When the liver eventually becomes so damaged by alcohol that the owner is able to notice something wrong one of three things may happen.
The stomach swells with fluid.
There is massive bleeding into the gut and the patient vomits huge amounts of blood, this is immediately fatal in 1/3 of cases.
The skin and eyes go bright yellow in colour, this is called alcoholic hepatitis and can be fatal within 3 weeks in 2/3 of severe cases, particularly if the patient is not treated in a recognised liver unit.
Quite often all three things will happen at once.
There are two reasons for this. As we said earlier the liver is so important to the body that it has quite a lot of spare capacity, when alcohol damages the liver with silent scarring nothing happens until all the liver reserve is used up. Its a bit like driving a car without a petrol gauge; there is no warning the car just stops when it has run out of petrol.
The second reason is that the liver defends itself against the poisonous effects of alcohol using a whole bunch of different techniques that are related to diet, general health and your genetic background. When these defences run out the liver can become very inflamed suddenly (inflammation is what happens to your skin when it burnt, it gets very red and very sore, a similar thing happens inside the liver).
We said earlier that we would discuss how to improve the defences against alcohol induced liver damage, well it is likely that eating a good varied diet full of vitamins and anti-oxidants will minimise the risk of developing acute alcoholic hepatitis. Having said this, we have seen plenty of very well nourished patients die of alcoholic liver disease over the years.
Sudden inflammation of the liver due to alcohol is called Alcoholic Hepatitis.
Unlike fat and scarring - showing you a picture of alcoholic hepatitis may not necessarily be the best way of explaining it, but here is one anyway.
On the top / left is the normal liver again; each of the round dots is the centre of a liver cell. On the bottom / right is a biopsy from a patient with alcoholic hepatitis, the liver cells are very swollen and white, these are extremely sick liver cells. Around the liver cells are lots of tiny black dots, these are white cells from the blood and they should not be there, this is the inflammation. The result of all these sick liver cells and inflammation is that the liver can no longer work properly. This is called liver failure.
Nearly 2/3 of patients who develop severe alcoholic hepatitis will die in hospital. Often people who develop alcoholic hepatitis are completely fit and healthy beforehand. We once had a patient who had just passed a very strict medical in order to be able to continue flying helicopters. He not only developed acute alcoholic hepatitis, but also had cirrhosis, and this was completely missed at the medical showing how this disease can devleop completely silently.
If you have been drinking around 8 or more units each day for a few years then you are at risk of developing alcoholic hepatitis. It is a very common problem and is usually the reason that someone who drinks too much is admitted to hospital as an emergency. The incidence of alcoholic hepatitis is increasing. Deaths from alcoholic hepatitis in young people have increased seven times since the 1970s and last year it killed over 500 men and 300 women under the age of 44 in the UK. Acute alcoholic hepatitis kills at least 4x more people in the UK every year than die of heroin, cocaine and ecstacy put together.
The purpose of this website is to give as many people as possible the information that they need to prevent them developing serious liver disease in the first place. Because liver disease can present so suddenly, many people will die of their first illness, either from bleeding or jaundice.
The good news is that if a person survives the first illness and stops drinking then the liver can still recover. The liver is one of the few organs in the body that can regenerate, providing it has not become too scarred. With most people after a few months of complete abstinence from alcohol the liver will improve, the yellow jaundice will settle and the tummy swelling will go down. Providing the person stays completely clear of alcohol in the future then the liver will often repair itself just enough to get by. At this stage cutting down on drinking is no longer an option. The only option for survival is to cut out all alcohol completely and permanently.
Medical treatment may also be necessary for certain aspects of liver failure. One side effect of the scarring in the liver is to squeeze the blood vessels, this raises the pressure in the veins of the gullet and they burst causing massive internal bleeding. Another problem is a build up of fluid in the abdomen. Finally there can be a build up of toxins that are normally processed by the liver - this poisons the brain, finally fluid can build up in the abdomen.
All of the blood from the gut passes through the liver so that food from the gut can be absorbed and processed. If the liver is scarred the blood vessels get squeezed and the pressure on the blood vessels in the gut rises. Eventually the blood vessels burst into the gut. The first thing that the patient normally notices is that they suddenly vomit huge amounts of fresh blood and are rushed to hospital in an ambulance. Sometimes it is possible to rescue the situation with a blood transfusion but in 25-50% of cases this first bleed is fatal.
The best way to stop people bleeding to death as a result of drinking is for them to recognise that they are at risk, and for them to cut down their drinking to safe levels.
The liver specialist in the hospital will try and stop the bleeding using an endoscope; this is a flexible tube with a television camera on one end. The bleeding can be stopped by either injecting the blood vessels to block them, by putting bands around them to stop the bleeding or by using a balloon to press on the vessels. If this is successful then further treatment will be needed to try and close up the remaining blood vessels.
Sometimes the bleeding continues despite all these efforts. In this case the specialist liver radiologist (x ray doctor) may try to relieve the pressure by draining the blood vessels through a special tube that goes through the liver, this is called a TIPSS.
For various reasons to do with the pressure in blood vessels, the proteins normally made in the liver and the function of the kidneys, it is very common for fluid to build up in the liver when it fails. The picture shows someone with a moderate amount of fluid in the abdomen, notice how the skin is also yellow with jaundice.
This fluid will often disappear as the liver failure improves over several months of abstinence from alcohol. Sometimes the patient may be given water tablets, but often it will necessary to drain the fluid off under local anaesthetic through a small tube.
We have many patients who need to come in every few weeks to have their fluid drained, most of them are still drinking alcohol. I had one patient who came in every few weeks for two years until he finally stopped drinking. After a further year free of alcohol he was then referred for a liver transplant.