Drunk liver

“To awake your dormouse valor, to put fire in your heart, and brimstone in your liver.” — William Shakespeare (1564–1616), British dramatist, poet. Fabian, in Twelfth Night, act 3, sc. 2, l. 19-20.

IN this scene, Fabian was trying to provoke Sir Andrew to challenge Cesario (Viola). Never mind if “brimstone” in this context is “sulfur” because the poor liver is poisoned just as well in an alcoholic marinade. We drown ourselves in it and use anything as an excuse to drink away. Alcohol is the liquid that lubricates society indeed but as in all things that give pleasure, there can be too much of it. The liver and the central nervous system are prime targets of alcohol (ethanol).

Liver Basics. Below your ribs on the right side is the largest internal organ of the human body. It is so large that a whole liver is four lobes big. Normally it is resistant to disease and even if some parts are destroyed by disease, it has the innate capacity to recover and work as hard as ever. Its functions are myriad: the production of bile (needed by the gallbladder to break down fats), cholesterol (vital in making hormones), blood-clotting factors, and proteins.

Alcohol as Poison. Dose and duration of alcohol abuse is linearly correlated to the worsening of liver disease. Textbooks note that as little as 20 grams of alcohol in women and 60 grams in men ingested daily for years can injure the liver. Note that 10 grams is already 30ml of 40-proof whiskey, 250ml of 5% beer or 100ml of 12% wine. Alcohol also provides empty calories, causes malabsorption, and promotes malnutrition. Another problem with alcohol is that it is readily absorbed by the gut and more than 90% is metabolized by the liver. So guess where most of the damage occurs?

Fatty Liver. The medical term for this initial stage of alcoholic liver disease is steatosis. It is also found in obese people. What happens is that fat cells accumulate within the liver cells or hepatocytes. It is still a reversible stage if the person stops drinking. If he or she doesn’t the stop, the next stage is just waiting to happen.

Alcoholic Hepatitis. This occurs in moderate and heavy drinkers. It may be precipitated by an episode of binge drinking where the person passes out from just too much alcohol. The liver responds with inflammation. The signs and symptoms are:

• Appetite loss.

• Nausea.

• Vomiting.

• Abdominal pain and swelling.

• Yellowing of skin and the white of the eyes (jaundice).

• Mental confusion.

• Fever.

• Abdominal distention because of fluid. Alcoholic Cirrhosis. This is the end of the road for about 20% of heavy drinkers. The key lesion is fibrosis. This means that much of the liver’s working cells are gone and now replaced by non-functioning tissue. In effect, it has shut down. The results are coma and death. So it’s true, people can die of too much drinking.

Diagnosis and Treatment. The mental, social, and economic effects of alcohol are well known. But as a purely physical malady, liver disease can be properly handled by a doctor specialized in the gastro-intestinal tract (gastroenterologist).

Physical exam may reveal fever, an enlarged, tender liver and jaundice as classic findings. Liver lab values will be deranged. An ultrasound of the liver may be requested and the result of a liver biopsy will usually show overlapping stages of alcoholic liver disease. Treatment begins with the total abstention from alcohol. Alcohol withdrawal symptoms require medical support because of delirium tremens, seizures, and of course extreme craving. Nutritional support is also needed from the chronic malabsorption and malnutrition.

This must be repeated – alcoholic liver disease is reversible. But the decision to turn away from alcohol falls squarely on the shoulders of the person – in a moment of epiphany, at a lucid interval – we hope.

Unfortunately, we can’t drink to that.

Dr. Pujalte is an orthopedic surgeon and takes care of his liver.