatment for malnutrition

Your doctor might recommend a special diet to correct nutritional problems. You might be referred to a dietitian who can suggest ways to increase your consumption of the vitamins and nutrients you lack.

If you have trouble eating, your doctor might recommend tube feeding. A tube is passed down your throat or through your side and into your stomach. A special nutrient-rich liquid diet is then passed through the tube.

Medications to reduce liver inflammation

If you have severe alcoholic hepatitis, your doctor might recommend:

• Corticosteroids. These medications have shown some short-term benefit in increasing the survival of certain people with severe alcoholic hepatitis. However, corticosteroids have serious side effects and generally aren't prescribed if you have failing kidneys, gastrointestinal bleeding or an infection.
• Pentoxifylline.Your doctor might recommend this anti-inflammatory medication if you can't take corticosteroids. The benefit of pentoxifylline (Pentoxil) for alcoholic hepatitis isn't clear. Study results are inconsistent.

Liver transplant

For many people with severe alcoholic hepatitis, the risk of death is high without a liver transplant.

Historically, those with alcoholic hepatitis have not been liver transplant candidates because of the risk that they will return to harmful drinking after transplant. Recent studies, however, suggest that carefully selected patients with severe alcoholic hepatitis have post-transplant survival rates similar to those of liver transplant recipients with other types of liver disease.

For transplant to be an option, you would need:

• To find a program that works with liver transplant patients who have alcoholic hepatitis
• To meet the requirements of the program, which would include lifelong commitment to alcohol abstinence as well as other requirements of the specific transplant center

Preparing for an appointment

You might be referred to a digestive disease specialist (gastroenterologist).

What you can do

When you make the appointment, ask about restrictions, such as restricting your diet for certain tests.

Make a list of:

• Your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment, and when they began.
• All medications, vitamins and supplements you take, including doses.
• Key medical information, including other conditions you have.
• Key personal information, including recent changes or stressors in your life. Track your alcohol consumption for a few days so that you can let your doctor know how much you regularly consume.
• Questions to ask your doctor.

Have a relative or friend accompany you, if possible, to help you remember the information you're given.

Questions to ask your doctor

• What's the most likely cause of my symptoms? Are there other possible causes?
• What tests do I need? How do I need to prepare for them?
• Is my condition temporary or chronic?
• What treatments are available? Which one do you recommend?
• I have other health problems. How can I best manage these conditions together?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, including:

• How severe are your symptoms? Are they occasional or constant?
• Does anything improve or worsen your symptoms?
• Have you had hepatitis or yellowing of the skin?
• Do you use recreational drugs?
• Are your family members or friends concerned about your drinking? Have you had social consequences — such as an arrest — because of your drinking?
• Do you get angry or anxious when the subject of your drinking is discussed?
• Do you feel guilty about drinking?
• Do you drink in the morning?

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