Alcohol and the Liver

This article has been recorded to audio for convenience. All Podcasts can be heard on: This Website (Podcast Episodes), Podbean, Spotify, Apple Podcast, Amazon Music Podcasts, Google Podcasts, Google Chrome, TuneIn, iHeartRadio, and more.

Picture Credit: @travelwithlace

Hello Sobertown,

Today we jump back into our tiny submarine and travel through the bloodstream and to the liver to observe the magnificence and incredible durability of this unique organ we possess, the liver. Buckle up and on we go.

To begin lets start with the basics, where is your liver. I would hazard a guess and say most drinkers probably know that the liver is located on your right side within the abdomen, it looks like a wedge or a cone, to be honest it kind of just looks like a red brown lump wedged between the diaphragm which sits above it like a ceiling and the stomach below it, if you see it outside of the body in an anatomy lab it looks quite ugly and misshapen with all of its contours and blobby shapes like it just wants to crawl off the table and head off in search of something to destroy. Liver monsters aside, the liver roughly follows the outline of the right lower rib cage so it sits behind the protection of these lower right ribs. The liver sits roughly from the area of the right nipple, depending on how low they might be on your chest and extends down to around the level of the lowest rib on the right, this is the broad side of the liver then it extends to a narrow pointed end an inch or two across the midline. As a rough indication, point at your right nipple then draw a line straight down to about the level of the lowest rib which is about two inches above the belly button level, done that? Ok then draw a line from there toward the left nipple but stop an inch or two before getting to that left nipple, then draw back to the start at the right nipple, that very roughly is where your liver sits inside your body. So the liver is actually quite a large organ, it weighs around 1.5kg or about 3 and a quarter pounds depending on where you live. The liver is actually considered a gland and unsurprisingly it takes the crown for being the largest gland in the body and it takes the trophy for being the heaviest organ in the body on average though the brain is quite heavy also the liver beats it on averages so, take that brain, sure the skin is considered as an organ depending on who you ask and it is the largest but put skin aside and give it to the liver for now. Next picture a pint glass, fill the glass with blood in your mind, that is about how much blood is flowing around the liver at any one time, processing about 10-15% of your blood at all times which is quite a lot. So the liver is a big heavy brown lump in your right side abdomen, great, but what does it do, how does it process alcohol and what happens to it if we forget to take care of it? All of these questions and more we shall answer soon.

Our liver, depending on which research or text you look at has around 500 functions, yes, you heard correctly, 500 functions so no, it does not just exist to process alcohol it does a grand amount more than this. Now, the liver is divided into sections such as the right an left lobes and more when viewed from below but for the sake of this article lets just say the liver has defined sections and also has impressions and molded shapes to allow it to fit with the surrounding organs and tissues happily, this is what makes it so globular and contoured when we look at it outside of the body.

