Symptoms of Alcoholic Liver Disease

[three sisters]

My father-in-law has been a heavy drinker for at least 10 years.  Currently, we believe he is consuming about 8 - 12 oz.  of gin everyday. Nobody is sure about the amount because he is a closet drinker. About two weeks ago, he began to exhibit slight personality change (moody, sarcastic, self-absorbed).  He also started forgetting things (i.e., a phone call that he made two days before).  His comprehension, already affected by a stroke that he had three years ago, is getting worse.  Physical symptoms include red palms, along with "knots" underneath the skin, and red, blotchy skin (upper torso).  In the past two months, he has lost about 15 lbs. without trying.  His appetite is poor, and he is easily fatigued.  He also sounds like he has a lot of congestion in his chest (kind of a wheezy, rattling sound).  His arms and legs are extremely thin; he looks like he doesn't have any muscle left.  The skin just hangs.  This seemed to come on all of a sudden.  He's been to the doctor for blood work; however, the liver function tests don't show any problem.

The entire family is worried about him.  He is on blood thinners because of the stroke.  Some of us feel that he may have liver disease.  My mother-in-law thinks his problems are due to the stroke.  Obviously, he shouldn't be drinking.  However, he doesn't feel that he has a problem and refuses to quit.

Anybody out there have any advice or information for us?  Thank you so much.

[three sisters]

I just wanted to thank you for the information concerning my father-in-law.  I've visited the websites you suggested and found a lot of useful information.  Thanks for taking the time to help us!

[imkindly]

He needs a "liver panel" done. (Sometimes called "liver function tests").
It's a simple blood test, where they look at the following things:
ALT
AST
Alkaline Phosphatase
GGT
Bilirubin
Albumin
PT (Prothrombin Time)


ALT, AST, alkaline phosphatase, and GGT are simply markers of disease.
Serum bilirubin, serum albumin, and prothrombin time are more true indicators of overall liver function.

These sites describe liver tests:

http://www.hepatitis.org.uk/s-crina/tests-lft.htm

http://cpmcnet.columbia.edu/dept/gi/labtests.html

http://medicine.creighton.edu/medschool/case-pres/global/labguide.html


People with advanced liver disease usually develop the following "complications" (not in any certain order):

1. Edema (swollen feet or legs), and then ascites (swollen abdomen).
2. Varices (Varices are swollen blood vessels in the throat, stomach or intestine, that can burst and bleed. A person will cough blood, vomit blood, or pass bloody or black stools.)
Varices are life threatening.
3. Encephalopathy. (Encephalopathy is a build up of ammonia, that affects the brain. It starts out with confusion or forgetfullness, can lead to stupor, slurred words, and the coma (and death).

Things can be done to slow all of this down:

1. a person with edema or ascites should
.....be on a low salt diet
.....take diuretics (water pills)

2. a person with varices should
.....get an endoscopy done (they can tie off varices with small rubber bands to prevent or stop hemmorhage)
.....MAYBE take beta blockers (not safe for all patients---only a doctor could say)

3. a person with signs of encephalopathy should
.....take Lactulose (it's a prescription laxative that removes ammonia from the body. You can only get it by prescription.)

When these things don't work, (if things get worse), a doctor can install a "shunt" to help with ascites and varices.
A doctor can also do a "paracentesis" to drain ascites fluid.

They can also prescribe antibiotics to help with any infections. (Infections are common in liver disease. If I were you, I'd get him checked for that rattle in his chest soon.)

They can also give him advice on diet (and maybe prescribe supplements) to help with malnutrition or weight loss. (Malnutrition is common in liver disease.)

I am not a doctor.
I do have a husband that's waiting on a liver transplant, and has liver failure right now. (That's why I learn all that I can about this.)

IF I WERE YOU

1. I'd get him a blood test (liver function) done.

2. I'd try to get him to a gastroenterologist (instead of a normal MD).
A good gastroenterologist will see the red palms, blotchy skin, and probably schedule him for an ultrasound (or an MRI or CT Scan) to look at his liver.
I'd tell the doctor about the confusion.
(Hopefully he'd prescribe Lactulose.)
I'd tell the doctor about the coughing up blood in the past.
(Hopefully he'd schedule an endoscopy.)
I'd tell the doctor about the congestion oin his chest.
(Hopefully he'd check that out, and if necessary give him an antibiotic.)

I've got a webpage for cirrhosis at
http://www.expage.com/cirrhosis

It may help you to check that out. (There's links there that you can click, To "learn more about Cirrhosis"
(Causes, Symptoms, Complications, Diagnosis & Treatment)

Hope this helps.

[three sisters]

You mentioned GGT test -- we didn't see that on his lab results.  They did a comprehensive metabolic panel.  What would we be looking for?

As far as the drinking goes, his PCP has told him more than once that the alcohol is killing him.  It's weakened his heart and lungs and who knows what else.  He's been in hospital three times for lung-related problems.  In fact, last year he was coughing up blood so we took him to the ER.  They told us that he probably broke a blood vessel because of his "violent" coughing.  Now that I think about it, I'm wondering if that episode had more to do with his drinking.

A few days ago, he asked me what happened to the 2nd Tower of the World Trade Center.  He wanted to know if it had collapsed.  I'm wondering if this is another symptom we need to worry about? He also seems more confused and it is taking us longer to answer his questions.  Again, this could be the stroke; however, he seems to be getting worse, not better.

[imkindly]

You know, if he did have further tests.....and if the tests show anything going on with his liver.....
The first thing they'd say to him is to stop drinking.

It seems strange that he would be able to drink gin and have a normal GGT (GGT is one of the blood tests they do for liver).

Good luck.

