Originally printed in IndyStar: “They were young. They thought they had time. Then they nearly died of liver disease.” By Shari Rudavsky, February 18, 2020.

Although Rachel Martin would never deny she had a drinking problem, she figured years would pass before it would take a toll on her health. After all, she had not yet hit 40 and she had managed to eke out two years of complete sobriety about a decade ago.

Even when she was drinking, she would hit the bottle hard for three weeks but then go cold turkey for a week.

So when Martin started feeling off about a year and a half ago, she tried to ignore the symptoms. She lost her appetite, her skin itched, and as she put it, she lost her waist as fluid accumulated in her abdomen. For four months she continued to drink, but in mid-March 2019, she decided she was done.

The next day she finally went to the doctor and found out she had cirrhosis of the liver, something that did not surprise her, given her internet-aided self-diagnosis.

What did surprise her, however, was what her doctor said: If she did not stop drinking she might die within a month. Even if she did quit, she might not make it three months.

“You know it’s bad for you, you know it’s not healthy at all whatsoever, but you think, ‘Oh, I have no family history of this,’ ” said the Bloomington resident, who is now 39. “I know people that drink more than I do, and they’re fine. I have years before I have to worry about this.”

Doctors are seeing more patients like Martin, people in their 20s and 30s with symptoms of acute liver disease related to alcohol consumption. The National Institute on Alcohol Abuse and Alcoholism published a study in January that found that from 1999 to 2017 the number of alcohol-related deaths per year doubled, rising from 35,914 to 72,558. Just under a third of those resulted from liver disease.

Similarly, a study in the British Medical Journal published in 2018 also noted a dramatic increase in deaths in the United States from cirrhosis from 1999 to 2016. In that time period, people ages 25 to 34 saw the highest increase.

Indiana came in No. 4 in the list of states with the highest average annual change in deaths stemming from cirrhosis.

“There is an epidemic of alcoholism and alcohol use disorder that I think is hiding behind the opioid crisis,” said Dr. Naga Chalasani, head of hepatology at Indiana University Health. “Alcohol consumption has risen in this country. … Everything is sort of going in the wrong direction. There are more people drinking, and the people who drink are drinking more.”

Many of those who wind up requiring care do not fit the stereotypical image of an alcoholic. They may be highly productive individuals who work and have families until suddenly they find themselves facing an acute health crisis brought on by alcohol-related liver disease, such as acute hepatitis or cirrhosis.

The trend is particularly pronounced in middle-aged women, where studies suggest that high-risk drinking is the highest it has ever been, Chalasani said. A 2019 study by University of Michigan researchers that looked at more than 100 million Americans with private insurance found a 50% increase in the prevalence of alcohol-related cirrhosis in women from 2009 to 2015.

The people getting sick are not necessarily the people you might expect.

How much alcohol is too much

Several factors likely contribute, experts say. The alcohol industry invests heavily in marketing. Many people who drink start in college and just continue into young adulthood and beyond. Many social events seamlessly incorporate the consumption of alcohol, from women’s nights out to football parties to business dinners.

Doctors are seeing more patients with alcoholic-related liver disease who have no trouble functioning day to day.

“They are people who consume alcohol on a moderate basis chronically enough to be harmful to them, and they didn’t really expect it to be that harmful,” said Dr. Mazen Alsatie, a gastroenterologist and hepatologist with Ascension St. Vincent.

“An almost daily basis of a moderate amount of alcohol can be much more harmful than a binge drinker who drinks once a month and then quits.”

Conventional wisdom used to hold that moderate drinking — a glass or two a day for women and up to three drinks for men — might actually benefit health. Studies also have touted the health benefits of wine. But experts have started to dial back such endorsements of alcohol, especially after a controversial 2018 study in The Lancet even suggested that no amount alcohol is safe.

The Centers for Disease Control and Prevention recommends that alcohol be consumed in moderation, which according to the U.S. Dietary Guidelines consists of no more than one drink a day for women and two for men.

Part of the problem may be that our notion of what counts as “one drink” has shifted over time. The medical literature considers a 5-ounce glass of wine as one serving of alcohol, said Lindsay Yoder, an IU Health physician assistant who specializes in treating people with liver disease. A single glass at a bar or restaurant can contain two to three times that amount. A highball glass filled with whiskey contains two servings.

Then there’s the conventional wisdom that alcohol-related disease does not strike people in their prime of life.

“They think it’s an older, white guy who has cirrhosis, he’s been sitting around in a bar after work for decades,” said Yoder, who runs a weekly outpatient clinic where she helps care for people with liver disease. “I see a really high percentage of patients in that clinic that are young. … It’s just devastating.”

Of course, not everyone who drinks winds up with health issues, which is why the problem is so confusing for the people who do.

