Alcoholic liver disease

Last updated: December 20, 2022

Summarytoggle arrow icon

Alcoholic liver disease (ALD) refers to a range of progressive liver conditions caused by chronic and excessive alcohol consumption. One-third of the US population consumes alcohol above the recommended levels, increasing their risk of ALD. There are three stages of ALD, which may or may not occur sequentially. The first stage is typically asymptomatic and involves the development of (potentially) reversible alcoholic fatty liver. Continued alcohol consumption will lead to alcoholic hepatitis, the second stage, which often becomes chronic. Clinical findings in this stage include jaundice, fatigue, and fever. In the third and final stage, the patient develops alcoholic cirrhosis. Patient history, transaminase levels, and imaging studies are crucial for diagnosis and show different patterns of hepatic injury. Nonalcoholic steatohepatitis is a differential diagnosis and is currently regarded as an important cause of cirrhosis. Treatment of ALD requires complete cessation of alcohol use.

The management of alcoholic hepatitis, including its diagnosis and treatment, is described in detail elsewhere.

Epidemiologytoggle arrow icon


Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon


Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

The stages of ALD may overlap and do not necessarily occur in sequence.

Alcoholic fatty liver (reversible)

  • Mostly asymptomatic
  • Some patients report feeling a sensation of pressure in the upper abdominal area.
  • Hepatomegaly: soft in consistency
  • Regresses after cessation of alcohol consumption
  • Acute exacerbation with risk of hepatic failure is rare.

Alcoholic hepatitis (reversible in mild cases)

See “Alcoholic hepatitis.”

Alcohol-related cirrhosis (irreversible)

  • Final stage of ALD
  • See “Clinical features” in cirrhosis.


Diagnosticstoggle arrow icon

A history of alcohol abuse that correlates with typical laboratory and imaging findings is diagnostic of alcoholic liver disease.

Alcoholic fatty liver

Imaging and laboratory studies in the case of alcoholic fatty liver will show a reversal of changes within a month if the patient abstains from alcohol.

Alcoholic hepatitis

See “Alcoholic hepatitis.”

Alcohol-related cirrhosis


Pathologytoggle arrow icon

Alcoholic fatty liver and mild alcoholic hepatitis may be reversible after cessation of alcohol intake. However, severe alcoholic hepatitis and cirrhosis are not reversible!


Differential diagnosestoggle arrow icon

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) [11][12]

NASH is a diagnosis of exclusion. Other causes of chronic liver disease must be ruled out by laboratory studies and/or biopsy.

A distinction between alcoholic and non-alcoholic fatty liver disease can only be drawn based on patient history.

There is more ALT than AST (AST/ALT < 1) if the Liver is infiltrated with Lipids.

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Complicationstoggle arrow icon

Decompensated cirrhosis

Mainly characterized by a constellation of clinical features resulting from decreased hepatic function:

Other organ damage following chronic alcohol use

Zieve syndrome

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Mauriello LM, Gökbayrak NS, Van Marter DF, Paiva AL, Prochaska JM. An internet-based computer-tailored intervention to promote responsible drinking: findings from a pilot test with employed adults. Alcohol Treat Q. 2012; 30 (1): p.91-108.doi: 10.1080/07347324.2012.635528 . | Open in Read by QxMD
  2. Hasin D, Keyes K. The epidemiology of alcohol and drug disorders. Springer New York ; 2010: p. 23-49
  3. Mathurin P, Bataller R. Trends in the management and burden of alcoholic liver disease. J Hepatol. 2015; 62 (1): p.S38-S46.doi: 10.1016/j.jhep.2015.03.006 . | Open in Read by QxMD
  4. Flegel K, MacDonald N, Hebert PC. Binge drinking: all too prevalent and hazardous. Can Med Assoc J. 2011; 183 (4): p.411.doi: 10.1503/cmaj.110029 . | Open in Read by QxMD
  5. O'Shea RS, Dasarathy S, McCullough AJ et al. Alcoholic liver disease. Am J Gastroenterol. 2009; 105 (1): p.14-32.doi: 10.1038/ajg.2009.593 . | Open in Read by QxMD
  6. Robert T Means. Hematologic complications of alcohol use. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: January 22, 2020. Accessed: August 17, 2020.
  7. Akunjee M, Akunjee N. CSA book: MRCGP CSA Symptom Solver: Clinical frameworks for the MRCGP CSA exam. Clinical Prep ; 2014
  8. Sakhuja P. Pathology of alcoholic liver disease, can it be differentiated from nonalcoholic steatohepatitis?. World J Gastroenterol. 2014; 20 (44): p.16474–16479.doi: 10.3748/wjg.v20.i44.16474 . | Open in Read by QxMD
  9. Orman ES, Odena G, Bataller R. Alcoholic liver disease: Pathogenesis, management, and novel targets for therapy. J Gastroenterol Hepatol. 2013; 28 (S1): p.77-84.doi: 10.1111/jgh.12030 . | Open in Read by QxMD
  10. Torruellas C. Diagnosis of alcoholic liver disease. World J Gastroenterol. 2014; 20 (33): p.11684-11699.doi: 10.3748/wjg.v20.i33.11684 . | Open in Read by QxMD
  11. Bayard M, Holt J, Boroughs E. Nonalcoholic fatty liver disease. Am Fam Physician. 2006; 73 (11): p.1961-1968.
  12. Adams LA, Feldstein AE. Nonalcoholic steatohepatitis: risk factors and diagnosis. Expert Rev Gastroenterol Hepatol. 2010; 4 (5): p.623-635.doi: 10.1586/egh.10.56 . | Open in Read by QxMD
  13. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2015

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer