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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