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​4 Reasons You May Be at Risk for Liver Disease

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

Old fashioned whiskey drink on ice with orange zest garnish.
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Experts are warning that a rise in alcohol consumption during the COVID-19 pandemic plus a trend in expanding waistlines are helping to fuel an epidemic of liver disease. Over time, these insults can lead to fibrosis or cirrhosis.

In fact, a recent study led by Harvard estimated that a one-year increase in alcohol consumption during the COVID-19 pandemic will result in 8,000 additional deaths from alcohol-related liver disease, 18,700 cases of liver failure, and 1,000 cases of liver cancer by 2040.

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Problem is, the epidemic is a silent one. Your liver could be losing the ability to do its job of filtering harmful substances from your blood long before symptoms ever show up.

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.”

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.

“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.

The signs of advanced disease are clearer. Any of the following symptoms necessitate immediate medical attention.

  • 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.
  • Dark-colored urine
  • Pale-colored stool
  • Chronic fatigue
  • Nausea or vomiting

It’s always better to prevent liver disease 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 

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 7 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.

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Risk No. 2: Fatty Liver Disease  

As weights rise in the U.S., there’s been — along with an alarming increase in diabetes and other metabolic ills — a growing incidence of nonalcoholic fatty liver disease (NAFLD), in which 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.

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 painkiller 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.

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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. 

“All of these compounds, whether they’re supplements or things we prescribe, are metabolized in the liver,” says Lammert. “And we don’t know what triggers the injury — whether it’s the actual drug causing direct toxicity or it’s that the drugs bind to certain proteins in liver cells, triggering something akin to an autoimmune reaction.” In any case, it’s important to tell your doctor everything you take and to ask what’s best.

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 CDC.

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.”

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