Alcohol and its medical complications

1. ALCOHOL AND ITS MEDICAL
COMPLICATIONS
ATWIINE CISSY TIBAYUNGWA
BYONANUWE SIMON

2. PRESENTATION OUTLINE
• Introduction
• Definitions
• Aspects of alcohol metabolism
• Acute and chronic complications of alcohol

3. INTRODUCTION
• Alcohol: An organic compound derived from hydrocarbons and
contains one or more hydroxyl groups (-OH)
• Ethanol (C2H5OH: Is the main psychoactive ingredient in alcoholic
beverages. It is a result of the fermentation of yeast.
• Consumed all over the world in large quantities
• Global consumption~6.2L/capita/yr, WHO 2011.
• ~1.8m deaths/yr(3.2% of all deaths)

4. Cont…
Uganda
• Commonest substance of abuse
• world's leading consumer(WHO 2004, 2005)
• Per capita consumption 19.5L(2004), 23.7L(2014) annually
• 89% unregulated, home brewed and illegally sold.

5. DEFINITIONS
• Abstainers-individuals who consume no alcohol.
• Moderate drinking-average number of drinks consumed daily that
places an adult at low risk for alcohol problems.
• At-risk drinking-level of alcohol consumption that imparts health
risks
Men: ≥15/week or ≥5 drinks/day
Women: ≥8/week or ≥4 drinks/day

6. Cont…
• Binge drinking or heavy drinking-episodic consumption of large
amounts of alcohol, usually ≥5drinks/occasion(men), ≥4drinks(F).
• Problem drinking- level of alcohol consumption that causes any
problems for the patient (medical, psychiatric, behavioral, or social—
alcohol problems).

7. ALCOHOL ABUSE
• Maladaptive pattern of alcohol use leading to clinically significant
impairment or distress, manifested within a 12-month period by ≥1 of
the following:
Failure to fulfill role obligations at work, school, or home
Recurrent use in hazardous situations
Legal problems related to alcohol
Continued use despite alcohol-related social or interpersonal
problems
Symptoms have never met criteria for alcohol dependence

8. ALCOHOL DEPENDENCE
• Maladaptive pattern of alcohol use leading to clinically significant
impairment or distress, manifested within a 12-month period by ≥3of the
following:
Tolerance
Withdrawal (withdrawal symptoms or use to relieve or avoid symptoms)
Use of larger amounts for a longer period than intended
Persistent desire or unsuccessful attempts to cut down or control use
Great deal of time spent obtaining, using, or recovering from use
Important social relationships, occupations, or recreational activities given
up or reduced
Use despite knowledge of alcohol-related physical or psychological
problems

9. Cont…
• Alcoholism- repetitive intake of alcoholic beverages to an extent that
the drinker is harmed.
Harm may be mental, physical, social, economic, political.
Person has lost control over his/her drinking and life.

10. PK
• Contains ethanol, a small water soluble molecule.
• Absorbed unaltered in stomach and small intestines(20%, 80% resp)
• Readily crosses all biological membranes
• Distributed to all tissues and fluids.
• >90% metabolized in the liver
• Remainder-urine, lungs, sweat.
• Amount exhaled is proportional to blood level, forms basis of the
breath test used by law enforcement agencies

11. METABOLISM
• 3 enzyme systems
ADH------Cytosol
MEOS------SER, and
Catalase( abt 5%)…...Peroxisomes

12. ADH
• Is the primary pathway
• Cytosol of hepatocytes
• But also in brain and stomach.
• Uses NAD+ as cofactor
• H+ transferred from etOH to NAD+ to form NADH.

13. MEOS
• A.k.a mixed function oxidase system
• Uses NADPH
• Consists primarily CYP-2E1, 1A2, 3A4.
• Little contribn at low etOH conc(100mg/dl or 22mmol/l)
• Wn large amts consumed, ADH saturated owing to depletion of NAD+

14. So what happens?

15. Cont…

16. Variations
• Food—Delayed absorption, slows gatric emptg.
• Sex-F high etOH levels>>M
• Genetic variation in ALDH----Inactive in 50% Asians.

17. MEDICAL COMPLICATIONS
• Can be acute or chronic
• Acute ---most commonly:
alcohol intoxication and
alcohol withdrawal.
• Chronic
almost every organ system.

