Excessive and habitual alcohol consumption or alcoholism is bad for the liver. Everybody knows that. Sometimes, though, patients ask what exactly alcohol does to your liver.

Alcoholic liver disease is a spectrum of manifestations, ranging from asymptomatic fatty liver to an end stage liver disease. The severity of liver disease varies significantly among individuals. The amount of alcohol ingested, preexisting liver problems, like steatohepatitis and a concomitant infection with Hepatitis B or C will affect the extent of liver disease as well.

Good history taking, physical exam and some basic blood tests (liver enzymes) are often sufficient to diagnose alcoholic live disease. Excessive alcohol consumption can also affect the heart, muscles, brain, peripheral nerves and pancreas. Liver biopsy occasionally is necessary when the diagnosis is in doubt or there is a possibility of multiple factors affecting liver.

Alcoholic fatty liver or steatosis is present in 90 to 100% of alcoholics. It is being described as liver infiltration with droplets of fat. At this stage most patients are asymptomatic. The condition is reversible once the patient stops drinking. On an imaging study, like a CT scan, the liver looks enlarged. Abdominal Ultrasound often shows abnormal echogenicity due to fat infiltration.

Ten to thirty five percent of patients with a fatty liver develop alcoholic hepatitis. Symptoms may include fever, enlarged liver, anorexia and jaundice. In severe cases, hepatic encephalopathy and bleeding can occur. Inflammation in the liver with resulting necrosis is a hallmark of this disease. The prognosis of alcoholic hepatitis depends on its severity. The mortality is high in severe cases.

And finally, there is alcoholic cirrhosis. Accumulation of scar tissue as a result of ongoing alcohol toxicity, leads to a progressive loss of liver function. The liver might look small and shrunk on a CT scan. Loss of liver function leads to multiple metabolic derangements.

Toxic metabolites, including ammonia, tend to accumulate causing encephalopathy or abnormal brain function. Clotting factors are not being adequately replaces with the blood becoming thinner – coagulopathy. Immune function is affected as well.

The blood flow through the fibrotic liver is impaired. This leads to an elevated pressure in the portal vein leading to a fluid accumulation in the abdomen – ascites. Collateral venous blood vessels get engorged leading to esophageal varicies and, potentially, bleeding.

Advanced liver failure can affect the kidneys (hepatorenal syndrome) and lungs (hepatopulmonary syndrome) as well.

I have an idea how to save billions of dollars in healthcare costs. Start serving alcohol to selected patients while they are being treated in the hospital. I am being absolutely serious. Every day I am seeing patients developing complications from alcohol withdrawal. Usually, the patient is admitted for a scheduled or an urgent surgery. Many patients tend to understate their level of drinking, and on a day 2 – 3 after the admission they go into an alcohol withdrawal. Alcohol withdrawal is not a mere inconvenience. It could be quite severe. Many patients end up being admitted to an Intensive Care Unit. Some patients could even have seizures. Going into an alcohol withdrawal will significantly prolong the hospitalization and will increase the cost tremendously. I figured, that if I am taking care of at least one patient a day, on a national level it will add up to billions of dollars.

You might ask: “So, now we are going to have drunk patients in the hospital?” Well, yes. For many patients who drink alcohol on a daily basis, this becomes a “requirement” for a normal functioning. Some people could even be productive while being…you guessed it – drunk. Alcohol withdrawal, in contrast, could be a severe or even lethal condition. I saw people trying to jump out of the window while going through Delirium Tremens (DT). It is not unusual to require five or six people to hold a patient in DTs down while a sedating medication is being administered. Sometimes, despite an industrial dose of sedatives, we have to put the patient on a ventilator and administer sedation via a continuous infusion. So, to answer your question, I would rather have a “drunk” patient than a patient going through DTs.

Not all the patients should be offered alcohol while in the hospital. It should only be given by a physician order, just like any other medicine. Careful screening and thorough examination will be performed by an admitting physician before the “need” for alcohol is determined.