So Sobertown, let’s pull up our sub and get a really close look, we are going to zoom right in and look at the microscopic functional units of the liver now so we can see what they look like and what they do. So as we zoom in to any of the lobes of the liver we see what are called hepatic lobules and these are a beautiful structure, far prettier to see up close than the liver as a whole. Imagine each lobule like this, remembering the lobule is the functional unit of the liver, we have a hexagon, a six sided 3-D shape and in the middle of this hexagon is a pipe extending through the hexagon, at the outside of the hexagon at each of the six points there are also three smaller pipes running up and down, so three at each point of the hexagonal shape. So you have a hexagon, a main pipe running up and down through the middle of it and at each point on the outside of the hexagon three smaller pipes also running up and down. Between the main central pipe and the outside pipes there are tiny vessels like the roots of a tree running throughout the hexagon structure. This is what the functional unit of the liver called a lobule looks like when we zoom in. The central pipe I mentioned is a vein called the interlobular vein, the outside pipes are the portal venule (a venule is just a smaller vein), the portal arteriole (again arteriole is just a smaller version of an artery) and the bile duct, these 3 pipes together are called the portal triad, just in-case you were wondering but don’t stress the particulars. So to summarise, the lobule is kind of like a hexagonal shape with blood vessels and bile duct running through and around it to feed in and out everything needed for the job to be done, or let’s anthropomorphize the liver cells, because that’s one of my favourite things to do, think of it like a big recycling plant, let’s zoom in to this tiny lobule so closely that it looks the size of a giant building, like a big hexagonal recycling plant and your are standing out the front of this huge recycling plant, you look at the corners of the hexagonal building and you see the big three pipes running from the ground up to the roof, you walk inside the front door and you see they have conveyors in feeding in mixed rubbish, you have conveyors taking out sorted recycling goods and conveyors dumping the non-recyclable stuff all running constantly and these conveyors are everywhere and they run at all different levels in and out of the building, you look to the centre of the giant recycling plant and there is one huge pipe running in the middle of the building from the floor to the ceiling which shuttles out the recycled goods, the good stuff ready to be put back into circulation. In this recycling plant there are people everywhere sorting and breaking down garbage and reconfiguring items and these people are standing in a neat row all along the conveyor belts side by side with no gaps and they have a big tool belt on in which they have a massive amount of special tools made to break down each type of garbage coming to them, these workers represent the live cells called hepatocytes and their tools represent enzymes which take the compounds in your blood such as ethanol and break them down to other compounds. This giant recycling plant is a highly active place, taking whatever comes in, processing it and sending it back out in a different state. This is like a giant version of just one lobule of which we have thousands in our liver each doing their bit to process and recycle the blood to break down the “muck”, sort the “junk” and send back out for reuse. Now let’s zoom back out, back back back we go and as we zoom out we see our recycling plant or lobule get smaller, then we see that plant is surrounded by more plants, surrounded above, below, left and right. Recycling plants at all sides, we zoom out further and they get smaller and we see lobules as far as the eye can see, each lobe of the liver having thousands of these plants or lobules and each working as hard as one another and connecting to one another shuttling goods from one to the next, so as we zoom out far enough to see the liver as a whole again we can now appreciate that although we can’t see then from this far away, there are thousands of lobules aka recycling plants in there and within these lobules are millions of little workers lining up along the feed in and out and working to clean the blood, this is our ultimate internal filter. So when somebody says, I am taking a special tea or a special diet to “detox”, well guess what, I hate to break it to them but it ain’t a tea or diet which is detoxifying anything, your liver is doing that constantly, it is a detox machine, the trick is to not feed it poison so often that it can’t cope, do that and you have yourself a constant and highly effective detox all day every day with thousands upon thousands of recycling plants called lobules and in each of these thousands of plants is millions of workers called hepatocytes, doing the work to make the plants run well. Amazing.

Let’s zoom back out now that we know the liver has a huge distance of veins feeding the lobules from the intestines and spleen, arteries feeding it oxygenated blood and a system of bile ducts to take away the processed bile and send it to the gall bladder.

Lets look at bile now briefly. Our liver creates something called bile which drains through the bile ducts out of the lobules and to the outside common bile duct and then this bile is either drained into the gall bladder for storage and then when needed to a section of the intestine called the duodenum or it just gets stored in the gall bladder until we eat and need it. So, if you ever wondered where the gall bladder is and what the heck it does, well it stores bile made by the liver. Why? Ok why, so bile is helpful in digestion of fats, think of it this way, when you see fat such as animal fat or oil in your sink or in water it globs up and it does not clean easily right? Well, fat in our intestines is the same, it is not easy for the body to digest or process so bile acts as a surfactant like detergent would in the sink which means it allows the fat to be mixed more effectively with the fluids around it, the bile acts like detergent and lowers the surface tension of the fats so they mix in and can be absorbed. Bile will be stored in the gall bladder and then discharged into the small intestine when we eat so it can do its job. Bile is a greeny, yellowy, brown sort of a liquid. Bile mainly contains salts, fats and something called bilirubin, bilirubin is the important ingredient here, ok so bilirubin is a breakdown product of old red blood cells which are past their use by date and ready to be retired, this is important with regards to alcohol. You have probably heard of or perhaps even experienced jaundice, that is yellowing of the whites of they eyes and the skin and this occurs when we have too much of something called bilirubin accumulated in our body. In fact, bilirubin is responsible for multiple forms of the coloring of us, bilirubin is responsible for the yellowish color which comes out in bruises, it causes yellow eyes or skin in jaundice when we we have certain diseased states, bilirubin also has breakdown products which contribute to the color of our poo and another breakdown product causes the straw-yellow color of urine. Thanks for all the yellow bilirubin.