Some can drink, some can’t

Jordon Mattingly admits in retrospect he probably drank too much, but it was an occupational hazard. For the past three years he has tended bar. Rarely did he wind up so inebriated he couldn’t drive, but he did down more than half of a fifth of vodka a day.

In October he started having acute stomach pains, and he went to the hospital in Evansville, where he lives. The doctors diagnosed him with alcoholic liver hepatitis and cirrhosis.

Eventually he grew so sick that the Southern Indiana hospital which was treating him transferred him to IU Health University Hospital. In three and a half weeks, he lost 40 pounds and was deathly ill when he arrived in Indianapolis.

Now 28, Mattingly never thought his drinking could jeopardize his health. His doctors explained to him that everyone’s liver handles alcohol differently.

“Some people can handle it; some people can’t,” he said. “But I guess I’m one that can’t.”

The question of why one person can drink heavily with no repercussions while another will drink even less and wind up in the hospital with alcohol-related liver disease plagues the experts.

One theory is tied to the rise in obesity. That trend has led rates of non-alcoholic liver disease to skyrocket to as much as a third of the U.S. population. Consuming greasy, fatty foods contributes to that disorder, Alsatie said.

So even people who are not obese but who have poor diets and who consume moderate amounts of alcohol may be inadvertently harming their liver in two different ways.

Counter to conventional wisdom, then, a heavier person who has two drinks a day may be more predisposed to acute liver-related disease than a slimmer person who has three drinks a day.

Genetics also may help explain the discrepancy. Experts know, for instance, that for some women just two to three drinks a day for four to five years can lead to alcohol-related liver disease. On average men can have one more than that, Chalasani said, but most people are not aware of the risk.

“There’s just a lack of understanding that you really don’t need to drink a bottle to get into trouble,” Chalasani said. “It’s just if you have the wrong set of genes you can get into trouble. I don’t think people appreciate that. … If you just ask people, even highly educated people, most don’t realize that two drinks a day is problematic.”

For those with a genetic predisposition, that seemingly innocuous level of alcohol can lead to serious health problems. About a third of people who drink heavily go on to develop alcoholic hepatitis, a condition in which the cells of the liver become inflamed, according to the American Liver Foundation. Between 10% and 20% of heavy drinkers develop cirrhosis, in which scar tissue in a damaged liver replaces healthy tissue.

In the early stages of liver disease, the condition can be reversed as long as the person stops drinking completely. An ultrasound of the liver can reveal how much damage a person’s liver has sustained, Alsatie said. If there is minimal to moderate damage, stopping drinking will allow the liver to recover.

But liver disease can be silent, so many people have no clue of the damage they are doing until the disease has advanced and they develop symptoms such as jaundice, nausea, vomiting, or abdominal pain and swelling.

“That’s the trickiest part about the liver. It is a dumb organ,” Yoder said. “It doesn’t complain about anything until it’s too late.”

Only hope a liver transplant

Like many people, Martin started with social drinking. In her mid-20s, she began turning to alcohol more as a coping mechanism. But even then she would have patches where she gave it up entirely, detoxing herself.

“I would drink hard for one week, don’t drink for three weeks,” she said. “I knew it was affecting my life, but it’s a really easy pattern to fall into.”

Each time, though, she would eventually return to drinking socially, which would then open the door to overindulging. At one point she went to an inpatient rehab. But once more after a few months, she started drinking again.

A few years ago, she suffered a loss that prompted her once more to start drinking heavily until that day last March in her doctor’s office. The disease had taken such a toll that she spent the next five months in and out of the hospital. Her liver was so damaged, her kidneys shut down and she had to go on dialysis.

Her only hope was a transplant.

Until recently Martin would not have been a candidate for a transplant, given her drinking history. But transplant centers have been relaxing their criteria, faced with the uptick in younger people. A transplant can afford years of life for someone not yet in middle age who stays sober. In the past half year or so, IU Health has started considering patients like Martin on a case by case basis, Chalasani said.

During the process, Martin did not tell many people about her medical travails. The three friends she did tell had little surprise. When she mentioned her liver transplant, often people would say that their cousin or dad or uncle had a transplant, too.

“The thing about alcohol-related liver disease, it’s a dirty little secret,” Martin said. “It’s embarrassing because you have done this to yourself.”

Since her transplant in August, Martin hasn’t had a drink, and she has no intention of ever drinking again. Her life, she said, is far better without alcohol.

Mattingly agrees. He hasn’t had a drink since October. He still is recovering, and his doctors have told him to give it time. He’s hoping his youth will be on his side.

“They think that because I’m so young that my liver will rejuvenate to a certain extent,” he said. “I just don’t ever want to go through it again.”