The concept of “prescribing” alcohol in the hospital is not new. In some places it is still being done. I once asked an older Dietitian about it. The answer that I got was quite surprising. Apparently, we used to give patients alcohol, but stopped doing it. Guess what was the reason? Not what you might think…we just didn’t have a good variety of beverages to suite every taste.

Alcoholism is a horrible problem. Billions of dollars are spent in US alone to treat alcoholism and medical conditions due to it. Indirect cost to the economy is likely huge as well. On a personal level it destroys families and ruins lives.

Imagine thirty plus year old male who was involved in a motor vehicle accident. It was a bad accident; the car rolled over six times. He sustained multiple injuries including cervical spine fracture with a spinal cord injury, at C5 level. The injury is such that the patient now is unable to control a single muscle from below his neck. He has no control over his bladder or bowels; all of this after a single stupid mistake. Now his mind is trapped in the useless body. His life is never going to be the same.
This is not a hypothetical situation. This is a real life example from trauma ICU.

Fortunately, the problems with alcohol abuse and related injuries are well recognized in our society. Millions of dollars are being spent on an anti-drinking and anti-DUI campaigns. (see image above)

What is being underecognized is that the withdrawal from alcohol could be a life threatening problem as well. The mortality from alcohol withdrawal used to be 37 percent. Now, it’s about 5 percent. Five percent mortality is still high considering the advances in modern medicine. A lot of people know (or even experienced) the symptoms of alcohol withdrawal. Restlessness, agitation, hallucinations and even seizures are not uncommonly seen in these patients. The patients are often tachycardic (elevated heart rate) and hypertensive. This is a horrible condition to live through.

Often patients minimize or even deny having a problem with alcohol use. Many patients tell me “I don’t really drink”. A day or two later this same patient starts seeing spiders on the wall and further investigation confirms that the patient was a heavy drinker prior to the admission.

I have seen patients who decide to quit “cold turkey” and “self-detox” at home. Few days later I admit those patients with an alcohol withdrawal seizure.

It’s almost as we need a public service campaign educating the patients not only about alcohol abuse itself, but the alcohol withdrawal as well.
It probably should say something like this: TELL YOUR DOCTOR IF YOU ARE HAVING PROBLEMS RELATED TO ALCOHOL USE AND SEEK MEDICAL ATTENTION OF YOU DECIDE TO QUIT. DON’T QUIT ALONE – IT CAN KILL YOU. (Well I am exaggerating a bit).

Brain atrophy in not uncommonly seen with aging. The brain looks shrunk on a CT or MRI brain, thus, brain shrinkage. We have talked about this problem before in the incredible shrinking brain blog. Alcohol abuse greatly “facilitates” brain shrinkage. Modest alcohol use has been proven to be beneficial for one’s health and can, actually, extend your life. Alcohol in excessive amounts is known to be toxic for the brain.

Compare two images above (click on the image to see a larger version). The upper image is of a 53 year old male with a long history of alcoholism. The bottom image is a “normal” brain. (I put normal in a quotation marks since it’s an image of my brain and my wife will argue that there is nothing normal with that brain).Anyway, do you see the difference?

Brain atrophy is not the only thing that happens to alcoholics. Wernicke - Korsakoff syndrome is a neuropsychiatric condition that sometimes affects chronic drinkers. This disorder is mainly due to thiamine deficiency. The psychiatric part of this syndrome (Korsakoff syndrome) manifests itself as an anterograde (future) and a retrograde (past) memory loss. The patients often make up things to fill their memory gaps. Some patients come up with “incredible” stories. This is known as a confabulation.

From a personal experience: the patients with this syndrome are very pleasant to talk to. The only problem is that the patient might not have any idea of what happened 15-20 minutes ago. The patient might still remember the events of the remote past.

The bottom line – everything, including alcohol, is good in moderation.