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Updated: Jun 3 2024

Chronic Alcohol Abuse

  • Snapshot
    • A 56-year-old man is brought to the ED after he had a severe episode of hematemesis. On exam, you note spider angiomas, and abdominal ascites. His hand is show at right.
  • Introduction
    • Definition is clinical
      • CAGE questions (need 2 positive)
        • Cut - Do you ever feel you should cut back on drinking?
        • Annoyed - Do you ever feel annoyed when other question your drinking?
        • Guilty - Do you ever feel guilty for your drinking?
        • Eye-opener - Do you never need an eye-opener in the morning?
  • Presentation
    • Symptoms
      • due to liver failure
        • altered mental status/encephalopathy
          • due to reduced excretion of ammonia
          • worse in alkalemic states
            • NH3 favored over NH4+
              • lactulose acidifies gut contents and leads to increased NH4+ loss in the stool
        • bleeding
          • due to reduced synthesis of coagulation factors
    • Physical exam
      • neurological findings
        • cerebellar dysfunction (gait instability, truncal ataxia, dysdiadochokinesia, intention tremor and hypotonia)
      • findings from liver failure
        • asterixis
        • jaundice
          • reduced excretion of billirubin
        • pitting ankle edema
          • reduced synthesis of albumin
      • findings from hyperestrinism
        • palmar erythema
        • gynecomastia
        • spider angiomas
        • female hair distribution
      • findings from portal hypertension
        • hepatosplenomegaly
        • caput medusae
        • ascites
  • Evaluation
    • CAGE test
      • tried to Cut down, been Annoyed, felt Guilty, and had an Eye-opener
      • 2 or more yes answers is considered positive test
    • Serology
      • transaminitis
        • AST:ALT > 2:1
      • serum ?-glutamyltransferase (GGT) is most specific for recent use
      • MCV will be elevated in chronic users
  • Treatment
    • Pharmacologic
      • disulfiram
        • aversive conditioning: blocks acetaldehyde dehydrongenase leading to build up of unpleasant intermediate metabolite when ETOH is consumed
      • acamprosate (low/medium evidence)
        • relapse prevention by blocking glutamate receptor
      • naltrexone
        • reduces cravings (opioid antagonist)
      • gabapentin
      • topiramate
    • Psychotherapy
      • Alcoholics Anonymous (AA) and other peer support groups - seem to be the most effective by some sources
      • motivational interviewing to encourage entrance into AA
      • rehabilitation
  • Prognosis, Prevention, Complications
    • Complications
      • alcoholic hepatitis/cirrhosis
      • esophageal varices
      • pancreatitis
        • chronic pancreatitis will present with weight loss, vitamin ADEK deficiency, low/normal amylase and lipase
      • peripheral neuropathy
      • testicular atrophy
      • increased cancer risk
        • oral, laryngeal, pharyngeal, esophageal, lung, and liver
        • squamous cell carcinoma is classically associated
    • ED Management
      Inpatient Management
      Chronic Management
      • Prevent further ethanol intake
      • Prevent individual from harming self or others
      • Sedate patient if agitated or aggressive
      • Order urine toxicity screen
      • Stabilize vitals if necessary
      • Administer (in order)
        • thiamine and Mg2+
        • multivitamin
        • B12/folate
        • IV fluids + dextrose
      • Begin CIWA and benzodiazepine taper if signs of withdrawal
      • Do not administer medications that lower seizure threshhold (bupropion, haloperidol)
      • Begin psychotherapy (must occur with medications)
        • individual
        • group (AAA)
      • Begin medication immediately
        • disulfiram
        • naltrexone
        • acamprosate
        • gabapentin
        • topiramate
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