Alcohol

Liver

Alcohol causes acute, reversible fatty liver, which in chronic alcoholics can lead to palpable hepatomegaly. Breakdown of peripheral fat stores leads to increased free fatty acids in the liver, and lipid biosynthesis is increased due to excess NADH production. As well, fatty acid oxidation is decreased.

Acute alcoholic hepatitis is much more serious but is also potentially reversible. It can lead to fever, liver tenderness, and jaundice. Ethanol and its metabolites are directly toxic to hepatocytes, leading to necrosis and fibrosis.

In chronic ethanol use, 10-15% of alcoholics develop cirrhosis, characterized by a hard, shrunken liver. The threshold for cirrhosis is and 40-80g/day for men, lower for women, for 10-20 years. Cirrhosis is a serious, potentially fatal disease accompanied by weakness, muscle wasting, ascites, GI hemorrhage, and coma.

Brain

The acute depressive effects of alcohol are thought to be due to changes in the fluiditiy of membrane phospholipids and altered signal transduction.

Ethanol acts on GABA_A receptors in the brain to cause its sedative/hypnotic effects.

Chronic thiamine deficiency is common in alcoholics and leads to nerve cell degeneration, reactive gliosis, and cerebellar and nerve atrophy. This leads to the ataxia, altered cognition, and nystagmus of Wernicke syndrome. Severe memory loss can also accompany alcohol use, termed Korsakoff syndrome.

Cardiovascular system

Ethanol-induced secretion of catecholamines can lead to hypertension.

Chronic alcohol use can cause cardiomyopathy, and while the mechanism is unknown, direct toxicity is likely involved.

Gastrointestinal Tract

Ethanol toxicity can lead to acute gastritis, and chronic users can develop acute and chronic pancreatitis. This may lead to vitamin deficiencies through a loss in pancreatic enzymes.

Oral/esophageal cancer can also be caused by alcohol consumption.

Chronic alcoholism often leads to reduced availability of vitamins due to dietary and liver insufficiency. Thiamine insufficiency (wernicke-Korsakoff Syndrome) is common, leading to peripheral vasodilation and myelin degeneration. Thiamine is involved in the oxidative decarboxylation of pyruvate and alpha-ketoglutarate, two important molecules in energy metabolism.

Cancer

Alcohol is associated with cancers of the mouth, pharynx, esophagus, liver, and possibly the breast. Upper GI cancers may result from the reduction in detoxification of carcinogens such as nitrates and nitrites.

Skeletal Muscle

Ethanol can be toxic to skeletal muscle, leading to muscle weakness, pain, and breakdown of myoglobin.

Hematology

Anemia and coagulopathies can be linked to alcohol.

Other

Insomnia, trauma, family violence, anxiety, depression, sexual dysfunction, and social/family problems can be caused or worsened by alcohol.

Reproductive System

Alcohol can lead to testicular atrophy and decreased fertility, both in men and women.

Fetal alcohol syndrome is a tragic consequence of alcohol during pregnancy.

Benefits of Alcohol

Increase HDL levels and decrease platelet aggregation at moderate levels.

Screening for Problem Alcohol Use

There are a number of tools useful for identifying alcohol abuse and dependence. These include the following:

CAGE questionnaire

The CAGE questionnaire is approximately 80% sensitive and specific for identifying lifetime problems with alcohol (Carr, 2011).

Two or more for men, or one or more for women, suggest need for further assessment.

• has anyone ever asked you to Cut down on drinking?
• have people ever been Annoyed by your drinking?
• have you ever felt bad or Guilty about drinking?
• do you never need an Eye-opener in the morning?

AUDIT

WHO AUDIT tool for primary care.

MAST

Michigan Alcoholism Screening Test

RAPS4

A positive response on any one of the RAPS4 items or both of the QF items is considered positive on the RAPS4-QF.

• During the last year have you had a feeling of guilt or remorse after drinking? (Remorse).
• During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (Amnesia, also called blackouts).
• During the last year have you failed to do what was normally expected from you because of drinking? (Perform).
• Do you sometimes take a drink in the morning when you first get up? (Starter, also called eye-opener).
  

The RAPS4-QF added the two QF items:

• During the last year have you had five or more drinks on at least one occasion? (Quantity)
• During the last year did you drink as often as once a month? (Frequency).

At-Risk Drinking

Drinking above low-risk levels, but with no alcohol-related physical or social problems, puts people at risk.

Alcohol Abuse

Alcohol abuse is defined as levels above low-risk drinking, with one or more of:

• health or social problems related to alcohol
• continued use, despite hazardous consequences
• inability to fulfill major life roles
• legal problems associated with use, but no evidence of alcohol dependence

Alcohol Use disorder is diagnosed with two or more of the following are occurring (DSM-V):

• alcohol is consumed in larger than intended amounts
• there is a persistent desire or unsuccessful effort to cut down or control alcohol use
• a great deal of time is spent to obtain or use alcohol, or to recover from its effects
• there is a craving, or strong desire or urge to use alcohol
• alcohol results in failure to fulfill obligations at work, school, or home
• continued use despire persistent or recurrent social or interpersonal problems caused by alcohol
• social, occupational, or recreational activities are altered because of alcohol use
• alcohol use occurs in physically hazardous situations
• alcohol use continues despite knowledge of persistent or recurrent problems likely to be caused by alcohol
• patient develops alcohol tolerance requiring increasing amounts to achieve the desired effect
• patient has withdrawal symptoms

Alcohol Dependence

Clinical Signs and Symptoms of Alcohol Abuse

Conjunctival injection. The condition of the conjunctival tissue is evaluated on the basis of the extent of capillary engorgement and scleral jaundice. Examination is best conducted in clear daylight by asking the patient to direct his gaze upward and then downward while pulling back the upper and lower eye-lids. Under normal conditions, the normal pearly whiteness is widely distributed. In contrast, capillary engorgement is reflected in the appearance of burgundy-coloured vascular elements and the appearance of a greenish-yellow tinge to the sclera.

Abnormal skin vascularization. This is best evaluated by examination of the face and neck. These areas often give evidence of fine wiry arterioles that appear as a reddish blush. Other signs of chronic alcohol ingestion include the appearance of 'goose-flesh" on the neck and yellowish blotches on the skin.

Hand tremor. This should be estimated with the arms extended anteriorly, half bent at the elbows, with the hands rotated toward the midline. Can also be caused nervousness, neurological disorder, nicotine, or caffeine.

Tongue tremor. This should be evaluated with the tongue protruding a short distance beyond the lips, but not too excessively.

Hepatomegaly. Hepatic changes should be evaluated both in terms of volume and consistency. Increased volume can be gaged in terms of finger breadths below the costal margin. Consistency can be rated as normal, firm, hard, or very hard.

Lab Investigations

Several laboratory tests are useful in the detection of alcohol misuse.

• gamma-glutamyl transferase (GGT - most sensitive)
• carbohydrate deficient transferrin (CDT)
• macrocytic anemia
• thrombocytopenia
• folate deficiency
• mean corpuscular volume (MCV) - macrocytic RBCs
• ratio of AST/ALT over 2
• PT

False positives can occur when the individual uses drugs (such as barbiturates) that induce GGT.