Alcohol Use Disorder

Alcohol is one of the most commonly used addictive substances in the world. Alcohol use disorder (AUD) is defined as pathologic consumption of alcohol leading to impaired daily functioning. Acute alcohol intoxication presents with impairment in speech and motor functions and can be managed in most cases with supportive care. Withdrawal from chronic alcohol use can have fatal consequences, including delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium and seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, and is managed with benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines. Chronic AUD affects almost every part of the human body and has serious impacts on a person’s mental and physical health. Alcohol user disorder can be managed with psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy as well as medications; however, the prognosis is usually poor, with high rates of relapse and complications.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Overview

Definition

Alcohol use disorder (AUD) is a chronic (> 12 months), problematic pattern of alcohol use causing significant distress.

Classification

There are varying definitions by different organizations for the classification of alcohol consumption.

  • Intoxication: 
    • Recent history of use
    • Symptoms such as stupor, unsteady gait, and slurred speech
  • Withdrawal: 
    • Development of a substance-specific syndrome due to the cessation (or reduction) of substance after heavy and prolonged use
    • Individuals experience physical (nausea, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, chills, and body aches) and/or psychological symptoms (compulsive or perceived need to use the substance). 
  • Tolerance: 
    • Need to increase the dose of the substance to achieve the same desired effect (diminished effect while using the same amount of the substance)
  • Moderate and at-risk drinking:
    • 1 standard drink contains roughly 14 g of pure alcohol. 
      • 350 mL (12 oz) of regular beer
      • 150 mL (5 oz) of wine
      • 45 mL (1.5 oz) of distilled spirits
    • Moderate consumption:
      • Women: ≤ 3 drinks on any single day and no more than 7 drinks per week
      • Men: ≤ 4 drinks on any single day and no more than 14 drinks per week
    • At-risk consumption:
      • Exceeds moderate drinking limits but without physical/psychological ill effects from AUD
      • Includes heavy-episodic drinking (binge drinking) or consumption of > 60 g of alcohol on a single occasion at least once a month

Epidemiology

  • Prevalence: 7% of adults in the United States have AUD.
  • Lifetime prevalence: 10% in men, 3%–5% in women
  • Caucasians have the highest rate of alcohol use. 
  • Only 8% of those who meet criteria for AUD seek treatment. 
  • 3rd leading preventable cause of death in the United States
  • Risk factors: Studies suggest a strong genetic predisposition to AUD.
  • Early onset of AUD associated with higher risk for developing future complications
  • Older population with AUD at higher risk of severe consequences of alcohol intoxication

Pharmacology

Biochemistry of ethanol metabolism Ethanol metabolism Ethanol is a chemical compound that is produced in small amounts within the small intestine and is also ingested from alcoholic drinks. Ethanol's digestion involves a complex catabolic pathway that mainly takes place in the liver. Ethanol is turned into acetaldehyde, then to acetate, and finally into acetyl-CoA. Ethanol Metabolism

  • Roughly 90% of alcohol is metabolized by an oxidative process in the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver; the rest is excreted unchanged through the lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs and kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys.
  • Ethanol is metabolized into acetaldehyde (enzyme: alcohol dehydrogenase Alcohol dehydrogenase A zinc-containing enzyme which oxidizes primary and secondary alcohols or hemiacetals in the presence of nad. In alcoholic fermentation, it catalyzes the final step of reducing an aldehyde to an alcohol in the presence of nadh and hydrogen. Ethanol Metabolism).
  • Acetaldehyde is metabolized into acetate (enzyme: acetaldehyde dehydrogenase).
  • In chronic alcohol consumers, enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes are up-regulated.
  • Individuals of Asian ethnicity have less aldehyde dehydrogenase (gene variation) → accumulation of acetaldehyde → flushing and nausea → less likely to develop AUD
  • Drugs that inhibit ethanol metabolism Ethanol metabolism Ethanol is a chemical compound that is produced in small amounts within the small intestine and is also ingested from alcoholic drinks. Ethanol's digestion involves a complex catabolic pathway that mainly takes place in the liver. Ethanol is turned into acetaldehyde, then to acetate, and finally into acetyl-CoA. Ethanol Metabolism:
    • Fomepizole ( antidote Antidote An antidote is a substance that counteracts poisoning or toxicity. Substances that can cause poisoning include heavy metals (from occupation, treatments, or diet), alcohols, environmental toxins, and medications. Overview of Antidotes for methanol or ethylene glycol overdose) → inhibits alcohol dehydrogenase Alcohol dehydrogenase A zinc-containing enzyme which oxidizes primary and secondary alcohols or hemiacetals in the presence of nad. In alcoholic fermentation, it catalyzes the final step of reducing an aldehyde to an alcohol in the presence of nadh and hydrogen. Ethanol Metabolism
    • Disulfiram → inhibits acetaldehyde dehydrogenase