18. SYSTEM COMPLICATION
NS Intoxication
Withdrawal
Cognitive impairment
Cerebellar degeneration
Peripheral neuropathy
Korsakoff±Wernicke’s encephalopathy.
CVS DCM
Hypertension
Cardiac arrhythmias
Stroke
GI Gastritis
Peptic ulcer disease
Liver cirrhosis
Mallory-Weiss tears
Esophageal varices
Pancreatitis
Neoplasms-HCC, Esophageal

19. SYSTEM COMPLICATION
RS Pneumonia, Tuberculosis
Hematopoietic Macrocytosis, Thrombocytopenoia, leucopenia
Psychiatric Hallucinations
Depression
Anxiety
Suicide, etc
Behavioral and Psychosocial Injuries
Violence
Crime
Child or partner abuse
Tobacco, other drug abuse
Unemployment
Legal problems
MSS Muscle atrophy, alcoholic myopathy
GUS Increase in sexual drive
Decrease in erectile capacity
Testicular atrophy
Amenorrhea,
Infertility
FAS

20. • Characterized by substantial neurological impairment
severe mental impairment
ataxia.
slurred speech and
lack of coordination.
coma, and death can occur at levels>60 mmol/L (non-tolerant
drinkers) and 90-120 mmol/L (tolerant drinkers)
death may occur due to respiratory depression and hypotension.
ALCOHOL INTOXICATION

21. Mgt
• A-reduced LOC
-reduced clearance of pulmonary secretions
-vomiting $ aspiration
• B-depression of resp centre
• C-dehydration/low BP/shock
-myocardial depression
-arrythmias

22. Cont…
• Thiamine
• Dextrose
• Manage hypothermia
• Gastric lavage

23. ALCOHOL WITHDRAWAL SYNDROME
• occurs within 12-48 h after prolonged heavy drinking
• 4 stages described, however not all may be experienced
1 (onset 12-18 h after last drink): “the shakes” tremor, sweating,
agitation, anorexia, cramps, diarrhea, sleep disturbance
2 (onset 7-38 h): alcohol withdrawal seizures, usually GTC, brief
3 (onset 48 h): visual, auditory, olfactory or tactile hallucinations
4 (onset 3-5 d): delirium tremens, confusion, delusions,
hallucinations, agitation, tremors, autonomic hyperactivity (fever,
tachycardia, hypertension)

24. Mgt
• monitor using the Clinical Institute Withdrawal Assessment for
Alcohol (CIWA-A) scoring system.
• areas of assessment include
nausea and vomiting,
tactile disturbances,
Tremor, auditory disturbances
Agitation,
paroxysmal sweats,
visual disturbances,

25. Cont…
Anxiety
haeadache,
fullness in head,
orientation and clouding of sensorium.
• all categories are scored from 0-7 (except: orientation/sensorium 0-
4), maximum score of 67
• mild <10
• moderate 10-20
• severe >20

26. Cont…
Basic Protocol Diazepam 20 mg PO q1-2h prn until CIWA-A <10 points
Observe 1-2 h after last dose and re-assess on CIWA-A
scale
Thiamine 100 mg IM then 100 mg PO OD for 3 d
Supportive care (hydration and nutrition)
History of Withdrawal Seizures Diazepam 20 mg PO q1h for minimum of three doses
regardless of subsequent CIWA scores
If Hallucinations are present Haloperidol 2-5 mg IM/PO q1-4h – max 5 doses/d or
atypical antipsychotics (olanzapine,
risperidone)
Diazepam 20 mg x 3 doses as seizure prophylaxis
(haloperidol lowers seizure threshold)
Admit to Hospital if Still in withdrawal after >80 mg of diazepam
Delirium tremens, recurrent arrhythmias, or multiple
seizures
Medically ill or unsafe to discharge home

27. DELIRIUM TREMENS
• The most severe manifestation of alcohol withdrawal syndrome.
• Charecterised by
disorientation,
confusion, hallucination,
diaphoresis, fever, and
tachycardia.
• Begins after 2-4 days of abstinence
• most severe form can result in death.

28. Mgt
• Diazepam 5-10mg per 5-15mins till patient is calm, then 1-4hrs PRN

29. WERNICKE-KORSAKOFF SYNDROME:
Wernicke’s encephalopathy
• due to thiamine deficiency
• Necrotic lesions: mammillary bodies, thalamus, brainstem
• Wernicke’s encephalopathy (acute and reversible)
• Triad of Othalmoplegia, ataxia and confusion

30. Mx
• Urgent Thiamine
• Iv 2-3 pairs of high potency ampoules 8hx7/7,
• Then oral.

31. Korsakoff’s syndrome
• Chronic and only 20% reversible with treatment
• Pt xtically fully conscious
• BUT has profound impairement of memory recall(anterograde) and
new learning ability.
• Striking feature is a tendency to confabulate
• Confab probably results from inability to distinguish the temporal
sequence of past events

32. Mx
• Thiamine 100 mg PO bid/tid x 3-12 mo

33. ……been a long journey, …SDL on e rest!
SucceSS.