The Realities of End-Stage Alcoholic Liver Disease

Gillian May
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My father died of alcoholic liver disease (ALD) five and a half years ago. Since then, I’ve been researching and writing educational articles about preventing ALD. As a former nurse, I’d like to fill a gap in this education as it barely exists in the general population. Preventing ALD is about being honest about alcohol consumption and catching the early signswhich are obscure and confusing.

However, I haven’t talked much about what happens when ALD reaches the end. Often the end-stage sneaks up on people, and they can die very quickly as in the case of my father. However, some individuals can hang on for a while, but cope with considerable disability.

Compensating versus decompensating liver

Survival and disability depend on whether a liver is compensating or not. However, a compensating liver can be a tricky balance. If a struggling liver loses a little more function, it can topple into decompensation leading to serious health issues and death.

A liver compensates when it has enough functionality for the basic necessities of survival. A compensating liver can still filter enough toxins, create blood products, manage blood glucose, and help with digestion. A compensating liver can still struggle (leading to those early symptoms), but it’s functioning well enough.

A decompensating liver is when certain vital liver functions become impaired. Often, this state leads to death. But sometimes, people can survive for a while longer with a decompensating liver. It depends on their state of health and whether they have other health problems at the same time.

A decompensating liver is what usually leads to end-stage ALD. People face certain realities when coping with end-stage ALD, and this often doesn’t get talked about in the general public either. Often families are left to suffer alone due to the stigma and emotional upheaval of alcohol addiction. Even doctors that treat the end-stage ALD can often hold stigma. In any case, let’s talk about some of the realities of end-stage ALD.

Portal hypertension

When liver tissue becomes too scarred and hard, blood that filters through the liver is diverted into the upper abdominal cavity. This is one of the reasons why the liver fails — lack of blood flow. When blood gets pooled in the abdominal cavity, it increases blood pressure and creates swelling in various veins and arteries. This pooling puts pressure on the heart, which can lead to heart problems. The swollen veins and arteries are called varices, and they look a lot like varicose veins in the esophagus and other parts of the abdomen.

Increased incidence of bleeding

The liver helps create blood products that aid in blood clotting. A failing liver slows down the production of these products, increasing the possibility of bleeding in any part of the body. On top of that, the varices created by portal hypertension are often swollen and can easily break. With fewer blood clotting factors, this can lead to a severe hemorrhage.
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Hepatic encephalopathy

A failing liver can’t filter out toxins as it used to, which means toxins like ammonia build up in the blood, which poisons the brain. This leads to something called hepatic encephalopathy, which is a type of brain disease. It can cause significant issues with cognition and balance. To decrease ammonia levels, people with ALD have to take laxatives to help clear the ammonia and other toxin levels through the bowels. Taking laxatives can cause diarrhea which can disrupt the electrolyte levels. All in all, hepatic encephalopathy can be extremely difficult to manage for both the patient and the caregivers.


One of the functions of the liver is to clear old dead red blood cells from the body. Red blood cells have a short life cycle, and the old ones burst and need to be removed from the body. Unfortunately, with end-stage ALD, the liver can’t do this job very well. This means the old red blood cells and their components build up in the body. One component is called bilirubin, and it has a yellowish pigment. The build-up of bilirubin causes jaundice, a yellowish tint to the skin. Bilirubin and old red blood cells can also cause damage to the kidneys, which can fail at the same time that a liver is failing.

Abdominal swelling

The liver helps to create a protein called albumin. We need a certain balance of albumin in our blood for various bodily functions, including fluid balance in the cells. As albumin decreases (because the liver can’t help create it anymore), more fluid enters the external abdominal cavity causing a fluid build-up called ascites. Often this fluid needs to be drained, which can be painful. Fluid can also build up in the lower legs.

Difficulties eating

Due to increased toxins in the blood and a liver that isn’t helping with digestion as much, eating can become difficult. Toxins can lead to a lot of nausea. Likewise, if the liver can’t aid in digestion, food is not metabolized correctly, which also causes bloating and nausea. This can make eating very difficult, which leads to weight loss and weakness.

These are some of the realities of end-stage alcoholic liver disease (ALD). The condition often leads to a quick death, but it can become a chronic condition that’s very difficult to treat and live with for some people.

End-stage ALD is rarely talked about in detail. Most people know their livers can fail with too much drinking, but they don’t know what happens or why. Hopefully, this article can shed some light on this topic and educate people more about ALD and its effects on the body.

The best prevention is to catch the disease early in the process, refrain from drinking alcohol, and allow the liver to heal. Although this is easier said than done, hopefully, more education can help people make better decisions about their drinking.

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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. Join my email list if you want to read more of my work - I also have a book on Alcoholic Liver Disease coming out in 2021.


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