Other types of alcohol

  • Methanol poisoning: 
    • Some individuals might drink methanol as an alternative to ethanol.
    • Intoxication:
      • Visual blurring
      • Central scotoma
      • Afferent pupillary defect
      • Headaches
      • Mental status changes
      • Nausea
      • Vomiting
      • Anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
    • Most dangerous complications: vision loss and coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
  • Ethylene glycol poisoning:
    • Some individuals might drink ethylene glycol as an alternative to ethanol.
    • Intoxication: 
      • Flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
      • Hematuria
      • Oliguria
      • Anion gap metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
      • Calcium oxalate crystals in urine
      • Kidney damage

Effects on the body

  • Alcohol is a potent CNS depressant: 
    • Activation of inhibitory receptors (GABA, dopamine, serotonin)
    • Inhibition of excitatory receptors (glutamate, voltage-gated calcium channels)
  • Alcohol withdrawal
    • With chronic alcohol use, body increases activity of excitatory receptors (e.g., glutamate) while decreasing activation of inhibitory receptors (e.g., GABA). 
    • Cessation of alcohol use leads to unchecked glutamate activation, presenting as withdrawal.

Clinical Presentation and Diagnosis

Alcohol intoxication

Signs and symptoms of acute alcohol intoxication differ depending on the blood alcohol level. 

Mild intoxication:

  • Talkativeness 
  • Feeling of tranquility and relaxation 
  • Mild feelings of sedation 
  • Impairment in tasks requiring skill and/or fine motor coordination

Moderate intoxication:

  • Uncontrolled eye movements
  • Clumsiness and unsteady gait (positive field sobriety test)
  • Slowed reaction time
  • Slurred speech
  • Impaired judgment
  • Altered perception of the environment
  • Changes in mood, behavior, and personality

Severe intoxication:

  • Nausea and vomiting
  • Dizziness
  • Problems speaking and articulating
  • Double vision
  • Amnesia
  • Delirium
  • Hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia, or feeling very cold
  • Lethargy
  • Respiratory depression
  • Seizures
  • Coma
  • Death

Diagnosis: 

  • If possible, obtain a history of alcohol use.
  • Breath alcohol test with breathalyzer
  • Increased blood alcohol level  
  • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests:
    • AST is 2 × more elevated than ALT. Mnemonic: “take A ShoT for me”
    • Elevation of AST and ALT is < 500 U/L.
    • Gamma glutamyl transpeptidase (GGT) might be elevated and is specific for recent use.
  • Monitor arterial blood gases (ABGs) and anion gap. 
  • Obtain amylase/lipase levels to rule out alcoholic pancreatitis: considered positive if serum lipase is > 3 × normal limits

Alcohol withdrawal

Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-A): 

  • Helps in determining the severity of withdrawal
  • Maximum score: 67 
  • Individuals who score < 10 usually do not need additional medication for withdrawal.
  • Assesses the following symptoms, most of which have a maximum score of 7 points:
    • Nausea and vomiting
    • Tactile disturbances
    • Tremor
    • Auditory disturbances
    • Paroxysmal sweating
    • Visual disturbances
    • Anxiety
    • Headache, fullness in head
    • Agitation
    • Orientation and clouding of sensorium (maximum: 4 points)

Diagnosis:

  • Must obtain detailed history of alcohol use, including most recent use
  • Alcohol withdrawal is a lethal condition if not treated. 
  • Complete mental status examination to assess severity 
  • Manifestations vary depending on the time of most recent alcohol consumption.
  • Urine drug screen
  • Blood alcohol level cannot independently predict severity of alcohol withdrawal symptoms. 
Table: Signs and symptoms of alcohol withdrawal
Signs and symptoms Most recent drink
Mild
  • Anxiety, insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia, and irritability
  • Tremors
  • GI upset (nausea and vomiting)
  • Mild autonomic hyperactivity (diaphoresis, tachycardia, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension)
6–24 hours
Seizures Generalized tonic clonic seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures (single or multiple) 12–48 hours
Hallucinations Predominantly visual (other types can also occur) 12–48 hours
Delirium tremens
  • Life-threatening condition
  • CNS changes: confusion, agitation, hallucinations, gross tremors
  • Severe hemodynamic instability: fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, tachycardia, and diaphoresis
> 48 hours

Alcohol use disorder

Screening for misuse of alcohol must be incorporated into routine visits.

