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​Hidden Risk Factors, Warning Signs of Liver Disease

Drinking, taking antibiotics, even high blood pressure can tax your liver in potentially dangerous ways


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Many think of alcohol as the main cause of liver complications. But contrary to popular belief, various factors impact liver health, including weight, certain medications, genetics and even viral infections.

No matter the trigger, a major concern surrounding liver disease is its silent progression. Your liver could be losing its ability to filter out harmful substances from your blood long before symptoms appear.

Most of the time you don’t know your liver has been harmed until you develop the advanced symptoms of cirrhosis. “That’s the tough part of treatment,” says Anurag Maheshwari, M.D., a gastroenterologist with the Institute for Digestive Health and Liver Disease at Mercy Medical Center in Baltimore. “Convincing patients that they need to act now in order to avoid complications in the future can sometimes be a challenge, because they don’t feel any different today.”

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Early symptoms and warning signs of liver damage

In the early stages of chronic liver disease there are often no symptoms. Occasionally people with early-stage liver disease experience fatigue, right-side abdominal pain, increased bruising or itching — symptoms that are usually missed because they could be caused by other ailments.

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Where is the liver?

The liver is located in the upper-right portion of the abdomen, below the diaphragm and on top of the stomach, right kidney and intestines. In adults, it weighs about three pounds and is shaped like a cone.

“If you have discomfort on your side, for instance, it could be a million other things,” says Jamile Wakim-Fleming, M.D., director of the Fatty Liver Disease Medical Home Program at Cleveland Clinic.

Routine checkups, lab tests or imaging studies are typically how patients first find out if they’re developing a liver problem or disease.

Signs of advanced liver disease

As liver disease advances, the signs become clearer and warrant immediate medical attention. These symptoms include:

  • Jaundice or yellowing of the eyes or skin.
  • Pain and distention of the abdomen due to the release of fluid from the liver.
  • Swelling of the lower legs due to fluid retention.
  • Confusion or forgetfulness. When the liver isn’t functioning properly, toxins build up in the blood and can travel to the brain, affecting brain function.
  • Chronic fatigue.
  • Nausea or vomiting

Liver disease and age

Older adults who are in good health are not inherently more prone to liver disease. But older age can amplify the severity of symptoms associated with liver problems, making recovery more challenging. What’s more, treatments may not work as well in older people as they do in younger people.

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Causes of liver disease

It’s always better to prevent liver failure than to treat it. Here are some common — and not so common — risks and how you can avoid or stop the damage.

Risk No. 1: Alcohol intake

We all know that alcohol can be hard on your liver. But how much is too much?

Maheshwari notes that a safe alcohol limit may seem surprisingly low: no more than one alcoholic beverage a day (or seven drinks in a one-week period) for women and two or fewer drinks for men (or 14 drinks over a week’s time).

“When patients drink alcohol in excess, beyond the capacity of the liver to metabolize it, the excess alcohol is turned into fat and stored,” Maheshwari says. “Called steatosis, this fat interferes with the liver’s function and causes cell death.”

The good news? Putting the brakes on alcohol consumption can stop the progression of fibrosis, and liver function may improve. “But it depends on when it was caught,” says Wakim-Fleming. “A lot of people who have alcoholic liver disease end up needing liver transplants because they don’t stop drinking until [too] late.”

If you suspect you may have a problem, talk to your doctor, who may refer you to a specialist for evaluation and tests.

Risk No. 2: Weight 

With obesity rates on the rise in the U.S., there’s been — along with an alarming increase in diabetes and other metabolic ills — a growing epidemic of nonalcoholic fatty liver disease (NAFLD), which occurs when too much fat is stored in the liver.

“Obesity, diabetes, high blood pressure, high cholesterol — common features of metabolic syndrome — are all known major risk factors for the development of fatty liver disease,” says Craig Lammert, M.D., assistant professor of medicine at the Indiana University School of Medicine and a practicing gastroenterologist and hepatologist at IU Health. As with alcohol-related liver damage, these conditions cause fat to be deposited in the liver.

“The scary piece of this is, anywhere from 15 to 50 percent of the nation’s population may have too much fat in the liver,” says Lammert. Of those, he says, about 5 percent are at risk of inflammation that can damage the liver. “But we don’t always know who that’s going to be.”

Inflammation hurts the liver by way of a condition known as nonalcoholic steatohepatitis (NASH), which damages and kills liver cells. “We’re hearing a lot about this because over the next few years, fatty liver disease will probably be near the top, if not the top, cause for liver transplantation in this country,” Lammert notes.

If you’re carrying around excess pounds or battling diabetes, high cholesterol or high blood pressure, the risk of liver failure just adds another good reason to shed some weight and get your blood sugar, cholesterol and blood pressure under control. Although there is no cure for NAFLD, it can be reversed.

Risk No. 3: Drugs and supplements

Certain drugs and supplements can also injure your liver, depending on the dose and other factors. Taking too much acetaminophen (Tylenol) is the most common over-the-counter risk. “People who overdose with Tylenol overwhelm the metabolizing system and drive liver toxicity,” Lammert says.

