Symptoms

Mild forms of alcoholic hepatitis may not cause noticeable problems, but as the disease becomes more advanced and the liver more damaged, signs and symptoms are likely to develop. These may include:

• Loss of appetite
• Nausea and vomiting
• Abdominal pain and tenderness
• Yellowing of the skin and whites of the eyes (jaundice)
• Fever
• Abdominal swelling due to fluid accumulation (ascites)
• Mental confusion
• Fatigue

When to see a doctor See your doctor if you have any signs or symptoms of alcoholic hepatitis or other signs and symptoms that worry you. If you ever feel as though you can't control your drinking or feel that you'd like help in cutting back on your drinking, see your doctor.

Causes

Alcoholic hepatitis occurs when the liver is damaged by alcohol you drink. Just how alcohol damages the liver — and why it does so only in a minority of heavy drinkers — isn't entirely clear. What is known is that the process of breaking down ethanol — the alcohol in beer, wine and liquor — produces highly toxic chemicals, such as acetaldehyde. These chemicals trigger inflammation that destroys liver cells. In time, web-like scars and small knots of tissue replace healthy liver tissue, interfering with the liver's ability to function. This irreversible scarring, called cirrhosis, is the final stage of alcoholic liver disease.

Risk increases with time, amount consumed Heavy alcohol use can lead to liver disease, and the risk increases with the length of time and amount of alcohol you drink. But because many people who drink heavily or binge drink never develop alcoholic hepatitis or cirrhosis, it's likely that factors other than alcohol play a role. These may include:

• Genetic factors. Having mutations in certain genes that affect alcohol metabolism may increase your risk of alcoholic liver disease as well as of alcohol-associated cancers and other complications of heavy drinking.
• Other types of hepatitis. Long-term alcohol abuse worsens the liver damage caused by other types of hepatitis, especially hepatitis C. 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, either because they eat poorly — often substituting alcohol for food — or because alcohol and its toxic byproducts prevent the body from properly absorbing and metabolizing nutrients, especially protein, certain vitamins and fats. In both cases, the lack of nutrients contributes to liver cell damage.

Risk factors

Risk factors for alcoholic hepatitis include:

• Alcohol use. Consistent heavy drinking or binge drinking is the primary risk factor for alcoholic hepatitis, though it's hard to precisely define what constitutes heavy drinking because people vary greatly in their sensitivity to alcohol. Moderate drinking is generally defined as no more than two drinks a day for men and one for women. Binge drinking is usually defined as more than four alcoholic drinks in one sitting for women, and more than five drinks in one sitting for men. Also a matter of debate is whether certain types of alcohol cause more harm than others. Some experts believe that wine is less damaging than hard liquor or beer, but this has yet to be proven.
• Your sex. Women have a higher risk of developing alcoholic hepatitis than men do. This disparity may result from differences in the way alcohol is absorbed and broken down.
• Genetic factors. Researchers have discovered a number of genetic mutations that affect the way alcohol is metabolized in the body. Having one or more of these mutations may increase the risk of alcoholic hepatitis.

Complications

Complications of alcoholic hepatitis include:

• Increased blood pressure in the portal vein. Blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. If scar tissue slows normal circulation through the liver, this blood backs up, leading to increased pressure within the vein (portal hypertension).
• Enlarged veins (varices). When circulation through the portal vein is blocked, blood may back up into other blood vessels in the stomach and esophagus. These blood vessels are thin walled, and because they're filled with more blood than they're meant to carry, they're likely to bleed. Massive bleeding in the upper stomach or esophagus from these blood vessels is a life-threatening emergency that requires immediate medical care.
• Fluid retention. Alcoholic hepatitis can cause large amounts of fluid to accumulate in your abdominal cavity (ascites). Abdominal fluid may become infected and require treatment with antibiotics. Although not life-threatening in itself, ascites is usually a sign of advanced alcoholic hepatitis or cirrhosis.
• Bruising and bleeding. Alcoholic hepatitis interferes with the production of proteins that help your blood to clot. As a result, you may bruise and bleed more easily than normal.
• Jaundice. This occurs when your liver isn't able to remove bilirubin — the residue of old red blood cells — from your blood. Eventually, bilirubin builds up and is deposited in your skin and the whites of your eyes, causing a yellow color.
• Hepatic encephalopathy. A liver damaged by alcoholic hepatitis has trouble removing toxins from your body — normally one of the liver's key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms of hepatic encephalopathy include forgetfulness, confusion and mood changes, and in the most severe cases, coma.
• Scarred liver (cirrhosis). Over time, the liver inflammation that occurs in alcoholic hepatitis can cause irreversible scarring of the liver (cirrhosis). Cirrhosis frequently leads to liver failure, which occurs when the damaged liver is no longer able to adequately function.

