Dr. Todd Sheer Answers Questions About Alcohol Use Disorder
What is the scope of the problem?
Excess alcohol use (or alcohol use disorder) is one of the most common causes of liver disease and is responsible for almost half of the cases of liver-related death in the United States and worldwide. One in 12 adults abuses alcohol and 88,000 Americans die from alcohol-related causes per year, including deaths from liver disease, motor vehicle accidents, and violence.
How much alcohol is too much?
At risk drinking is usually defined as two drink equivalents for women and three drink equivalents for men per day. The definition of a drink equivalent is 1.5 ounces of liquor, 5 ounces of wine, or 12 ounces of beer. In reality, most “drinks” are even greater than these volumes.
Binge consumption of alcohol is also a form of alcohol abuse. Binge consumption consists of > 4 drinks for women and > 5 drinks for men, consumed over a 2-hour period.
The widely purported health benefits of alcohol are far from certain and very variable from person to person. It is not advisable abstinent person to start consuming alcohol for “health benefits.”
What are the effects of alcohol on the liver (and beyond)?
Alcohol ingestion initially results in accumulation of fat droplets in the liver cells, known as steatosis. This leads to cell injury and death with a resultant immune response and scarring. Eventually, scarring can lead to cirrhosis and despite the liver’s excellent ability to regenerate, the damage at this point is irreversible. From cirrhosis as host of complications can ensure including development of abdominal distention from fluid (ascites), confusion (encephalopathy), jaundice, gastrointestinal bleeding, liver cancer, and frank liver failure. These complications are more likely if one continues to drink alcohol. A significant additional entity worth mentioning is that of alcoholic hepatitis, a particularly devastating immune attack on the liver with minimal to no effective treatment options and a high rate of mortality.
Outside of the liver, alcohol abuse can cause additional injuries of which a few are listed below:
- Pancreatitis – a painful inflammation of the pancreas with significant chance of death and permanent loss of function
- Cardiomyopathy – heart muscle damage with heart failure
- Neuropathy – damage to peripheral nerves with chronic pain and balance difficulties
- Encephalopathy – atrophy of the brain with loss of cognitive function
- Cancer – besides liver cancer as mentioned above, rates of breast, colon, mouth/throat, and esophagus cancers are higher
- Depression and suicide
- Accidents such as falls, motor vehicle accidents, and those related to other poor choices often made while intoxicated
Who is at most risk?
The amount of alcohol ingested is the most important risk factor for the development of liver disease. However, only 10-20% of chronic heavy drinkers develop cirrhosis or alcoholic hepatitis and therefore there must be additional variables involved. These are not fully known but as hinted above, women are at greater risk than men for equal amounts consumed. Possible causes for this discrepancy include sex differences in stomach and liver metabolism of alcohol as well as the liver’s inflammatory reaction to alcohol, a greater proportion of body fat in women, and menstrual cycle-induced variations in alcohol absorption. Genetics and race are other variables to be considered. There appears to be an inherited predisposition to alcoholism and the amount of damage alcohol has on the liver. The frequency of alcohol-induced cirrhosis is higher in African-American and Hispanic males compared to Caucasian males and the mortality rates are highest in Hispanic males. Coexisting liver diseases (which are often undiagnosed) such as hepatitis B and C and fatty liver from being overweight or obese also increase the risk of progression to chronic liver disease. Cigarette smoking is not uncommon in individuals consuming alcohol and likely exacerbates the effects of alcohol on the liver, including increasing the risk of liver cancer once cirrhosis is established.
The type of alcohol (wine, beer, or liquor) does not appear to be a determinant in the chance of liver disease, despite the common misconception to the contrary. In other words, keeping in mind the equivalents defined above, your liver is no safer with the consumption of wine or beer over liquor. Exercise and drinking black coffee may be protective but should not be relied upon as an alternative to reducing alcohol use or abstinence.
What can be done?
Minimization of alcohol intake or abstinence is the cornerstone of decreasing the risk of alcohol related liver disease. The good news is that even if advanced liver disease, including cirrhosis, is already established, significant improvements in liver function and survival can be achieved with abstinence. This improvement is often rapid, with two-thirds of individuals seeing a clinical difference within 3-6 months of alcohol cessation. Societal studies have shown a decline in liver disease during times of alcohol rationing, prohibition, and price increases. Recidivism, or a return to drinking, is a major problem, with rates ranging from 67%-81% within a year. Ways to maintain sobriety include consultation with addiction specialists, community-based support networks (e.g., Alcoholics Anonymous), and even medications. If you suspect you have an alcohol use disorder, it is encouraged to discuss with your physician. Testing can be relatively easily performed to determine the status of your liver and assistance with quitting and maintaining sobriety can be provided.
Dr. Todd Sheer is a fellowship-trained, board-certified gastroenterologist and hepatologist. Dr. Sheer graduated from Georgetown University School of Medicine and completed his fellowship in gastroenterology and hepatology at the Naval Medical Center in San Diego. He previously served for 11 years as an officer with the U.S. Navy and Marine Corps.
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