  • Initial screening: How many times in the past year have you had > 5 drinks in 1 sitting? 
  • CAGE questionnaire: 
    • Have you felt you should Cut down on your drinking?
    • Have people Annoyed you by criticizing your drinking?
    • Have you felt Guilty about your drinking?
    • Have you felt you needed a drink early in the morning to steady yourself (Eye opener)
  • Alcohol Use Disorders Identification Test (AUDIT):
    • Issued by WHO 
    • Aim: Identify persons whose alcohol consumption has become harmful to their health. 
    • 10-item screening questionnaire
      • 3 questions on amount and frequency of drinking
      • 3 questions on alcohol dependence
      • 4 questions on harmful impact of alcohol consumption
    • Maximum: 4 points per question
      • 1–7 points: suggests low-risk consumption 
      • 8–14 points: suggests hazardous or harmful alcohol consumption
      • ≥ 15 points: suggests alcohol dependence (moderate-to-severe AUD)

Laboratory findings

  • Carbohydrate-deficient transferrin (CDT): 
    • Chronic heavy alcohol consumption elevates CDT
    • Used to distinguish chronic heavy drinkers from light or “social drinkers”
  • RBCs:
    • Total number
    • ↑ MCV and MCH 
    • Changes can be observed after 4–8 weeks of excessive alcohol consumption
    • May be present even with normal folate Folate Folate and vitamin B12 are 2 of the most clinically important water-soluble vitamins. Deficiencies can present with megaloblastic anemia, GI symptoms, neuropsychiatric symptoms, and adverse pregnancy complications, including neural tube defects. Folate and Vitamin B12 levels 
  • WBCs
  • Electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes:
    • Hypomagnesemia 
    • Hypokalemia Hypokalemia Hypokalemia is defined as plasma potassium (K+) concentration < 3.5 mEq/L. Homeostatic mechanisms maintain plasma concentration between 3.5-5.2 mEq/L despite marked variation in dietary intake. Hypokalemia can be due to renal losses, GI losses, transcellular shifts, or poor dietary intake. Hypokalemia 
  • Note: Individuals with increased tolerance may not show alcohol intoxication symptoms even with increased blood alcohol level.

Management and Complications

Alcohol intoxication

  • Primarily supportive
  • Airway, breathing, circulation assessment (ABC): Check regularly.
  • Thiamine (vitamin B₁): 
    • Should be administered to all individuals with alcohol intoxication–induced coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
    • To prevent or treat Wernicke encephalopathy Wernicke encephalopathy Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Wernicke Encephalopathy and Korsakoff Syndrome
    • Administer before glucose → giving glucose alone worsens Wernicke encephalopathy Wernicke encephalopathy Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Wernicke Encephalopathy and Korsakoff Syndrome
  • Regularly monitor: 
    • Glucose
    • Electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes
    • Acid–base status
  • Agitation: Administer benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines or 1st-generation antipsychotics. 
  • GI evaluation:
    • Not generally indicated in the treatment of alcohol intoxication
    • Might be considered if a significant amount of alcohol was ingested within the preceding 30–60 minutes
    • Options include gastric lavage, induction of emesis, and/or administration of charcoal.

Alcohol withdrawal

  • Setting:
    • Treatment method depends on the severity of withdrawal symptoms. 
    • Otherwise healthy individuals with mild symptoms can be treated in an outpatient setting.
    • Individuals with CIWA-A > 15 or with medical comorbidities should be treated in an inpatient setting.
    • If hemodynamically unstable or nonresponsive to benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines → intensive care level treatment 
  • Medications:
    • Benzodiazepines (chlordiazepoxide, diazepam, lorazepam) 
      • 1st-line treatment
      • Given orally or IV (in severe cases) 
      • Lorazepam preferred in individuals with liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver abnormalities
      • Usually given on as-needed basis in conjunction with CIWA-A
      • Start at a high dosage and then taper or titrate as condition improves
    • Antipsychotics (caution: lower seizure threshold) 
    • Barbiturates: can be used as adjunct to benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines 
    • Sedatives (dexmedetomidine, propofol): used in severe benzodiazepine-resistant alcohol withdrawal
  • Thiamine (vitamin B₁) and folic acid (vitamin B₉) 
  • Correct electrolyte and fluid abnormalities