Appointment

Start by seeing your family doctor or a general practitioner. If your doctor determines you may have a liver problem, such as alcoholic hepatitis, you'll likely be referred to a gastroenterologist.

Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes. Let your doctor know how much alcohol you regularly consume. It's a good idea to track your alcohol consumption for a few days by writing it down, because people tend to underestimate the amount they've consumed.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Take a family member or friend along. Sometimes it can be difficult to absorb all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your appointment. List your questions from most important to least important in case time runs out. For alcoholic hepatitis, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need? How should I prepare for them?
• Is my condition temporary or chronic?
• What treatments are available? Which one do you recommend?
• Are there any alternatives to the primary approach that you're suggesting?
• What resources are available to help me stop drinking? Which ones will my insurance pay for?
• I have other health conditions. How can I best manage them together?
• Are there any dietary restrictions that I need to follow?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Are there any brochures or other printed material that I can take with me? What websites do you recommend visiting?

In addition to the questions that you've prepared, don't hesitate to ask questions any time you don't understand something.

What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to discuss. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• How often do you drink alcohol, and how many drinks do you usually consume?
• Have you ever had hepatitis or yellowing of the skin before?
• Do you use any other recreational drugs?
• Are your family members or friends concerned about 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 — do you need an eye-opener?

What you can do in the meantime Stop drinking alcohol if you think it may be causing your health problems. If you believe you're dependent on alcohol, your doctor can recommend the treatment options that might work best for you. However, if you need help to stop drinking while you're waiting to see your doctor, Alcoholics Anonymous or counseling may be helpful.

Tests and diagnosis

Because there are numerous liver diseases and a wide range of factors that can cause them, including viral infections, drugs and environmental toxins, diagnosing alcoholic hepatitis can be challenging. In an effort to reach a diagnosis, your doctor may include one or more of the following steps:

• Medical history and physical exam. Your doctor will ask you questions about your health history, including alcohol use, and conduct a physical exam.
• Blood tests. These check for high levels of certain liver-related enzymes, such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT).
• Ultrasound. Your doctor may use this noninvasive imaging test to view your liver and to rule out other liver problems.
• Liver biopsy. In this procedure, a small sample of tissue is removed from your liver and examined under a microscope. Liver biopsy usually involves inserting a long, thin needle through your skin and into your liver in order to draw out a sample of tissue.

Treatments and drugs

Stop drinking alcoholIf you've been diagnosed with alcoholic hepatitis, you must stop drinking alcohol. It's the only way to reverse liver damage or, in more advanced cases, to prevent the disease from becoming worse. If you continue to drink alcohol, you're likely to experience serious complications.

If you are dependent on alcohol and want to stop drinking, your doctor can recommend a therapy that's tailored for your needs. This might include medications, counseling, Alcoholics Anonymous, an outpatient treatment program or a residential inpatient stay.

Treatment for malnutrition Your doctor may recommend a special diet to reverse nutritional deficiencies that can occur in people with alcoholic hepatitis. You may be referred to a dietitian who can help you assess your current diet and suggest changes to increase the vitamins and nutrients you may require more of.

