Clnical Features of Alcoholism (majorly edited)

What Is Alcohol Abuse?
•People whose use of alcohol has negative effects on any aspect of their lives, including health, relationships, work or school and money, are considered to have an alcohol problem
•Severity factors: type of alcohol you drink, how much you drink, and how long you have been drinking.
•Levels of alcohol use and abuse:
moderate drinking;
at-risk drinking;
alcohol abuse; and
alcohol dependence (alcoholism).

Moderate Drinking
•men: no more than two drinks per day
•women: no more than one drink per day (due to smaller amount of water in their bodies)
•over age 65: no more than one drink per day (besides smaller amount of water, have medical conditions that can be worsened by alcohol and take medicines that can have harmful effects when mixed with alcohol)
•A standard drink is considered to be:
12 ounces of beer or wine cooler;
5 ounces of wine; or
1.5 ounces of 80-proof distilled spirits
At-Risk Drinking
•drinking that poses a risk of developing problems:
men: more than 14 drinks per week or more than 4 drinks per sitting.
women: more than 7 drinks per week or more than 3 drinks per sitting.

Alcohol Abuse
•Involves one or more of the following problems within a one-year period:
Failure to carry out major responsibilities at work, school, or home;
Drinking in physically dangerous situations, such as while driving;
Legal problems related to using alcohol; and
Continued drinking despite ongoing problems in relationships with other people that are related to alcohol use.
Alcohol abuse does not involve physical dependence on alcohol. But if it is not treated, alcohol abuse can lead to alcohol dependence.

Alcohol Dependence
•"alcoholism”, chronic and potentially fatal disease in which a person is addicted to alcohol
•characterized by three or more of the following occurring in a one-year period:
Tolerance: increasing amounts of alcohol needed to get the same effect.
Withdrawal symptoms, such as shakiness, sweating, nausea, anxiety, and depression (symptoms of increased excitability of the central nervous system= delirium tremens or “DTs”)
Drinking larger amounts and for longer than you intended.
Inability to cut down or quit drinking.
Spending a lot of time getting and drinking alcohol or recovering from its effects.
Reducing or giving up important work or leisure activities.
Continued use despite the physical or emotional problems it causes to the drinker or other people.

Diagnosis of Alcoholism
•usually recognized by the friends and family of the drinker.
•C.A.G.E is usually practised clinically.
•Diagnostic tests used by docs:
Michigan Alcohol Screening Test (http://www.ncadd-sfv.org/symptoms/mast_test.html)
Alcohol Use Disorders Identification Test (http://www.testandcalc.com/etc/tests/audit.asp)
•However, a common symptom of alcoholism is denial!

Amnesic Episodes (Blackout)
- Long term memory creation is imparted.
- Similar to anterograde amnesia
- Believed to disrupt activity of the hippocampus
(part of the brain that is involved in the formation of memory)
- Not directly dependant on amount of alcohol consumed

http://pubs.niaaa.nih.gov/publications/arh27-2/186-196.htm


Liver Damage
(i) Fatty Liver
- build up of fat around liver
- appears within 3-7 days after excessive drinking

Signs and Symptoms
- usually none.
- sometimes an enlarged liver and tenderness in the

(i) Alcoholic Hepatitis

What is it?
Inflammation of the liver

Why does it happen? :
Consumption of alcohol causes the liver to break ethyl ethanol down to acetaldehyde (highly toxic)
Acetaldehyde triggers inflammation and destroys liver cells.

Symptoms
• Loss of appetite
• Nausea and vomiting, sometimes with blood
• Abdominal pain and tenderness
• Yellowing of the skin and whites of the eyes (jaundice)
• Fever
• Abdominal swelling due to fluid accumulation (ascites)
• Mental confusion
• Fatigue
• Dry mouth
• Unusual thirst

http://www.mayoclinic.com/health/alcoholic-hepatitis/DS00785/DSECTION=causes

Test and diagnosis
(a) full medical history, including drinking habits and a physical exam
(b) Blood tests. These check for high levels of certain liver-related enzymes
Eg. gamma-glutamyltransferase (GGT), aspartate aminotransferase (AST) and alanine aminotransferase (ALAT).
(c) Ultrasound. the liver may be enlarged
and to rule out other problems such as gallstones or bile duct obstruction.
(d) Liver biopsy.
(http://www.patient.co.uk/showdoc/27000462/)

(iii) Cirrhosis
What it is:
irreversible replacement of a large amount of normal liver tissue with non-functioning scar tissue.
The scar tissue forms bands throughout the liver,
Destroys the liver's internal structure
impairs the liver's ability to regenerate itself or function.

