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How Not to Die

How to Tell if Your Liver is Screwed

Let's put down the IPA and assess the damage.
Picture: Phil Ashley/Getty Images.

This article originally appeared on Tonic.

It's easy to take the liver for granted: Long after you've gone to bed, cursing the friend who ordered Jäger shots, the vital organ is hard at work, soaking up the toxins you've recklessly introduced into your bloodstream. But what happens when those Friday nights begin to add up? And are there even ways to tell if your liver is beginning to show signs of strain from years of making questionable decisions?


Let's start with the good news: Unlike most of your major organs, your liver can regenerate, salamander-like, after it's been damaged. But that doesn't mean you can repeatedly abuse it and get off scot-free. Your odds of escaping your party years without major liver damage depend in part on when you emerge from your alcohol-induced haze, says Steven Flamm, medical director of the liver transplant program at Northwestern Memorial Hospital in Chicago.

"If somebody is 26 and they've been drinking a lot for four or five years, they've almost certainly not developed any chronic liver disease that they have to be worried about yet," he says. But the years between 25 and 35 can pass quickly, especially when you spend a good chunk of them blacked out. Charging hard for a decade or so—say, averaging three to four drinks per day or going on 20-drink weekend benders—puts you at high risk of developing chronic liver disease from alcohol.

What's worse, you might not catch it until years later. At that point, you'll have to put down the bottle for good. "It's very sad, because when people do get sick from this, they're generally in their mid-30s to mid-40s," Flamm says. Often, they have a significant other, young kids, a house. "Every one of them, when you walk into the room, tells you, 'I wish I didn't do this. It wasn't worth it.'"

In some cases, the consequences are truly frightening: A single episode of serious bingeing can cause a condition called acute alcoholic hepatitis, an inflammation of the liver, says Hardeep Singh, a hepatologist with St. Joseph Hospital in Orange, California. Symptoms include abdominal pain, nausea, and vomiting. (This is a very serious problem—about half the time, patients die within a month.)


But before you freak out, you should know that alcoholic liver disease more commonly sets in slowly, over time. First, fat builds up in your liver, making it harder for the organ to carry out functions like breaking down medications and absorbing nutrients from your food, says Jessica Lue, a family medicine physician at One Medical in Chicago.

Keep drinking, and booze will continue to damage or destroy cells in your liver, leading to full-blown hepatitis. In many cases, however, this damage is reversible, Flamm says. But once it crosses the line into cirrhosis, or scarring of the liver, you might not be able to turn back.

Cirrhosis doesn't develop in everyone who drinks heavily or abuses alcohol for reasons that aren't quite understood. "Some people can drink 20 beers a day and never get sick, liver-wise," Flamm says. "Then other people drink much less and do get sick."

That said, some factors undeniably up your odds. For one thing, unfortunately, being female—and not just because women tend to weigh less. "Drink for drink, women are twice as sensitive to the toxic effects of alcohol on the liver," says Allan Wolkoff, professor of medicine and director of the Marion Bessin Liver Research Center at Albert Einstein College of Medicine.

Any other source of stress or strain on your liver causes alcohol to hit it that much harder. Another issue on the rise: fatty liver disease not caused by alcohol. This condition—called non-alcoholic steatohepatitis, or NASH—affects an estimated one in four Americans, according to the American Liver Foundation.


Being overweight or obese also puts you at risk for having adipose tissue infiltrate your liver tissue even before you introduce it to your friends Jack Daniels or Captain Morgan, says Tyree Winters, associate professor of pediatrics at Rowan University School of Osteopathic Medicine in Princeton, N.J. (Certain medications like calcium channel blockers, or other heart risk factors like high cholesterol and high blood pressure, may also play a role in NASH.) Then when you do drink, it's that much worse.

Same with other causes of liver damage, including congenital defects and infections like hepatitis B and hepatitis C. "Having alcohol on board with hepatitis C is very, very deleterious to the liver," Flamm says. "The liver does not like that. Those people get sick worse and faster."

So what are a few of the red flags? Unfortunately, when your liver first falls ill, you'll often show no symptoms at all. "I have patients with cirrhosis that run the Chicago Marathon," Flamm says. "That tricks people. People with advanced-stage liver disease can feel fine."

Usually, the first warning sign is fatigue, which is frustratingly non-specific. In other words, it could be due to liver disease or it could just be that you're sleep-deprived, Flamm notes. Once you're pretty far along the path to liver failure, you'll likely get a yellowing of the skin and eyes called jaundice. Your urine gets darker. As your liver stops clearing toxins from your blood, they affect your brain, causing confusion. You may vomit up blood—caused by swollen, burst veins in your esophagus and stomach—or develop severe swelling in your legs or gut. All of these things, obviously, are very bad signs, Flamm says.


If you get a physical and your doctor mentions "running your labs," he or she is probably checking your liver function along with things like your cholesterol and blood sugar, Flamm says. A series of tests called a liver panel assesses how well your liver's working by looking at compounds like enzymes, proteins, and bilirubin, a yellow substance found in bile.

You can ask for these tests specifically if you're concerned about your liver. But there's a problem, Flamm says: If you used to drink more but cut back, your results can look normal, even if you do have underlying damage. "The liver blood tests can sometimes trick you into thinking you don't have a liver problem, when underneath, you do," he says.

So, you'll want to shed any shame and be completely honest with your doc about your lifestyle and habits. "Most cases of liver problems related to alcohol intake are mild and have a really good prognosis," Winters says. "But your physician has to be your partner in this. There's no judgment pattern associated with it."

If you're really at risk—say, you didn't cut back till your 30s, you have other complicating factors, or you have symptoms like fatigue or jaundice—your doc may run additional tests, Winters says. These include blood tests to check for markers of scar tissue, or imaging like CT scans or MRI. A machine called a FibroScan, similar to an ultrasound, can also tell your doctor how stiff and scarred your liver is. You can even have a biopsy—where your doctor checks slices of your liver under a microscope—to inspect it down to the cellular level. "But nobody would do that unless there was some great suspicion," Flamm says.

No medicine can cure chronic liver disease, Flamm says. Some medications can ease symptoms of advanced cirrhosis, such as swelling, bleeding, or confusion. But in the end, the only remedy is complete abstinence from alcohol. "If you're in your 30s and 40s and you've already started to develop chronic liver disease, taking care of yourself means you don't drink. At all," Flamm says. No occasional champagne toast at weddings, no sip of scotch at night, nada. "If you cheat, it's bad news."

Downgrading to beer or wine from "the hard stuff" does you no good, Flamm says. You'll get the same dose of booze from a 12-ounce beer as a five-ounce glass of wine or a one-ounce shot of liquor. If you're heavy and also have fatty liver in addition to alcohol-induced liver damage, losing weight can help, he notes. Exercise is always a good idea, since it may aid in weight loss and also reduce your levels of bad cholesterol, another source of strain on the liver, Winters says. But there's no evidence a specific diet or other regimen can help, Flamm says.

And if you, like most people, escaped young adulthood with your liver intact, congratulate yourself—and go ahead and drink moderately. (Moderately, by the way, means one drink per day or seven per week for women, and two daily or 14 weekly for men.) Keep in mind, too, that many bartenders, whether it's the pros or your buddies, pour heavy, and many mixed drinks contain far more than one shot. You could easily be consuming four drinks on a given night—or more—without realizing it