In the United States, about 35 to 40 percent of heavy drinkers will develop alcoholic hepatitis, and 10 to 15 percent will develop cirrhosis — the replacement of healthy liver tissue with scar tissue. (1) Heavy drinking is defined by the Centers for Disease Control and Prevention (CDC) as more than 14 drinks per week for men and more than 8 drinks per week for women. (2) ARLD is a spectrum of disease, says Christina Lindenmeyer, MD, a gastroenterologist at the Cleveland Clinic in Ohio. The less severe end of the spectrum may mean no symptoms and little effect on health. There are essentially two types of ARLD: chronic and acute. Fatty liver disease is considered a chronic condition and may not cause any symptoms, says Dr. Lindenmeyer. Alcoholic hepatitis is an acute inflammatory condition of the liver that occurs on top of chronic liver disease. Patients can be symptomatic, turning yellow, experiencing weakness, or even having acute liver failure. Alcoholic hepatitis is a serious, potentially fatal, condition. Alcoholic cirrhosis is the most severe form of ARLD. Normal liver cells are destroyed and replaced by nonfunctioning scar tissue. If patients with cirrhosis continue to drink, they will start having complications like intestinal bleeding, kidney failure, excess fluid in the abdomen, and memory issues. Alcoholic cirrhosis can progress into liver failure, in which the liver is losing or has lost all its function; and to end-stage liver disease, where a liver transplant is the only possible treatment. (3)

Overconsuming alcohol is the number one risk factor for ARLD. “For men, drink no more than two alcoholic drinks per day and for women, no more than one,” says Dr. Lindenmeyer. In the United States, a standard drink is equal to 14 grams, or 0.6 ounces, of pure alcohol. This is the amount of alcohol found in:

12 ounces of beer (5 percent alcohol content)8 ounces of malt liquor (7 percent alcohol content)5 ounces of wine (12 percent alcohol content)1.5 ounces of 80-proof distilled spirits or liquor (40 percent alcohol content) (4)

The risk also increases in relation to how many years a person has been drinking. In addition to alcohol, there are other factors that increase the risk of developing ARLD, which include:

Obesity Obesity contributes to nonalcohol-related fatty liver disease, and the combined effect of alcohol and obesity increases the risk of alcohol-related fatty liver disease.Malnutrition Many people who drink alcohol to excess are malnourished. Loss of appetite and nausea can be one cause, or sometimes alcohol and its toxic byproducts keep the body from breaking down and absorbing nutrients. Either case can lead to liver cell damage.Genetic factors Genetics may play a role in how likely someone is to develop liver disease or an addiction to alcohol. It can also play a role in how the body processes alcohol.Gender Women are more likely to develop long-term health problems from drinking than men. Women absorb more alcohol and take longer to metabolize it; the immediate effects of alcohol occur faster and last longer in women than in men. More high-quality research is necessary to elucidate the role of other risk factors, such as genetic vulnerability, body weight, metabolic risk factors, and drinking patterns over the life course.Chronic viral hepatitis The combined effect of hepatitis, especially hepatitis C, and alcohol consumption increases risk and severity of ARLD.

People who have another form of liver disease may be at higher risk for a more rapid progression of toxic liver insult, says Dr. Lindenmeyer. “That is to say, if someone has metabolic syndrome and then also overconsumes alcohol, they have two reasons to develop fatty liver disease,” she says.

Two people may both be lifelong heavy drinkers, and one may develop liver disease while the other does not. Why? “We all wish we knew the answer to that,” says Dr. Lindenmeyer. There are some genes that have been identified that make some people more at risk for fatty liver disease, either alcohol- or nonalcohol-related, says Dr. Lindenmeyer. The pattern of alcohol intake may also play a role, according to Dr. Lindenmeyer. Binge drinking — drinking five or more drinks within a two-hour period for men, four or more drinks for women (5) — may have a different effect than regular overconsumption. “There is some evidence that binge drinking might involve a different phenotype, or form, of liver disease,” says Dr. Lindenmeyer. Although daily overconsumption may affect the liver in different ways than binge drinking, research links both to ARLD. One study suggested that binge drinking can have more immediate negative effects than consuming in moderation. In just 21 drinking sessions over a seven-week period, mice began to experience symptoms of early-stage liver disease. (6) Other research found that long-term daily drinking above recommended guidelines was by far a greater risk for developing alcohol-related liver disease than binge drinking. In their study of drinking patterns, 7 out of 10 people with ARLD drank on a daily basis. (7)

Life expectancy is dependent on the severity of the liver disease. Fatty liver disease with no inflammation is relatively benign and usually does not affect mortality. When drinkers develop acute alcoholic hepatitis, however, overall mortality is 26 percent at 28 days, 29 percent at 90 days, and 44 percent at 180 days. (8) The median survival time of a person with advanced cirrhosis is one to two years. (9)

The physical effects of ARLD can depend on the severity of the disease and how a person experiences symptoms. “All the symptoms can occur, or it can be silent,” says Dr. Lindenmeyer. The most common signs and symptoms for ALRD can include the following: (3)

Enlarged liverFeverNauseaVomitingJaundice (yellowing of the skin and eyes)Increased white blood cell countSpider-like veins in the skinPortal hypertension, or high blood pressure in the portal vein, which carries blood between the digestive organs and liverEnlarged spleenAscites (fluid buildup in the abdominal cavity)Kidney failureConfusion

Severe acute alcoholic hepatitis is a very serious medical condition, and unlike other forms of ARLD, it can happen very quickly. “A person with severe acute alcoholic hepatitis can feel fine one week and then have bright yellow skin, confusion with ascites, and renal (kidney) failure the next week,” Dr. Lindenmeyer says. “There is a very profound and very acute presentation of the illness, and it carries a high mortality rate,” she adds. Unlike cirrhosis, which is caused by the buildup of scar tissue in the liver, alcoholic hepatitis is caused by “a profound inflammatory reaction in the liver that can cause a systemic illness that’s very severe,” Dr. Lindenmeyer says.

A medical history and physical exam are usually the first steps in determining if a person has ARLD. The other tests that may be performed include the following. (10)

Liver function tests analyze the blood to determine if the liver is functioning normally.A liver biopsy involves taking a tissue sample from the liver to examine under a microscope.Imaging tests may include a CAT scan, ultrasound, or MRI.

There isn’t a cure for ARLD, but there are ways to improve or stop the progression of liver disease, especially if it’s diagnosed early. (3)

Quit drinking Stopping drinking is the most important part of the treatment for ARLD.Nutrition therapy A special diet might be recommended to address possible nutritional deficits.Medications In patients with severe alcoholic hepatitis, medications can be used short-term to help reduce inflammation. Steroids are first line, followed by pentoxifylline if steroid therapy is ineffective.Liver transplant For people with advanced alcoholic cirrhosis, this may be the only option.

Years of heavy alcohol use can eventually lead to complications from ARLD, many of which can be life-threatening. Portal hypertension, which can be caused by cirrhosis, or scarring, of the liver is the root of many of the complications. The continued buildup of scar tissue results from long-term alcohol use and blocks the flow of blood through the liver. This leads to abnormally high blood pressure in the portal vein, which is the large vein that carries blood from the intestine to the liver, causing buildup of fluid in the abdomen, bleeding from veins in the esophagus or stomach, and enlarged spleen. (11) Additional complications from ARLD include:

Brain disorders and comaKidney failureLiver cancerProblems with multi-organ, nonliver conditions, such as heart failure