Why does it happen?
Similar reason to alcoholic hepatitis

Symptoms
• weakness
• fatigue
• loss of appetite
• nausea
• vomiting
• weight loss
• abdominal pain and bloating when fluid accumulates in the abdomen (ascites)
http://www.merck.com/mmhe/sec10/ch135/ch135e.html
• itching

Test and Diagnosis
Similar to Alcoholic Hepatitis

http://www.merck.com/mmhe/sec10/ch136/ch136c.html

Cardiomyopathy
What is it?
Heart muscles weakens due to excessive alcohol intake

Causes
heart becomes enlarged
heart muscle thins
pump inefficiently,
leads to heart failure.

Symptoms
There are usually no symptoms until the disease is in an advanced stage. At that point, the symptoms occur due to heart failure and may include:
• Awakening during the night with shortness of breath)
• Breathing difficulty while lying down (orthopnea)
• Cough containing mucus, or pink, frothy material
• Decreased alertness or concentration
• Fatigue, weakness, faintness
• Irregular or rapid pulse
• Loss of appetite
• Sensation of feeling the heart beat (palpitations)
• Shortness of breath, especially with activity (dyspnea)

http://www.nlm.nih.gov/medlineplus/ency/article/000174.htm


Cognitive impairment
Damage to the brain occurs, especially the frontal lobe.
This results in :
-loss of memory, deterioration of personality and loss of intellectual ability. Interpersonal skills, attendance to usual interests and responsibilities may deteriorate and self-neglect may result.

Depression caused by a direct effect of alcohol on the brain and exacerbated by social problems that include unemployment, divorce and debt. There is an increased incidence of deliberate self-harm. The suicide rate is increased six fold in people who are dependent upon alcohol.

Anxiety. People often use alcohol to relieve symptoms of stress and anxiety. However, anxiety symptoms increase during periods of withdrawal, leading to a cycle of increased consumption.

Psychosis. Alcoholic hallucinosis is a rare condition that is not due to alcohol withdrawal. Auditory hallucinations, often derogatory, develop in an otherwise clear consciousness. The condition usually lasts for a few days, but can persist after several months of abstinence.

Hepatic Encelopathy

What is it?
deterioration of brain function that occurs because toxic substances normally removed by the liver build up in the blood and reach the brain

Causes
Usually due to alcoholic binging

Signs and symptoms
• decreased brain function
• subtle changes appear in logical thinking, personality, and behavior.
• Normal sleep patterns may be disturbed.
• Seem drowsy and confused
• movements and speech become sluggish
• Disorientation is common
• lose consciousness and lapse into a coma.

http://www.merck.com/mmhe/sec10/ch135/ch135f.html

Acute intoxication symptoms
•Alcohol increases the effect of the body's naturally occurring neurotransmitter GABA (gamma amino butyric acid), an inhibitory neurotransmitter reduces this signal flow in the brain. This explains how alcohol depresses both a person's mental and physical activities.
Resulting:
•Disinhibition of normal social functioning (excessive talking, showing off)
•Loss of memory
•Confusion
•Disorientation
•Movement not coordinated
•Progressive lethargy
•Coma
Ultimately the shutdown of the respiratory centers (death)

Atrial fibrillation(AF)
•irregular and often rapid heart rhythm (arrhythmia)
•electrical impulses running through the heart being delayed or disrupted
•develops when muscles in the heart's upper chambers contract too quickly, resulting in an ineffective, irregular heartbeat
•Irregularity can be continuous, or it can come and go
•the heart pumps blood less efficiently, allowing blood to pool within its chambers and increasing the risk of heart attack, stroke, and heart failure.
•However, moderate alcohol consumption is associated with a lower risk of cardiovascular disease than abstention or heavy drinking among older adults in observational studies (done in the US in 2007)
•development of AF after an episode of heavy alcohol intake is sometimes called "holiday heart syndrome."

Blood
•Alcohol excess can cause:
1)Anaemia due to deficiency of folic acid, resulting in fatigue.
Folic acid (Vitamin B9)- needed for the production of deoxyribonucleic acid (DNA) in all tissue cells and is a component of three of the four DNA bases -- thymine, adenine, and guanine -- (the fourth is cytosine).
In bone marrow, it is required for the normal production of the red blood cells and for RNA synthesis.
Alcohol abuse contributes to this type of anemia since alcohol interferes with folate metabolism in the liver, resulting in a profound depletion of folate stores.
2)A reduction in the white blood cells [leucopaenia] resulting in an increased susceptibility to infections.
Also caused by the shortage of vitamin B9.
3)A reduction in the platelet count [thrombocytopaenia] resulting in an increased tendency to bleeding and bruising.
Also caused by the shortage of vitamin B9.