[three sisters]

Thanks for the information.  I looked at the palmar erythema image -- that's what my father-in-law's hands look like.  My husband and I aren't sure what to do next.  After reading about the various symptoms, neither one of us can understand why his doctors haven't evaluated him for liver disease.  It seems so obvious to us that something is wrong.  Since his liver panels have been normal, you'd think that his doctors would order other tests.  I feel that he needs to see a specialist; however, convincing my father-in-law is another matter.  Again, thanks for your help.

[imkindly]

"Alcoholism" is medically diagnosed by using the "CAGE" Questionaire, and the "AUDIT" test.
Here they are:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

CAGE QUESTIONNAIRE:

1. Have you considered Cutting back on your drinking?

2. Does it Annoy you when people note you may be drinking too much?

3. Do you ever feel, Guilty about your drinking?

4. Do you ever need an Eye-opener drink first thing in the morning to straighten yourself out following a drinking episode the evening before?

Two or more positive answers indicate a patient has a 90% or greater chance of being an alcoholic.

http://www.findarticles.com/cf_0/m3233/11_34/63602918/print.jhtml

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Another effective self-report screening test is the Alcohol Use Disorders Identification Test (AUDIT), designed by the World Health Organization.
A score of 8 or more on this test strongly suggests alcoholism:

Alcohol Use Disorders Identification Test (AUDIT)

1. How often do you have a drink containing alcohol?
(0) Never
(1) Monthly or less
(2) 2-4 times/mo
(3) 2-3 times/wk
(4) 4 or more times/wk

2. How many drinks containing alcohol do you have on a typical day, when you are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7-9
(4) 10 or more

3. How often do you have 6 or more drinks on one occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

4. How often during the last year have you found that you were unable to stop drinking once you had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

6. How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session the night before?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

9. Have you, or has someone else, been injured as a result of your drinking?
(0) No
(1) Yes, but not in the last year
(2) Yes, during the last year

10. Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested that you cut down?
(0) No
(1) Yes, but not in the last year
(2) Yes, during the last year Note: I drink 10 g of alcohol.

Note: 1 drink = 10 g of alcohol.

Scoring: A score of 8 or higher suggests the possibility of an alcohol problem.
More specifically, high scores on the first 3 items in the absence of high scores on the remaining items suggest hazardous alcohol use.
Elevated scores on items 4 to 6 suggest the presence or emergence of alcohol dependence.
High scores on items 7 to 10 suggest harmful alcohol use.

http://www.findarticles.com/cf_0/m3233/11_34/63602918/print.jhtml

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
ALD (Alcoholic Liver Disease)

Red flags for alcoholism and possible liver damage:

Defensiveness
Be wary of patients' responses to your questions regarding alcohol use. When asked if they drink, and if so, how much, alcoholics' defenses tend to go up. A typical response from an alcoholic might be, "Sure, I drink a few beers every day. Doesn't everybody?" Nonalcoholics, on the other hand, tend to have no reservations admitting how much they drink.

Lifestyle disruption
Even patients with stage-1 ALD may drink heavily enough for this habit to affect their lives. Ask them if they have ever been arrested for drunk driving, been involved in a social situation or with people they later regretted seeing, or had blackouts.

Monday flu
Many alcoholics are unable to fulfill commitments following weekend binges. Find out when and how often they call in sick to work and/or miss school.

Trauma history
Assess past incidents of trauma, including frequent falls, fractures, burns, and lacerations, which may require visits to the emergency department.
Families also may show evidence of trauma as alcoholics may be physically abusive.

Depression
Excessive alcohol consumption produces increases in enzymes such as monoamine oxidase that can cause depression and tolerance to alcohol.

Insomnia
Determine if a patient is having trouble sleeping. Many alcoholics drink themselves to sleep and then awaken once the alcohol wears off and are unable to fall back asleep.
Alcoholics do not experience REM sleep when they pass out, so they may never feel rested if this is the way they get to sleep every night.

Poor sex life
Many alcoholics suffer from sexual dysfunction. Drinking also suppresses activity of the ovaries and testes.

Masking symptoms
Be alert when patients smell of excessive mouthwash or perfume, which is often used to mask the smell of alcohol on their breath.

http://www.findarticles.com/cf_0/m3233/11_34/63602918/print.jhtml
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Hope this helps

[imkindly]

Here's where you can see a picture of Palmar Erythema ("liver palms") (the red palms you describe):
http://www.medicouncilalcol.demon.co.uk/handbook/images/palmar_erythema.htm

Here's some general information for you
http://www.merck.com/pubs/mmanual_home/sec10/117.htm
(scroll down to alcoholic liver disease)

[three sisters]

I wanted to thank both of you for responding.  Yes, I am glad that my father-in-law's test were normal.  However, I've been told that this doesn't necessarily rule out cirrhosis. Sometimes, what is required is a liver biopsy.  He won't consent to this, since he doesn't feel that he has a problem.  His PCP feels that he is an alcoholic.  Case in point:  I took him to the urologist last week.  I was helping him fill out forms.  When asked about medical history/habits, he put down that he doesn't drink.  When I looked at him in disbelief, he changed it to moderate drinking (a few beers now and then) -- far from the truth.  So while I appreciate the suggestion about counseling, you can see why it'll probably never happen.

I will look into the other suggestions offered by littlejen02. However, some of the family suspects that liver disease is present because of his symptoms, including the nodules and red palms. I have a friend who's a nurse.  She used to work in a alcohol/drug addiction ward.  She said that individuals with cirrhosis present these symptoms.

Again, thanks for your help.  I appreciate your advice.

[littlejen02]

Have you had his hormone's checked?
Mabye he has adrenal insuffiency...
Not enough Cortisol being produced.
Not sure.. just a thought.

[avion]

alcohol's not good but u should be happy that LFTs are not afftected.
May be he needs to see somebody for counselling