Before we move into more depth about how alcohol consumption affects the liver, let’s summarise some of the major functions our liver has. Our liver is a major manufacturing site within our body, it takes compounds and builds many types of proteins, proteins which circulate in our blood, proteins that clot our blood when we injure ourselves, it makes proteins which help with transport through the bloodstream and it makes proteins which enhance the ability of the immune system. Our liver cells create their own proteins and their own enzymes within. The liver makes and excretes bile. The liver resists infections and removes pathogens and bacteria from the blood. The liver takes excess glucose (sugar) from the blood and converts it to something called glycogen then stores it within its cells, it can then take this glycogen which is stored away and convert it back to glucose to fuel our body when we need it. The liver cells store significant amounts of vitamins A, D, E, K, and B12, as well as iron and copper which is also a very handy function. One of the most vital functions the liver provides us is filtration, it filters our blood and removes toxins, poisons, junk, it removes and breaks down what we do not want to be in our system and one of these poisons it breaks down for us is ethanol, aka alcohol. So these are very summarised functions of our liver but as mentioned it has over 500 functions in total and many of these are vital for life. The liver is a diverse workhorse of a body machine.

Let’s move forward to look at alcohol in relation to the liver. You drink, ethanol is absorbed through the gastro-intestinal system and it heads to the liver through the portal vein, time to go to work lobules because this stuff needs to be processed as fast as it can be, the desired psychoactive effects are unfortunately created alongside a rough time for the liver cells. The ethanol hits the functional units of the liver and they grab the tool from their belt named alcohol dehydrogenase, this enzyme allows the liver cells to break down the ethanol compound into something called acetaldehyde. I have created whole podcast about acetaldehyde, it is seriously bad stuff so please go back and listen to this podcast too. Acetaldehyde is a terrible compound, it is a carcinogen and very harmful to the body, from there the liver cells use another enzyme and they break down acetaldehyde to more safe compounds such as acetate. Your livers recycling plants, the lobules and its workers have a certain limit to their abilities, they can process ethanol at a certain rate and clear it, when we exceed this limit, which is variable between each of us this is when we begin to harm the liver. When the liver is forced to process too much ethanol, more than it can handle the cells are unable to handle the amounts of aldehydes being created and then the first change we see is usually a fatty liver, this is very much as it sounds, recall the workers within the recycling plant, these are the livers cells and when fatty change occurs in the liver these workers, the liver cells accumulate fats called liposomes inside them around their nucleus which is the centre of their cell. This is the early stages of fatty change where the cells accumulate small fatty droplets inside of them like a worker being forced to wear a weight vest as they go about their day, later though, when the fatty change worsens the size of these fatty deposits in the cells increases and they become so large they push the nucleus of the cell aside and can even form large fatty cysts, these can then be seen on imaging such as MRI and in some cases but not all cases we can see elevated liver enzymes within the blood, picked up through blood testing. Often when the liver is fatty, the person will note tiredness and dull pain over the right upper abdomen where the liver resided, but this is not always the case, fatty change can occur in the absence of elevated enzymes or pain as a silent problem and in-fact this is often the case. Why does this happen? One of the many roles of the liver is the processing of fatty acids in the body and this process is hindered when we overconsume alcohol leading to the fatty change. As fatty change in the liver progresses, we may see increasing inflammation within the liver and as this increases it leads to the liver cell death, so the millions of workers in the recycling plant, when there is too much fatty change in the liver these workers are forced to work with heavier and heavier weight vests on and eventually they can not cope, they fall down and they die, when these cells begin to die what happens is the next stage of liver disease because where they die there are cells which live in the liver called stellate cells and they come in and they form scar tissue where the dead hepatocytes or workers should be, this is permanent, the scarring should not be there, working cells should be there, but instead the liver develops more and more scar tissue called fibrosis where the workers have died. This is not good. Fatty liver changes occur in most heavy drinkers, around 90% of heavy drinkers will develop a fatty liver. Interestingly fatty change in the liver can be seen after even one heavy drinking session. A disclaimer now, I am not a medical doctor or providing medical advice of any type in these podcasts however a fatty liver has been shown to improved by reduction of caloric intake, exercise and generally healthy lifestyle choices in diet, weight loss, Vitamin-E intake which can be found in nuts, seeds and green leafy vegetables and most importantly stop drinking alcohol, because until that part occurs the rest may be in vein.

