Updated: 8/5/2018

Chronic Alcohol Abuse

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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 γ-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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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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