DAVID MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks. If you're sitting in front of your computer screen with a glass of wine or a beer, you're not alone. Almost two thirds of us over 14 years of age drink alcoholic beverages. Now, a little bit is okay, but a lot can get you into trouble. What you're seeing on your computer screen is called fatty liver. That's one of the problems that can be associated with drinking alcohol.
Joining me to talk about alcohol and liver disease, we have two experts. The first is Dr. Carol Semrad. She is the director of clinical nutrition at Columbia University. Welcome. Next to her is Dr. Howard Worman. He is director of the Division of Digestive and Liver Diseases, also at Columbia University. Welcome.
So, Dr. Worman, we just saw a picture of fatty liver. What exactly is that?
HOWARD WORMAN, MD: Fatty liver is essentially what the name says. It's the accumulation of fat in the liver cells. As fat accumulates, the liver can look like it looked in that picture, just a yellowish accumulation of fat.
DAVID MARKS, MD: What's the problem with that?
HOWARD WORMAN, MD: Fatty liver itself may not be that much of a problem, or isn't that much of a problem. The problem is that, with fatty liver, fatty liver can progress to other problems, especially if you continue to drink.
DAVID MARKS, MD: Now, somebody who goes out and drinks a few beers at night, they build up that fat in their liver, but it does go away, doesn't it?
HOWARD WORMAN, MD: Right. Probably not a few beers, but let's say many beers for several nights, they can accumulate fat in the liver, and then the fat will go away after they stop drinking.
DAVID MARKS, MD: How is it diagnosed?
HOWARD WORMAN, MD: Fatty liver really can only be diagnosed by liver biopsy. It's a histological diagnosis you make by looking at a piece of liver under the microscope. But we can suspect it based on clinical grounds and laboratory tests.
DAVID MARKS, MD: Dr. Semrad, when would you suspect fatty liver in a patient?
CAROL SEMRAD, MD: I would expect probably fatty liver in a patient who said they were drinking and perhaps came in complaining of some pain in their right upper quadrant, or in a patient who I drew routine tests on and found an elevation in one of their liver tests. That would tip me off that there may be a fat accumulation.
DAVID MARKS, MD: Would you automatically send them for a biopsy?
CAROL SEMRAD, MD: No, I would not automatically send them for a biopsy. I would recommend, if they gave a history of drinking, to stop and see if the chemical abnormality went away.
DAVID MARKS, MD: So the treatment really is to stop, and then you wait and see to make sure everything gets better.
CAROL SEMRAD, MD: Yes.
DAVID MARKS, MD: Anything else on fatty liver that people should know about?
HOWARD WORMAN, MD: What's important to realize, alcohol is not the only cause of fatty liver. Obesity or some people with diabetes can also accumulate fat in the liver. So alcohol is probably the major cause, but not the only cause.
DAVID MARKS, MD: Let's move on to something else. Hepatitis. When people say hepatitis, they think of some kind of viral infection, usually. But it can occur with alcohol intake, too, isn't that right?
HOWARD WORMAN, MD: Right. Hepatitis means inflammation of the liver, and that can be from many causes: alcohol, other drugs, viruses, metabolic diseases. But the type of hepatitis caused by alcohol is referred to as alcoholic hepatitis.
DAVID MARKS, MD: Tell me exactly what it is, what alcoholic hepatitis is.
CAROL SEMRAD, MD: It's the destruction of the liver cells in response to drinking. It's not exactly clear whether it's the fat accumulation that ultimately is the irritant or the alcohol itself, per se, is the toxin to the liver.
HOWARD WORMAN, MD: Yeah, it's not really clear what causes the liver cell destruction or inflammation despite knowing about it for all these years. We really don't know how alcohol damages the liver.
DAVID MARKS, MD: Now, someone who drinks casually, are they going to get alcoholic hepatitis?
HOWARD WORMAN, MD: Casually, no, depending on your definition of casual.
DAVID MARKS, MD: A couple, one or two drinks a night, or maybe drinking on the weekends. Are they susceptible to alcoholic hepatitis?
CAROL SEMRAD, MD: I think it depends on what "one or two drinks" means. Some people drink a double or triple martini, a couple of them, and call that two drinks. That's more than what one would call two drinks, so it depends on what they call a drink. I think people tend to usually underestimate how much alcohol they actually are drinking, so you have to be a little careful about the definition.
HOWARD WORMAN, MD: I would say if you look at a drink as 10 grams of alcohol -- a single shot of whiskey, a single beer, one glass of wine -- two drinks or three drinks is not going to give alcoholic hepatitis.
DAVID MARKS, MD: What are the symptoms of alcoholic hepatitis?
CAROL SEMRAD, MD: Early on, actually, people tend to not be symptomatic, from what I know of it. But I think if the inflammation becomes severe, they become very sick, and one of the characteristics is they come in with fever, pain, vomiting, oftentimes anorexia and feeling extremely sick, unlike viral hepatitis, some of the viral hepatitises where people don't even know they have it and are walking around. But I think early on, even with alcoholic hepatitis, you may not know you have it until --
HOWARD WORMAN, MD: Right. It's a broad spectrum of disease, from virtually asymptomatic to severely ill, comatose, even. It's difficult. The ones we usually see are in the hospital quite sick, but people could be walking around with hepatitis from alcohol.