Alcohol use disorder

  • 1st step is identification.
  • Followed by intervention, detoxification, and rehabilitation 
  • Relapse prevention: social support, individual and group counseling, self-help groups (Alcoholics Anonymous) 
  • Factors predicting poor prognosis:
    • Preexisting major psychiatric diagnosis ( bipolar disorder Bipolar disorder Bipolar disorder is a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, flight of ideas) with or without depressive symptoms. Bipolar Disorder, schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia)
    • Preexisting personality disorder (antisocial personality disorder) 
    • Other substance use disorder
    • Lack of social stability
Table: 3 most important drugs for the management of alcohol use disorder
Medication Mechanism of action Features
Naltrexone Opioid receptor antagonists
  • 1st-line option
  • Used in individuals who are still drinking
  • Decreases craving
  • Precipitates withdrawal in individuals with opioid dependence
  • Contraindicated in individuals with liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver failure
Acamprosate Modulates glutamate transmission
  • 1st-line option
  • Used to prevent relapse in individuals who stopped drinking (after detoxification phase)
  • Decreases craving
  • Suitable for individuals with liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease
  • Contraindicated in individuals with renal disease
Disulfiram Inhibits aldehyde dehydrogenase
  • Results in accumulation of aldehyde, causing severe toxic symptoms → aversive reaction to alcohol
  • Symptoms include flushing, headache, nausea/vomiting, palpitations, shortness of breath.
  • Contraindicated in cardiac disease, pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, and psychosis
  • Indicated for highly motivated individuals

Complications

  • Wernicke encephalopathy Wernicke encephalopathy Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Wernicke Encephalopathy and Korsakoff Syndrome (WE): neurologic symptoms caused by thiamine (vitamin B₁) deficiency, which is common in individuals with AUD. Wernicke encephalopathy Wernicke encephalopathy Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Wernicke Encephalopathy and Korsakoff Syndrome is marked by 3 features: ataxia (broad-based), oculomotor dysfunction, and encephalopathy (confusion, altered mental status). Treatment is supplementation with thiamine. 
  • Korsakoff syndrome Korsakoff syndrome Korsakoff syndrome is a severe and late neuropsychiatric manifestation of Wernicke encephalopathy. Korsakoff syndrome presents with personality changes, anterograde and retrograde amnesia, and confabulation. Some of these changes are irreversible. Wernicke Encephalopathy and Korsakoff Syndrome: neurologic disorder that occurs as a result of damage to the medial dorsal nucleus of the thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus and mammillary bodies. Korsakoff syndrome Korsakoff syndrome Korsakoff syndrome is a severe and late neuropsychiatric manifestation of Wernicke encephalopathy. Korsakoff syndrome presents with personality changes, anterograde and retrograde amnesia, and confabulation. Some of these changes are irreversible. Wernicke Encephalopathy and Korsakoff Syndrome can occur in combination with WE or separately. Korsakoff syndrome Korsakoff syndrome Korsakoff syndrome is a severe and late neuropsychiatric manifestation of Wernicke encephalopathy. Korsakoff syndrome presents with personality changes, anterograde and retrograde amnesia, and confabulation. Some of these changes are irreversible. Wernicke Encephalopathy and Korsakoff Syndrome is characterized by confabulation (unconsciously producing fabricated memories about oneself or the world), personality changes, and permanent memory loss (impaired recent memory, anterograde amnesia). Treatment is replacement of thiamine as well as proper hydration and nutrition. 
  • Pancreatitis: One of the top causes of pancreatitis, both acute and chronic, is recurrent alcohol consumption. Alcohol stimulates pancreatic cells to secrete lytic enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes, producing an inflammatory process and inducing autolysis. Both forms of pancreatitis present with severe abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, nausea, and vomiting. Treatment involves supportive care as well as cessation of alcohol use. 
  • Alcoholic liver disease Alcoholic Liver Disease Alcoholic liver disease is a spectrum of disorders ranging from fatty liver to cirrhosis secondary to chronic alcohol abuse. Excessive and prolonged consumption of alcohol results in impairment of the lipolysis pathway, causing inflammatory changes within the hepatocytes. Patients typically present during the hepatitis stage with jaundice, fever, and abdominal pain. Alcoholic Liver Disease: spectrum of liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disorders that occur as a result of excessive alcohol consumption. Alcoholic liver disease Alcoholic Liver Disease Alcoholic liver disease is a spectrum of disorders ranging from fatty liver to cirrhosis secondary to chronic alcohol abuse. Excessive and prolonged consumption of alcohol results in impairment of the lipolysis pathway, causing inflammatory changes within the hepatocytes. Patients typically present during the hepatitis stage with jaundice, fever, and abdominal pain. Alcoholic Liver Disease can range from fatty liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver to liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis, and it affects up to 20% of heavy drinkers. Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests and liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver biopsy are helpful in establishing the diagnosis. Individuals with alcoholic liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver diseases are susceptible to further damage to their liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver by infection and drugs. Alcohol abstinence is key at all stages of this disease. 
Long-term effects of ethanol consumption

