How to Know if Someone Has Advanced Alcoholic Liver Disease (ALD)

Gillian May

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I lost my father five years ago to alcoholic liver disease (ALD). As a former nurse and a recovering alcoholic, I’ve made it my mission to research ALD to help others understand this disease. The truth is, I couldn’t believe how fast he died after he was formally diagnosed. He was admitted and diagnosed on June 23rd, 2016, and died on July 18th, 2016.

The first thing to know about ALD is that it’s like an iceberg; you never know how bad it is because most of it is hidden. Although I’ve written about the early signs of liver disease before, I want to write about how to know if someone has advanced alcoholic liver disease.

I want to make a quick note that I am not a doctor and this isn’t a replacement for consulting a doctor. But I can provide some medical education around this condition and things to watch out for. All the research for this article can be found at the end and I highly encourage anyone to read and educate themselves.

The thing about ALD compared to the hundreds of other liver disease types is that alcoholics usually cover up their drinking and how bad they feel. To protect the one thing they think helps them survive, alcoholics are apt to defend their habit even if it costs them their life. In this sense, most of the early symptoms of the disease are not caught by doctors.

Further confusing the issue is the fact that the liver is one of the most resilient organs in our body and can put up with a lot of abuse. It has an incredible capacity to not only survive insults but to regenerate itself under the right circumstances. Also, as an organ, the liver is quite intelligent in how it chooses which insult to tackle on a day-to-day basis.

For the most part, the liver will prioritize the metabolism of dangerous toxins like alcohol first. This means that while the liver is dealing with alcohol, it has less capacity to manage things like medication, food, stress and illness. If more demands are piled on top, that’s when liver cells get damaged. These cells can recover but only if given the time to do so. For someone who drinks heavily or daily, there’s little time for these cells to bounce back. This is when ALD sets in and becomes a more chronic issue.

Damaged liver cells often turn to fat first, hence the term alcoholic fatty liver disease. A fatty liver can still regenerate, but only if it has time and space for healing. However, if healing doesn’t occur, as it often does in alcoholism, the fatty cells become calcified. At this point, those calcified cells are permanently damaged, which means the disease has advanced to cirrhosis. Almost any liver disease can turn to cirrhosis. The difference is that non-alcoholic cirrhosis tends to be diagnosed much earlier because there’s no denial or cover-up inherent in those diseases.

The most important thing to understand about any liver disease is the difference between a compensating and decompensating liver. Even in cirrhosis, if there are still healthy liver cells, they can compensate for the non-healthy ones. But again, this can only happen if the person stops drinking.

A compensating liver is still diseased but has enough healthy liver cells to do the work required. So let’s say 50% of the liver is cirrhotic; the other 50% can compensate and do all the work. However, because the liver is only at 50%, it will have to work very hard. If a person stops drinking, that 50% could become strong enough to do all the work needed by a liver, but they will never gain the calcified cells back.

Many people who suffer from ALD can get confused by this issue. Often they are told by their doctors that their liver is compensating, but they think everything is fine and they continue drinking. This is exactly what happened to my father. Years before his death, he was told by his doctor that he had a diseased yet compensating liver.

He had quit drinking for about six years, and during that time, the healthy part of his liver was able to compensate for the unhealthy part. Unfortunately, he began drinking again and the alcohol started to erode the healthy part of his liver.

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Once healthy liver tissue goes down to about 10%, the liver will begin to decompensate. This means that the liver can’t keep up with the demands placed on it, and liver failure symptoms begin to show themselves.

But here’s the fascinating thing about the liver. Even when it’s decompensating, depending on how much healthy tissue is left and when interventions start, the liver can still do some functions. If a person can quit alcohol and engage in rigorous rehabilitation, they can live on a small amount of liver function.

The symptoms of a decompensating liver are:

  • Swollen abdomen (fluid in the belly)
  • Portal hypertension (swollen blood vessels above the liver — around the heart, esophagus, and stomach)
  • Yellow skin and eyes
  • Bleeding in the stomach and throat
  • Nausea and vomiting
  • Confusion, slurred speech (hepatic encephalopathy)
  • Blood sugar issues
  • Blood clotting delays

These symptoms are due to the liver not being able to filter toxins, make blood products, manage blood sugar, create clotting enzymes, and manage fluid balance.

When I look back at my father, he was likely in a decompensated state for a month or two before he was admitted to hospital. He was still eager to protect his drinking at that time, but he didn’t feel well. I should also say that my father had type 2 diabetes for years, which can further delay a diagnosis of liver disease.

He had gone to the doctor months before his admission, and all they found was that his kidneys were struggling. Kidney issues are a common thing in late-stage type 2 diabetes, but it’s also something that happens as a by-product of toxins not being filtered by the liver. However, since he still didn’t tell the doctor about his drinking, the doctor figured his diabetes was causing his kidneys to struggle.

The important thing is, when a liver begins to decompensate, time is of the essence. If a person doesn’t quit drinking, the liver will fail. And although liver failure only takes two weeks or so, the person may appear to be only mildly ill right up until the liver finally stops doing any work at all. This is why liver failure usually comes as a surprise to most people.

The liver can do a lot of work even with minimal amounts of healthy tissue, and it will keep doing that work until it reaches a kind of tipping point. Once over that point, everything crashes quickly and suddenly.

ALD is an unfortunate yet highly preventable disease. The good news is that a liver can recover, even after many insults have been hurled at it. A liver can be highly diseased, but as long as it’s compensating, it will do the job. It may not be the best job, but it’s good enough.

This is why it’s crucial to understand this condition fully. There’s a lot of medical jargon that comes with ALD, and I hope I’ve spelled it out in as simple terms as possible. The more we understand how ALD works, the better we can prevent liver failure from happening.

The number one preventative strategy is to divulge all drinking and medical history to medical specialists. If symptoms like nausea, chronic heartburn, confusion, swelling, mobility issues, and blood sugar problems begin to take hold, it’s time to talk openly with a doctor about the amount of alcohol ingested per day.

Alcohol cessation is also critical but carries many complexities that need to be discussed with a medical professional. Alcohol withdrawal can be hazardous, particularly with someone who has ALD and other medical problems. Be sure to detox safely with medical supervision.

Lastly, in the case of my father and many others like him, alcoholics tend to have severe depression. Depression is often a by-product of alcohol use, but it can also be the reason why people seek alcohol in the first place. Untreated depression can seriously impact ALD and its recovery, so it’s important to seek mental health help.

If you want to learn more about ALD and a compensating versus decompensating liver, read the resources listed below. I firmly believe education can change the course of this disease little by little.

Below is the research used to write this article. These are also good if you want to further educate yourself:

I don’t want to tell alcoholic patients to keep drinking, but I have to
Alcoholic Liver Disease: Pathogenesis and Current Management
Alcohol and the Nervous System
Alcoholic Liver Disease
Neuroplasticity and predictors of alcohol recovery
Vitamin B1 Thiamine Deficiency
Medical Care of the Patient With Compensated Cirrhosis
Clinical outcomes of compensated and decompensated cirrhosis
Prognostic indicators of survival in patients with compensated and decompensated cirrhosis
How to Prevent Alcoholic Liver Disease

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I'm a former nurse turned freelance writer. I have extensive experience in administration, frontline care, and education in mental health, public health, and geriatrics. However, after 20 years, I needed a change and always wanted to write. I have personal and family experience in mental health and addictions, so I'm passionate about advocacy and education in those areas. I'm also a traveler, photographer, and artist. I funnel all my various expertise into my writing and hope to provide valuable content that is entertaining and educational.


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