Alcohol

Question 1

With which cancers is alcohol intake associated?

Answer 1

Oral cavity, larynx, pharynx, esophagus, liver, and lung. Also may be associated with gastric, colon, pancreatic, and breast cancer.

Question 2

What is the most common cause of cirrhosis and esophageal varices?

Answer 2

Alcohol

Question 3

Describe the relationship between alcohol and accidental or intentional (i.e. suicide and murder) death?

Answer 3

Alcohol is involved in 50% of fatal car accidents, 67% of drownings, 67% of homicides, 35% of suicides, and 70-80% of deaths caused by fire.

Question 4

What may happen if you give glucose to an alcoholic without giving thiamine first?

Answer 4

May precipitate Wernicke encephalopathy. Always give thiamine before glucose to avoid this.

Question 5

What is the difference between Wernicke and Korsakoff syndromes?

Answer 5

Wernicke - acute encephalopathy characterized by ophthalmoplegia, nystagmus, ataxia, and/or confusion; can be fatal but is reversible with thiamine
Korsakoff - chronic psychosis characterized by anterograde amnesia (inability to form new memories) and confabulation; generally irreversible and thought to be due to damage to mamillary bodies and thalamic nuclei
*Both conditions result from thiamine deficiency

Question 6

True or false: Alcohol withdrawal can be fatal.

Answer 6

True. Alcohol withdrawal needs to be treated on an inpatient basis because it can result in death (mortality rate of 1-5% with delirium tremens).

Question 7

How is alcohol withdrawal treated?

Answer 7

Benzodiazepines (or, in rare cases, barbiturates). Dose is tapered gradually over several days until symptoms have resolved.

Question 8

What are the stages of alcohol withdrawal?

Answer 8

Acute withdrawal syndrome (12-48 hrs after last drink)
Alcoholic hallucinosis (24-72 hrs after last drink)
Delirium tremens (2-7 days after last drink, possibly longer)

Question 9

Describe acute withdrawal syndrome

Answer 9

12-48 hrs after last drink: tremors, sweating, hyperreflexia, and seizures (“rum fits”)

Question 10

Describe alcoholic hallucinosis

Answer 10

24-72 hrs after last drink: auditory and visual hallucinations and illusions without autonomic signs

Question 11

Describe delirium tremens

Answer 11

2-7 days after last drink: hallucinations and illusions, confusion, poor sleep, autonomic lability (sweating, increased pulse and temp); fatality associated with this stage

Question 12

What are the classic physical stigmata of liver disease in alcoholics?

Answer 12

Abdominal wall varices (caput medusae), testicular atrophy, esophageal varices, encephalopathy, hemorrhoids (internal), asterixis, jaundice, scleral icterus, ascites, edema, palmar erythema, spider angiomas, gynecomastia, Terry nails, fetor hepaticus, dupuytren contractures

Question 13

What are the classic lab findings of liver disease in alcoholics?

Answer 13

Anemia (classically macrocytic)
Prolonged prothrombin time
Hyperbilirubinemia
Hypoalbuminemia
Thrombocytopenia

Question 14

What diseases and conditions may be caused by chronic alcohol intake?

Answer 14

Gastritis, fatty change in the liver, Mallory-Weiss tear, hepatitis, pancreatitis (acute or chronic), cirrhosis, peripheral neuropathy (via thiamine deficiency and a direct effect), Wernicke or Korsakoff syndrome, cerebellar degeneration (ataxia, past-pointing), dilated cardiomyopathy, rhabdomyolysis (acute or chronic)

Question 15

Describe the classic derangement of AST and ALT in alcoholic hepatitis

Answer 15

Ratio of AST to ALT is at least 2:1 although both may be elevated

Question 16

What is the best treatment for alcoholism?

Answer 16

Alcoholic Anonymous or other peer-based support groups

Question 17

What is disulfiram?

Answer 17

Aldehyde dehydrogenase inhibitor - makes people sick when they drink (or take metronidazole or certain cephalosporins)

Question 18

Describe the effects of alcohol on pregnancy

Answer 18

Definite teratogen and most common cause of preventable mental retardation in the U.S. No amount of alcohol consumption can be considered safe during pregnancy.

Question 19

Describe fetal alcohol syndrome

Answer 19

Mental retardation, microcephaly, microphthalmia, short palpebral fissues, midfacial hypoplasia, cardiac defects
Rates vary but estimated around 1 in 1000 births

Question 20

Epidemiology of alcohol abuse?

Answer 20

10-15% of population abuses alcohol
More common in men
Genetic component is passed most easily from father to son

Question 21

What kind of pneumonia should you suspect in a “skid-row” alcoholic?

Answer 21

Aspiration pneumonia

Look for enteric organisms (anaerobes, E. coli, streptococci, staphylococci)

Question 22

What does Klebsiella spp. pneumonia sputum and culture reports looks like?

Answer 22

Sputum resembles currant jelly

Culture reports mention thick, mucoid capsules

Question 23

True or false: Alcohol can precipitate hypoglycemia.

Answer 23

True. But give thiamine first, then glucose.

Question 24

What are the classic electrolyte abnormalities in alcoholics?

Answer 24

Low magnesium
Low potassium
Low sodium
Elevated uric acid (resulting in gout)

Question 25

What are the classic vitamin abnormalities in alcoholics?

Answer 25

Deficiencies of folate and thiamine

Question 26

How are the bleeding esophageal varices treated?

Answer 26

ABCs, stabilized patient with IV fluids and blood if needed, correct clotting factor deficiencies with fresh frozen plasma, fresh blood, and vitamin K
Endoscopy -> sclerotherapy of veins with cauterization, banding, or vasopressin
Try transjugular intrahepatic portasystemic shunt (TIPS) over open surgical portacaval shunt
Most physiologic shunt type among surgical options is the splenorenal shunt

Question 27

How are varices with no history of bleeding treated?

Answer 27

Nonselective beta-blockers (propranolol, nadolol, timolol)