Alcohol Use & Abuse
Alan J. Hunter, MD
Assistant Professor of Medicine
Director; Hospitalist Program
Modifiziert T. Cremer 2004
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Effects of Alcohol
Alcohol Dose-Response
Level (mg/dL)
20-50
“party”
Sporadic Drinkers
Chronic Drinkers
euphoria
no observable effect
gregarious
often no effect
80-100
legally intoxicated
uncoordinated
minimal effects
125-150
unrestrained behavior
congenial euphora or mild
uncoordination
200-250
lethargy
effort required to maintain
motor/emotional control
300-350
Stupor, coma, death (?)
drowsy and slow
Death
Coma
75
> 500
* Toxicities significantly increased with concurrent benzodiazepines
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Pharmacology
• Absorbed rapidly form GI tract
Proximal
>>>
Small Bowel
Mouth
Stomach
Large Bowel
>>>
Esophagus
• Rapidly equilibrates in blood and all tissues.
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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
EtOH
NAD
NADH
Acetaldehyde
ADH
Acetate
ALDH
– Microsomal ethanol oxidizing system (MEOS)
Highly inducible, (Especially during chronic EtOH)
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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
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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
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Epidemiology
•
•
•
•
> 10 million in the United States (1988)
Ethnic Groups ( Irish & Native Americans)
Social ( Separated > divorced > single)
“Hereditary” (4X  in children of alcoholics)
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Alcohol Abuse
Deaths per year
100,000†
significant contributor to;
Suicides
Domestic violence
Homelessness
† USA figures. This is a conservative estimate
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Alcohol Withdrawal
• chronic alcohol consumption,
• leading to physical dependence.
Stage
Mild
Onset Duration
(hrs)
8-12  14 d Tremors, sweating,
tachycardia, anxiety,
diarrhea, insominia
Moderate
12-24
6d
Severe
12-48
3-5 d
< 6 hrs
<3d
Most-severe
(15% Mortality)
Marked tremulousness,
tachycardia, HTN, visual
hallucination, cravings
Withdrawal seizures
Delirium, fear, agitation,
fever, gross tremor, HTN
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Alcohol Related Medical Disorders
Organ
Disorder
Nutrition
Deficiencies in folate, thiamine, pyridoxine, niacin, &
riboflavin, magnesium, zinc, calcium, phosphate, & Protein
Brain
Hepatic encephalopathy, Wernicke-Korsakoff’s syndrome,
Cerebral atrophy, Amblyopia, Central pontine myelinolysis
Marchiafava-Bignami disease,
Nerve, muscle
Neuropathy, myopathy
Liver
Fatty liver, hepatitis, cirrhosis, hepatoma
Cardiovascular
Hypertension, cardiomyopathy, arrhythmia, strokes
Blood
Anemia, leukopenia, macrocytosis
GI
Esophagitis, gastritis, varices, pancreatitis
Metabolicelectrolytes
Hypoglycemia, hyperlipidemia, hyperuricemia, ketoacidosis,
hypomagnesemia, hypophosphatemia
Endocrine
Pseudo-Cushing’s syndrome, testicular atrophy, amenorrhea
Bone
Osteopenia
Oncology
10X  Cancer (head & neck, esopohagus, stomach, liver,
pancreas, breast)
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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
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Alcohol & The Nervous System
(Chronic Use)
•
•
•
•
•
Thiamine Deficiency
Peripheral neuropathy
Cerebellar degeneration
Wernicke’s encephalopathy
Korsakov’s syndrome (psychosis)
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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.
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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
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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
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Alcohol & The Nervous System
Alcoholic Peripheral Neuropathy
• Associated Myopathy
• Myelin degeneration of nerve
sheaths.
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Alcohol & The Heart
(Chronic Use)
• Thiamine deficiency
• Edema ( Sodium retention)
• Biventricular cardiac failure
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Normal liver
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Alcohol & the Liver
• Portal Hypertension
“Caput Medusa”
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Alcohol & the Liver
Cirrhosis
Micronodular cirrhosis, solid, scarred, yellow
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• physical signs of liver cirrhosis
–
–
–
–
–
–
Jaundice
Portal Hypertension
Hepatomegaly
Ascites
Gynecomastia
Skin changes (spider angiomata, palmar erythema)
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Alcohol & the Skin
• “Spider Angiomas”
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Alcohol & the Skin
• Rhynophyma
(Acne rosacea variant)
Seen with EtOH &
other vasodilatory
substances
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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
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