Important long-term effects resulting from low to high alcohol consumption

Image by BioDigital, edited by Lecturio

Alcohol consumption during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care:

  • Cardiac congenital defects: ventricular and atrial septal defects, tetralogy of Fallot Tetralogy of Fallot Tetralogy of Fallot is the most common cyanotic congenital heart disease. The disease is the confluence of 4 pathologic cardiac features: overriding aorta, ventricular septal defect, right ventricular outflow obstruction, and right ventricular hypertrophy. Tetralogy of Fallot, patent ductus arteriosus Patent ductus arteriosus The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) 
  • Fetal alcohol syndrome:
    • Marked by 3 specific facial dysmorphisms:
      • Small palpebral fissures
      • Smooth philtrum
      • Thin vermilion border
    • Associated with low height and/or weight, microcephaly, and cognitive and behavioral impairments

Differential Diagnosis

  • Hepatic encephalopathy Hepatic Encephalopathy Hepatic encephalopathy is a reversible condition in which elevated ammonia levels cause impaired brain function in patients with advanced liver disease. Hepatic encephalopathy can be precipitated by conditions that affect the normal absorption, metabolism, or clearance of ammonia, including dehydration, renal failure, infections, and gastrointestinal bleeding. Hepatic Encephalopathy: altered mental status secondary to severe liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease. Hepatic encephalopathy Hepatic Encephalopathy Hepatic encephalopathy is a reversible condition in which elevated ammonia levels cause impaired brain function in patients with advanced liver disease. Hepatic encephalopathy can be precipitated by conditions that affect the normal absorption, metabolism, or clearance of ammonia, including dehydration, renal failure, infections, and gastrointestinal bleeding. Hepatic Encephalopathy often presents with cognitive impairment, ataxia, and findings of chronic liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease, which are commonly found in those with a history of chronic alcohol use. Even in individuals with severe AUD, a full workup to determine other potential causes of hepatic encephalopathy must be completed. Treatment is supportive.   
  • Sedatives and hypnotics intoxication: Sedative and hypnotic agents include benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines (BDZs), barbiturates and non-BDZs. Medically, sedative and hypnotic agents are used as anxiolytics, hypnotics, anticonvulsant Anticonvulsant Anticonvulsant drugs are pharmacological agents used to achieve seizure control and/or prevent seizure episodes. Anticonvulsants encompass various drugs with different mechanisms of action including ion-channel (Na+ and Ca+2) blocking and GABA reuptake inhibition. First-Generation Anticonvulsant Drugs medications, and muscle relaxants. Symptoms include ataxia and short-term memory loss. History and urine drug screen can distinguish sedative and hypnotic use from AUD; however, alcohol is often taken with sedatives and hypnotics, resulting in synergistic effects. Treatment is supportive, with special attention to airways (aspiration, respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure) and cardiac arrhythmias.

References

  1. Sadock, B. J., Sadock, V. A., Ruiz, P. (2014). Substance use and addictive disorders. Chapter 20 of Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams & Wilkins, pp. 659–666.
  2. Thompson, A. (2021). Alcohol and drug withdrawal syndromes and their clinical management. DeckerMed Medicine. Retrieved February 16, 2021. doi:10.2310/im.13042
  3. Tetrault, J. (2020). Risky drinking and alcohol use disorder: epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved March 4, 2021 from  https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis 
  4. Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., Sellers, E. M. (1989). Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). British Journal of Addiction 84:1353–1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x
  5. Alcohol and its Biomarkers. (2015). Alcohol Biomarkers: An Overview. Chapter 4 of Clinical Aspects and Laboratory Determination. Elsevier, pp. 91–120. https://www.sciencedirect.com/science/article/pii/B9780128003398000043 
  6. National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorders Identification Test (AUDIT). Retrieved July 31, 2021, from https://pubs.niaaa.nih.gov/publications/audit.htm 
  7. Babor, T.F., de la Fuente, J.R., Saunders, J., Grant, M. AUDIT: the Alcohol Use Disorders Identification Test: guidelines for use in primary health care. Geneva, Switzerland: World Health Organization, 1992.

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details