If you have trouble eating enough to get the vitamins and nutrients your body needs, your doctor may recommend tube feeding. This may involve passing a tube down your throat and into your stomach. A special nutrient-rich liquid diet is then passed through the tube.

Medications to reduce liver inflammation People with severe alcoholic hepatitis may consider short-term treatment with medications to control liver inflammation. In certain situations, your doctor may recommend corticosteroids or pentoxifylline.

Liver transplant When liver function is severely impaired, a liver transplant may be the only option for some people. Although liver transplantation is often successful, the number of people awaiting transplants far exceeds the number of available organs. For that reason, liver transplantation in people with alcoholic liver disease is controversial.

Some medical centers may be reluctant to perform liver transplants on people with alcoholic liver disease because they believe a substantial number will return to drinking after surgery, won't take the necessary anti-rejection medications, or will require more care and resources than will other patients. Most of these objections have not been borne out in practice, however, and many doctors now feel that some people with alcoholic liver disease are good candidates for transplant surgery. But requirements are still stringent, including abstinence from alcohol for at least six months before surgery and enrollment in a counseling program.

Alternative medicine

No alternative medicine treatments have been found to cure alcoholic hepatitis. Still, some herbs and supplements are touted as treatments for liver diseases. Herbs and supplements can't replace your doctor's treatments or abstaining from alcohol. But if you'd still like to try supplements, talk to your doctor about the risks and benefits first.

Milk thistle The leaves and seeds of the milk thistle plant are thought to control inflammation in the liver. Milk thistle supplements are a popular alternative treatment among people with liver disease. But studies haven't found a benefit for people with alcoholic liver disease who take milk thistle supplements.

Milk thistle is generally safe, but can cause diarrhea and nausea. Talk to your doctor about milk thistle if you're considering taking this supplement. Because milk thistle can interfere with prescription medications, ask your doctor whether it's safe for you.

SAMe SAMe (S-adenosylmethionine) is a supplement that's thought to reduce liver inflammation and help the liver repair itself. Your body naturally makes SAMe, but some evidence suggests people with liver disease have a deficiency of SAMe. In theory, taking a SAMe supplement might restore levels of the substance in the liver. But whether this can reverse or stabilize liver disease has yet to be proven.

SAMe is generally safe when taken as a supplement. Side effects may include gas, nausea, vomiting and diarrhea. Because SAMe can interfere with prescription medications, ask your doctor about whether SAMe is safe for you to take.

Prevention

You may reduce your risk of alcoholic hepatitis if you:

• Drink alcohol in moderation, if at all. If you choose to drink, limit yourself to no more than one drink a day if you're a woman or two drinks a day if you're a man. The only certain way to prevent alcoholic hepatitis is to avoid all alcohol. If you've ever been diagnosed with alcoholic hepatitis, don't drink alcohol.
• Check the label before mixing medications with alcohol. Check the label of over-the-counter medications for warnings about drinking alcohol. Ask your doctor if it's safe to drink alcohol when taking your prescription medications. Don't drink alcohol when taking medications that warn of complications when combined with alcohol. This includes over-the-counter pain relievers such as acetaminophen (Tylenol, others).

• Protect yourself from hepatitis C. Hepatitis C is a highly infectious liver disease caused by the hepatitis C virus. Untreated, it can lead to cirrhosis. If you have hepatitis C and drink alcohol, you're far more likely to develop cirrhosis than is someone who doesn't drink. Because there's no vaccine to prevent hepatitis C, the only way to protect yourself is to avoid exposure to the virus.

  In the past, many people with hepatitis C became infected through blood transfusions before improved blood-screening tests became available. Today, contaminated drug paraphernalia is responsible for the majority of all new cases of hepatitis C. Don't share needles or other drug paraphernalia. Hepatitis C can sometimes be transmitted sexually. If you aren't absolutely certain of the health status of a sexual partner, use a new condom every time you have sex. See your doctor if you have or have had hepatitis C or think you may have been exposed to the virus.