While fatty change occurs generally earlier, some drinkers experience alcoholic hepatitis, this simply means inflammation of the liver. Yes there are several types of hepatitis including that caused by viral means but one type is simply due to alcohol consumptions, sufferers of hepatitis more often have a long history of quite heavy consumption and it is usually associated with fatty liver changes. Where alcoholic hepatitis occurs the hepatocytes, the liver cells or as we covered you can think of them as the workers in the recycling plants they swell up with water, protein and fats which should be transported out into the blood but get stuck in the cell and the cells blow up causing impingement of the flow of bile and ducts and often these cells will die and when they die the debris left behind attracts immune cells called neutrophils which come in and gobble up the debris, but ordinarily this job should be done by other cells in the liver and the neutrophils should not be there. Alcoholic hepatitis is very serious and needs medical care asap and those with hepatitis caused by chronic drinking are also at risk of cirrhosis, infections and cancer. Sorry to be a downer but this is just what can happen in long term drinkers. Hepatitis is often associated with ascites which is swelling of the abdomen with fluid due to increased pressure in portal vein, the vein which supplies the liver. Hepatitis is also often associated with jaundice, as we discussed earlier where the bilirubin is not processed and accumulates in the blood causing yellowing of the skin and eyes. Management of alcoholic hepatitis is medical and very serious ranging from medications to early transplant, obviously alcohol abstinence is vital. Again, this is not medical advice, simply information.

We already covered how the liver can become essentially scarred where the scar tissue replaces the worker cells who die in a process called fibrosis, now if this is allowed to occur for a long duration for example months and years or even decades then gradually the worker cells, the hepatocytes are slowly replaced with scar tissue, fibrosis, and do you know what good scar tissue does where there is supposed to be working liver cells? None, useless, this turns functioning liver tissue into dead scar tissue. If we allow this to continue over time, more and more tissue becomes scarred and less and less hepatocytes remain to do the work, the workers lined up along the conveyor belts, they die one by one and get replaced with a cardboard cut out, a fake replacement which does absolutely nothing. Essentially this is what cirrhosis is, it is excessive scarring where liver cells have packed up and died causing the liver to function poorly, very poorly. So what symptoms might you experience in cirrhosis?

Early side effects of cirrhosis may include.

Tiredness, weakness, loss of appetite, unexplained weight loss, nausea, vomiting, abdominal discomfort and more.

Later effects may include: Itchiness, swelling in the lower extremity, abdominal fluid build up, jaundice aka yellowing, bruising easily and spider veins.

Sobertown, this is sobering, but liver cirrhosis is serious. Irreversible and if left untreated and habits continue for too long it may lead to the only option left which is liver transplant, this is a whole other kettle of fish, organ transplant is a huge deal and somebody close to me has experienced this process, unless you know somebody who has been through the process of organ transplant you can not understand the extreme effects it has on your whole life in terms of management of both physical and mental aspects of health post surgery.

Ok wow, so alcohol does really terrible things long term especially to the state of the liver, it damages those thousands of little recycling plants to the point at which the workers are running around with fire extinguishers putting out fires and alarms are going off while big immune cell monsters are stomping around making a mess, truly zoom in and see your livers cells and lobules, they are amazing but they need your care. You can keep them optimal or destroy them with ethanol.

Now, some positive news I think that last period was a little lets say, scary?

The liver has an incredible durability, it can do what other organs can not.

The liver is the only organ which is capable of regeneration of lost tissue, that my friends is great news.

This part is amazing, as little half of the liver can regenerate to a whole liver and some studies suggest even a quarter is capable of this feat, think about that.

How? The liver does not actually truly regenerate in terms of growing back like a salamander with a cut off tail, for example if we lop off a lobe of the liver it doesn’t regrow technically but what it can do is a form of compensatory growth. What this means is that the hepatocytes, that is the liver cells or the workers can enter into a phase where they undergo mitosis which is cell division and they create daughter cells so basically they multiply. Essentially the liver can replace the damaged areas with remaining cells. Because the liver compensates and does not actually perfectly regrow it does not reassume its original shape or structure perfectly but as imperfect as it may be, it does work the same way and the cells function fine.

Here is the bad news, oh yes there is always bad news when it comes to alcohol. The liver can regenerate incredibly with a single event such as a trauma or a single toxic event such as a drug induced toxicity as I said to the point where it can literally have half of its lobe lopped off and can compensate back to full function but unfortunately alcohol destroys the liver bit by bit, causing fibrosis and scar tissue to develop gradually over time and because of this, the scar tissue spreads and spreads and the liver will not repair in the same manner as it might had there been a single toxic or traumatic event, it is not reversible, cirrhosis is there to stay. Alcohol is so damaging over time that when it scars the liver, the organ which can regenerate after a physical injury, it can not adequately repair. From what I have seen, sometimes it is bandied about that the liver is able to regenerate, regrow or repair to an incredible degree and this for some serves as a justification to allow taking the liver to a harmful point with drinking alcohol with the mindset of, well, the liver is incredibly resilient and can regenerate so even if I take it too far it will repair if I stop when it gets to this point, so, yes the liver is incredibly durable and yes it is able to essentially regrow through compensatory growth, but, no, if damaged over time with alcohol causing scar tissue throughout the lobules, no, in-fact the same incredible repair won’t happen, it is what it is, alcohol use over time is able to destroy one of the most incredible durable organs we possess and we only own one of them, I felt it necessary to dispel this myth about taking the liver to brink with booze and having it complete a full repair through abstinence, as with most aspects of health, it is best not to wait for the alarm bells to ring, because once they do, it can be too late in many cases.