DAVID MARKS, MD: Without even knowing it?
HOWARD WORMAN, MD: Without knowing it. Another thing to mention about alcoholic hepatitis is that often the patient will have other symptoms from drinking too much alcohol not necessarily attributable to the liver -- for example, neurological problems or mental status problems or other problems that alcohol may cause, shaking or withdrawal.
DAVID MARKS, MD: Worse than alcoholic hepatitis is cirrhosis. We're kind of progressing from fatty liver to hepatitis to cirrhosis. How common is cirrhosis from alcohol?
HOWARD WORMAN, MD: In the United States alcohol is the number one cause of cirrhosis.
DAVID MARKS, MD: Maybe we should say what cirrhosis is.
HOWARD WORMAN, MD: Cirrhosis is fibrosis, or scarring, in the liver with abnormal regeneration of liver tissues.
DAVID MARKS, MD: What does that mean, regeneration?
HOWARD WORMAN, MD: Liver cells can grow after they're damaged. You can remove 90% of your liver, and the liver will come back. With continued alcohol use or viral infections or other toxins, the liver grows back in an abnormal pattern, so cirrhosis is this abnormal growth of liver cells with scarring.
DAVID MARKS, MD: When it grows back in an abnormal pattern, does that mean it doesn't work right?
HOWARD WORMAN, MD: Eventually the liver will stop working right in cirrhosis. At the beginning, everything might work okay. As the disease progresses, things could stop working completely.
DAVID MARKS, MD: How long a period of time does a person have to drink to worry about cirrhosis? Is there some kind of time frame?
HOWARD WORMAN, MD: Do you want to try that one, Carol?
CAROL SEMRAD, MD: You're the expert in this area.
HOWARD WORMAN, MD: I say that because you can't predict with an individual person. Some people can drink two bottles of whisky a day, never get cirrhosis, never even get liver disease. Maybe get in a bar fight or get run over by a bus and have other problems from alcohol. Some people can drink maybe three drinks a day for many years and develop cirrhosis. It's difficult to predict.
DAVID MARKS, MD: Does it matter what kind of alcohol a person drinks?
CAROL SEMRAD, MD: No.
HOWARD WORMAN, MD: No.
DAVID MARKS, MD: Too much of any alcohol can end up with liver damage?
CAROL SEMRAD, MD: Right.
HOWARD WORMAN, MD: As long as it's ethyl alcohol and not rubbing alcohol.
CAROL SEMRAD, MD: I think it's high amounts over years, in general, although, as Howard said, it can be lower amounts over a more prolonged time. Again, there's somewhat of a difference in whether you metabolize it easily.
DAVID MARKS, MD: You mean break it down?
CAROL SEMRAD, MD: Right, break it down.
DAVID MARKS, MD: Is there a difference between men and women in the incidence of liver disease from alcohol?
HOWARD WORMAN, MD: There are several studies that suggest that women -- alcohol liver disease is less common in women, because women tend to drink less than men, but several studies suggest that women who drink smaller amounts may get alcoholic liver disease as opposed to men. So men may have to drink more to get liver disease than women. Some studies suggest that.
DAVID MARKS, MD: Why is that?
HOWARD WORMAN, MD: It's not entirely clear. Some studies have suggested that men may break down alcohol more readily in their stomach as opposed to women, so before the alcohol gets into the circulation to the liver, men may break down more alcohol than women.
DAVID MARKS, MD: But you're not saying that men should go and drink more than their wives or girlfriends because they can handle it, right?
HOWARD WORMAN, MD: Well, maybe on one given occasion, but not on a regular basis.
DAVID MARKS, MD: That begs the question of how much is too much? I know it is variable, but is there any general rule that a person can follow to know if they're drinking too much alcohol?
CAROL SEMRAD, MD: I think it's hard to predict that, because people don't tend to measure the amount of alcohol they drink in any given drink, and even in wines there's a variety of alcohol content, or the contents varies in different wines and different drinks that you take. So it's very hard to keep track of it, I would think. But certainly anyone who's drinking several or many drinks a day is probably drinking too much.
DAVID MARKS, MD: On a daily basis?
CAROL SEMRAD, MD: On a daily basis.
HOWARD WORMAN, MD: In general, one, maybe two drinks a day is not going to make problems, but once you start getting above that one- or two-drink-a-day limit, it's very hard to predict if you might have liver problems or not.
DAVID MARKS, MD: And of course we should emphasize that alcohol affects other organs besides the liver, too, so that if you drink too much alcohol, you can run into a whole host of problems.
HOWARD WORMAN, MD: Absolutely. Maybe only 10% of alcohol abusers get liver disease, but the other 90% who are serious alcohol abusers get many, many other problems.
DAVID MARKS, MD: Great. Well, Dr. Semrad, Dr. Worman, thank you very much. And thank you for joining our webcast. I'm Dr. David Marks. Goodbye.