Alcohol Use & Abuse

1. Alcohol Use & Abuse Alan J. Hunter, MD Assistant Professor of Medicine Director; Hospitalist Program Modifiziert T. Cremer 2004

3. Effects of Alcohol

4. Alcohol Dose-Response * Toxicities significantly increased with concurrent benzodiazepines

5. Pharmacology • Absorbed rapidly form GI tract Mouth Esophagus Proximal Small Bowel Stomach Large Bowel >>> >>> • Rapidly equilibrates in blood and all tissues.

6. Metabolism • 2-10% of blood EtOH excreted in lungs, urine, sweat • Increased clearance with high blood levels • 90% metabolism in liver • Alcohol Dehydrogenase Pathway (ADH) - 2-20% NAD NADH NAD NADH EtOH Acetaldehyde Acetate ADH ALDH • Microsomal ethanol oxidizing system (MEOS) • Highly inducible, (Especially during chronic EtOH)

7. Metabolism • These metabolites result in many of the metabolic derangements seen with chronic alcohol abuse • “Lactic acidosis,  uric acid, •  lipids,  glucose, •  protein • Acetaldehyde  blocks protein secretion from liver cells • Increased protein/fat/water deposition  liver edema/damage • Crosses placenta  inhibits DNA methylation fetal alcohol syndrome

8. Alcoholism • “Alcohol related difficulty” in  3/7 areas • Tolerance (Less effect/drink) • Withdrawal • Chronically increased consumption • Loss of control of use •  Time spent/day drinking • Sacrificing other activities to drink • Continued use, despite problems w/EtOH DSM IV Manual

9. Epidemiology • > 10 million in the United States (1988) • Ethnic Groups ( Irish & Native Americans) • Social ( Separated > divorced > single) • “Hereditary” (4X  in children of alcoholics)

10. Alcohol Abuse † USA figures. This is a conservative estimate

11. chronic alcohol consumption, leading to physical dependence. Alcohol Withdrawal

12. Alcohol Related Medical Disorders

13. Nutritional Impact • 1 drink of EtOH ~ 70-100 kcal • risk for nutrient deficiencies in chronic EtOH abuse. • Folate, B-12, thiamine, vitamin A… • Electrolyte deficiencies (potassium, magnesium, phosphate…) • inhibits gluconeogenesis,  • risk for developing hypoglycemia

14. Alcohol & The Nervous System(Chronic Use) • Thiamine Deficiency • Peripheral neuropathy • Cerebellar degeneration • Wernicke’s encephalopathy • Korsakov’s syndrome (psychosis)

15. Alcohol & The Nervous System(Chronic Use) Korsakov’s Psychosis • Medical emergency! • Potentially irreversible syndrome • Short-term memory loss • Confabulation • Disordered temporal sequencing • Thiamine deficiency • Rx: Thiamine BEFORE glucose.

16. Alcohol & The Nervous System(Chronic Use) Wernicke’s Encephalopathy (cerebral beriberi) • Thiamine deficiency (Malnutrion: EtOH #1) • Preventable syndrome (Clinical triad-“plus”) • Ophthamoplegia • Confusion • Ataxia (gait)– (neuropathy/cerebellar/vestibular) • Korsakov’s Psychosis may develop as sensorium clears

17. Alcohol & The Nervous System Alcoholic Cerebellar Vermis Degeneration. • Common in alcoholics • Symptoms develop over weeks to months onset • Gait & Stance instability • Legs >>> arms • Nystagmus & dysarthria

18. Alcohol & The Nervous System Alcoholic Peripheral Neuropathy • Associated Myopathy • Myelin degeneration of nerve sheaths.

19. Alcohol & The Heart(Chronic Use) • Thiamine deficiency • Edema ( Sodium retention) • Biventricular cardiac failure

20. Normal liver

21. Alcohol & the Liver • Portal Hypertension “Caput Medusa”

22. Alcohol & the Liver Cirrhosis Micronodular cirrhosis, solid, scarred, yellow

23. physical signs of liver cirrhosis • Jaundice • Portal Hypertension • Hepatomegaly • Ascites • Gynecomastia • Skin changes (spider angiomata, palmar erythema)

24. Alcohol & the Skin • “Spider Angiomas”

25. Alcohol & the Skin • Rhynophyma (Acne rosacea variant) Seen with EtOH & other vasodilatory substances

26. Treatment for Alcoholism •  Successful treatment/cessation • Family, friends, & peers MUST be supportive & involved • Support groups • Alcoholics Anon • Pharmacologic intervention – “antabuse” • Best if linked to the above