Alcohol Use & Abuse Alan J. Hunter, MD Assistant Professor of Medicine Director; Hospitalist Program...

Alcohol Use & AbuseAlan J. Hunter, MD

Assistant Professor of Medicine

Director; Hospitalist Program

Modifiziert T. Cremer 2004

www.ohsu.edu/sod-OralPath/opth641/ alcoholism-dental-handout.ppt

Effects of Alcohol


Alcohol Dose-Response Level (mg/dL) Sporadic Drinkers Chronic Drinkers

20-50

“party”

euphoria no observable effect

75 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

> 500 Death Coma

* Toxicities significantly increased with concurrent benzodiazepines


Pharmacology

• Absorbed rapidly form GI tract

• Rapidly equilibrates in blood and all tissues.

Mouth

Esophagus

Proximal

Small Bowel

Stomach

Large Bowel>>> >>>


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%

EtOH Acetaldehyde Acetate

NAD NADH NAD NADH

ADH ALDH

– Microsomal ethanol oxidizing system (MEOS)Highly inducible, (Especially during chronic EtOH)


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


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


Epidemiology

• > 10 million in the United States (1988)

• Ethnic Groups ( Irish & Native Americans)

• Social ( Separated > divorced > single)

• “Hereditary” (4X in children of alcoholics)


Alcohol Abuse

Deaths per year 100,000†

significant contributor to;Suicides

Domestic violence

Homelessness

† USA figures. This is a conservative estimate


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

Stage Onset (hrs)

Duration

Mild 8-12 14 d Tremors, sweating, tachycardia, anxiety, diarrhea, insominia

Moderate 12-24 6 d Marked tremulousness, tachycardia, HTN, visual hallucination, cravings

Severe 12-48 < 6 hrs Withdrawal seizures

Most-severe(15% Mortality)

3-5 d < 3 d Delirium, fear, agitation, fever, gross tremor, HTN


Alcohol Related Medical DisordersOrgan DisorderNutrition 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

Metabolic-electrolytes

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)


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


Alcohol & The Nervous System(Chronic Use)

• Thiamine Deficiency• Peripheral neuropathy• Cerebellar degeneration• Wernicke’s encephalopathy• Korsakov’s syndrome (psychosis)



Korsakov’s Psychosis • Medical emergency!• Potentially irreversible syndrome

– Short-term memory loss

– Confabulation

– Disordered temporal sequencing

• Thiamine deficiency• Rx: Thiamine BEFORE glucose.



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


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


Alcohol & The Nervous System

Alcoholic Peripheral Neuropathy• Associated Myopathy

• Myelin degeneration of nerve sheaths.


Alcohol & The Heart(Chronic Use)

• Thiamine deficiency• Edema ( Sodium retention)

• Biventricular cardiac failure


Normal liver


Alcohol & the Liver

• Portal Hypertension

“Caput Medusa”


Alcohol & the Liver

Cirrhosis

Micronodular cirrhosis, solid, scarred, yellow


• physical signs of liver cirrhosis

– Jaundice

– Portal Hypertension

– Hepatomegaly

– Ascites

– Gynecomastia– Skin changes (spider angiomata, palmar erythema)


Alcohol & the Skin

• “Spider Angiomas”


Alcohol & the Skin

• Rhynophyma

(Acne rosacea variant)

Seen with EtOH & other vasodilatory substances


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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Alcohol Use & Abuse Alan J. Hunter, MD Assistant Professor of Medicine Director; Hospitalist Program...

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