But patients should have few problems if they take the pain reliever as prescribed, which includes consuming no more than 4,000 milligrams in a day. Those with existing liver disease may be advised to take less than 2,000 milligrams. One caveat: If you’re taking acetaminophen at those levels, be sure to avoid alcohol, which would add to the cumulative burden on the liver, Lammert advises. Other painkillers, including NSAIDs like ibuprofen (Motrin) and naproxen (Aleve), can be similarly harmful under the same circumstances.

If you are taking anything approaching the maximum dose of acetaminophen, be aware that the drug is often found in other products, such as multi-symptom cold and flu formulations, making it easy to unwittingly double the amount you are taking. So be sure to check product labels for acetaminophen.

Surprisingly, “antibiotics are probably the most important cause of liver injury we see,” Lammert says. This is particularly true of Augmentin (a combination of amoxicillin and clavulanate), which is used to treat common bacterial problems like sinus and urinary tract infections. Liver complications affect an estimated 30,000 people a year taking this compound in the U.S. And although most of the harm is temporary, some is so damaging as to require a liver transplant.

There are also reports of liver damage with certain supplements, including bodybuilding and weight-loss supplements that contain green tea extract, linoleic acid and androgenic anabolic steroids. Even two essential nutrients, vitamin A and niacin, can harm the liver if taken above the recommended doses.

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Risk No. 4: Viral infections

Hepatitis B and C are viral infections of the liver that can lead to liver damage and even cancer. (The vast majority of people with hepatitis A recover with no lasting harm.) As with other liver diseases, people with hepatitis often don’t have symptoms and may not know they are infected, Wakim-Fleming says.

People contract hepatitis B (HBV) through blood, semen and other body fluids and by sharing personal items (needles, razors) with someone who has the infection. Hepatitis C (HCV) is contracted through contact with the blood of someone with HCV, often through the sharing of drug paraphernalia or through a transfusion of contaminated blood or organ transplant prior to 1992, when blood started to be screened for the virus. More than half of people with HCV develop a chronic infection, and up to 25 percent develop cirrhosis over 10 to 20 years, according to the Centers for Disease Control and Prevention.

Vaccines are available for HBV, and everyone ages 18 to 79 should get an HCV test at least once, particularly those born between 1945 and 1965. “The guidelines over the past 10 years or so are that all baby boomers should be screened for hepatitis C,” Lammert says. Despite this recommendation, too few people who are eligible seek testing. “The good news is we now have good treatments to eradicate the disease.”

Risk No. 5: Genetics and autoimmune conditions

Genetic conditions like hemochromatosis and Wilson’s disease can contribute to the development of liver disease. In these conditions, excess metals can build up in the liver, causing cirrhosis and organ toxicity.

Additionally, autoimmune conditions may lead to liver disease and, to some extent, genetics may play a role as well. The exact cause of autoimmune liver disease is not fully understood by doctors; however, it is theorized that factors such as infection, medication or chemical exposure could act as triggers. While there may be a genetic predisposition, the specific role of genetics in causing autoimmune diseases remains unclear. Treatment for autoimmune liver disease typically involves long-term management, and while the majority of patients respond well to treatment, they often require lifelong medication.

When to see a doctor

Given liver disease’s silent nature, patients should see a doctor as soon as they become concerned about their liver function, said Maheshwari. Make sure that routine liver tests are incorporated into physical exams so any abnormalities can be detected early.

Note that AST and ALP blood tests, which assess liver function, don’t necessarily correlate with liver injury. If levels are slightly elevated longer than six months, a full evaluation may be necessary to determine the underlying cause. A specialist may administer a noninvasive test, such as an elastography, to better understand liver function.

Treatment options for liver disease vary depending on the cause, with a liver transplant being the last resort. For some, eliminating alcohol or inflammatory medications may be necessary. In the case of viral hepatitis, medications may be required to combat the virus.

Meanwhile, for individuals dealing with an autoimmune liver disease, a medication to suppress the immune system from attacking itself may be needed. Unfortunately, genetic conditions often have limited treatment options, and a liver transplant becomes the ultimate recourse for those with end-stage liver damage.

The Four Stages of Chronic Liver Disease

  1. Hepatitis: Inflammation in your liver that can lead to scarring, known as fibrosis
  2. Fibrosis: The liver gradually stiffens and scar tissue replaces healthy tissue, restricting blood flow. Some amount of fibrosis can be reversible if detected early because liver cells can regenerate.
  3. Cirrhosis: Scarring of the liver becomes irreversible because there are no longer cells healthy enough to regenerate lost tissue. The damage can be slowed or stopped at this stage by consulting a liver specialist.
  4. Liver failure: The liver can no longer function adequately for the body’s needs and has lost the ability to regenerate and its function is slowly declining.

Editor’s Note: This story, originally published Nov. 9, 2021, was updated to reflect new information.

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