Cerebellar degeneration
•The cerebellum sits in the lower portion of the skull, behind the brain stem. One of its main jobs is to smoothly coordinate movements.
•This disorder occurs more commonly among men. It is characterized by an unsteady gait, instability of the trunk, and poor coordination of the extremities. Additionally, difficulties with speech may occur. The disorder may progress over weeks or months.
•Alcoholic cerebellar degeneration is most likely due to nutritional deficiencies, such as the vitamin deficiencies seen in Wernicke-Korsakoff's syndrome.

Wernicke Korsakoff syndrome
•Wernicke-Korsakoff syndrome is a severe memory disorder usually associated with chronic excessive alcohol consumption, although the direct cause is a deficiency in the B vitamin thiamin.
•mental confusion, eye movement disorders, and ataxia (poor motor coordination)
•Thiamine helps produce energy needed to make neurons function properly. Insufficient thiamine can lead to damage or death of neurons.
•Thiamine deficiency damages regions of the brain, particularly the thalamus and the mammillary bodies.
•a syndrome of anterograde amnesia—an inability to form new memories—and confabulation in individuals with severe alcoholism or certain medical illnesses. (Confabulation refers to the practice of filling in gaps in memory by fabrication.)

Myopathy
•Breakdown of muscle tissue (myonecrosis), can come on suddenly during binge drinking or in the first days of alcohol withdrawal.
•The severe form - sudden onset of muscle pain, swelling, and weakness; a reddish tinge in the urine caused by myoglobin, a breakdown product of muscle excreted in the urine; and a rapid rise in muscle enzymes in the blood.
•Muscle atrophy occurs. The nerves of the extremities may also begin to break down, a condition known as alcoholic peripheral neuropathy.
•Proposed mechanisms:
Alcohol - metabolized in the liver, ethanol à acetate. Acetate is metabolized by skeletal muscle, and alcohol-related changes in liver function may affect skeletal muscle metabolism, decreasing the amount of blood sugar available to muscles during prolonged activity.
Because not enough sugar is available to supply needed energy, muscle protein may be broken down as an alternate energy source.
However, toxic effects on muscle may be a direct result of alcohol itself rather than of its breakdown products.

Alcoholic neuropathy
•decreased nerve functioning
•Otherwise known as primary axonal sensorimotor peripheral polyneuropathy
•May also be referred to as peripheral neuritis (Inflammation of a nerve accompanied by pain and sometimes loss of function), or if many nerves are involved, the terms polyneuropathy or polyneuritis may be used.
•May have tingling, numbness, unusual sensations, weakness, burning pain, impotence (in men), swallowing difficulty, speech impairment, loss of muscle function or feeling.
•However, it is unclear whether alcohol alone is responsible for the neuropathic symptoms, because chronic alcoholism is strongly associated with malnutrition.
•May also be the toxic effect of alcohol on nerve tissue
•Alcohol is very rich in energy, packing 7 calories per gram, thus causing euphoria, which depresses appetite, so that heavy drinkers tend to eat poorly and become malnourished.
•It is suspected that the B vitamins have a significant role. For example, thiamine (vitamin B1) deficiency, as it affects the CNS and PNS.

Pancreatitis
•acute pancreatitis - sudden inflammation of the pancreas. Can be mild or life threatening. However, the pancreas can usually return to normal function after the condition clears up. When patients suffer repeated attacks of acute pancreatitis, the pancreas gradually becomes scarred. This leads to the 2nd stage of pancreatitis.
•Chronic pancreatitis = 2nd stage. When the pancreas becomes inflamed, the digestive enzymes that it produces begin to attack its own tissues. Chronic pancreatitis always causes permanent damage to the pancreas. Over time, it is more difficult for the damaged pancreas to produce normal digestive enzymes and hormones.
•One theory is that excessive alcohol leads to protein plugs - precursors to small stones - that form in the pancreas and block parts of the pancreatic duct.
•Another theory is that alcohol directly injures pancreatic tissues.
•Alcohol now is known to exert a number of toxic effects on acinar cells. Notably, acinar cells have been shown to metabolize alcohol (i.e., ethanol) via both oxidative (i.e., involving oxygen) and non-oxidative pathways.