Damn, right, ok but good news, when the damage from alcohol stops, the liver damage from alcohol stops wherever it may be, the scarring and cell death stops, but the alcohol has to stop. Cirrhosis and fibrosis may not be reversible but these are the later stages of alcohol damage, fatty change in the liver CAN be reversed, inflammation CAN be improved. The rate of healing will depend on how healthy the lifestyle is and how far along the damage was but fatty change can be reversed, so this is great, time is now to slow the change. What needs to happen though is abstinence, not moderation, abstinence and yes, this can be challenging when we are referring to to an addictive psychoactive drug but it can be done and Sobertown we are doing it, whether it takes months of day zero’s or sticks right away, we all have our journey to a sober life but when we dedicate adequate work and planning to it, we do it, we make it and on we go. The trick when it comes to protecting your body is this, learn from the physiology, learn from the millions of others who left it too long, plan the transition to come about before you do the damage, wherever you are at, whatever age you are at, whatever damage may be present it does not matter as long as you stop poisoning the liver, and the sooner the better. That is not preaching, it is fact, alcohol harms our liver, it kills our workers and trashes our recycling plants and the earlier your liver is able to do its job without being bombarded by carcinogenic chemicals the healthier it will be into the future.

Having no functional liver is incompatible with life, unfortunately we can not make an artificial one, dialysis is only good for so long and so when the liver gives up thee is only one option which is a new one, specifically, somebody else’s.

So you might be sitting there thinking, ok so what level of drinking is going to excuse me from these rather horrible changes? Well, the thing is firstly there are many factors involved from age, gender, genetics which determine your enzymes and their functionality, weight and other conditions. The other interesting point is that some of these conditions are notable in those who do not necessarily drink very high levels or for many many years. Fatty change for example can begin very rapidly and progress in people who consume only a few drinks a day. The safe levels of consumption to avoid these changes are very low, for example in my country the current recommendation is no more than 10 standard drinks per week or 4 per session. So in all honestly that means if you drink one bottle of wine per week and more than one glass in a sitting then you truly are pushing up against that safe limit, with that said many problems such as increased risk of breast cancer have been noted in moderate drinkers and not only heavy drinkers. Fact is, the risk is present for multiple conditions with relatively low levels of drinking and over time, moderate or high levels of drinking are a very real risk of many disease states occurring as we age.

Sobertown. Picture in your mind that big hexagonal recycling plant, with the huge pipe through the middle and the conveyors throughout its interior, picture all those workers lined up side by side along the conveyor belts, picture them working non stop taking garbage and breaking into pieces to place on another conveyor with the tools in their belt. Now zoom back out to see the liver, you may not be able to visually see the livers cells inside these little recycling plants of which you have thousands in your liver alone, but they are there, and they are living cells, they are part of you, you have the choice whether to overwork or perhaps kill them to reach a different mind state briefly or to allow them to do their hundreds of Say g’day to your liver and say thank you to that ugly brown lump under your ribs, or perhaps say sorry, I have, it is a remarkable piece of living machinery and I would say it is the ultimate filtration unit. It can take a pounding and it can regenerate after being sliced in half. But there is one enemy to the liver, especially long term, that is alcohol. Give the big lumpy filter a break. Pour the poison down the sink.

Sobertown, you can do this, you can stop the effects of alcohol before they happen or before they get worse and we are all here cheering you on.

Thanks Sobertown.

The Sobertown Blog articles and recordings are created as a means of assisting others in achieving and maintaining sobriety and freedom from alcohol. Experiences, entries, research and article content are that of the author and should be applied in a safe manner deemed best by the reader and applied safely, if relevant, with medical oversight. This is not medical advice and the author is not a medical doctor. No advice within is based on or crosses over with the authors profession or professional opinion as an AHPRA registered allied health practitioner or FA registered exercise professional.