Alcohol: Clinician's Perspective

Question 1

Which country in the UK has the highest rate of alcohol related deaths?

Answer 1

Scotland

Question 2

How much does alcohol cost the NHS each year?

Answer 2

£3.5 billion (12% of total NHS spending on hospitals)

Question 3

What can affect the medical consequence of alcohol?

Answer 3

Age, gender, BMI, pattern and volume of alcohol consumption, length of time someone has been consuming alcohol

Question 4

How early can alcohol withdrawl begin?

Answer 4

6-8 hours after last drink

Question 5

What are some features of mild alcohol withdrawl?

Answer 5

12-36 hrs from last drink = fine tremor, sweating, anxiety, raised heart rate and BP, hyperactivity, fever, anorexia, nausea, retching

Question 6

What are some features of moderate alcohol withdrawl?

Answer 6

12hrs-5 days from last drink = course tremor, shaking, agitation, confusion, disorientation, paranoia, seizures, hallucinations

Question 7

When are patients most susceptible to seizures?

Answer 7

12-48 hours after last drink

Question 8

What are some features of severe alcohol withdrawl?

Answer 8

12hrs-7+ days after last drink = severe agitation, anxiety, confusion, dellusions, hallucinations, circulatory collapse, death

Question 9

When are patients at risk of DTs?

Answer 9

Around 48 hrs after last drink

Question 10

What are the hallucinations of alcohol withdrawl like?

Answer 10

Tactile and visual, “crawling bugs”

Question 11

What are the features of alcohol consumption?

Answer 11

Sedative, mild anaesthetic, activates pleasure/reward centres (dopamine/serotonin release), sense of well-being, disinhibition, euphoria

Question 12

What are the features of alcohol intoxication?

Answer 12

Increased risk of accidental injury, garrulous, elated, aggression, drowsiness, slurred speech, unsteadiness, loss of consciousness

Question 13

What are the features of an alcohol withdrawl seizure?

Answer 13

Sudden cessation/reduction of alcohol, 12-24 hours after last drink, generalise T-C, clustered over few hours

Question 14

What are the features of an epileptic seizure?

Answer 14

Alcohol ingestion precipitates seizures in susceptible individuals, usually morning after intoxication, any pattern (T-C vs focal)

Question 15

What is Peripheral neuropathy?

Answer 15

Sensorimotor axonal polyneuropathy (glove and stocking)

Question 16

What are some features of peripheral neuropathy?

Answer 16

Burning pain, weakness, direct damage to peripheral nerves, nutritional deficiencies

Question 17

What occurs in Compression neuropathy?

Answer 17

Temporary damage to myelin sheath (Saturday night palsy), radial nerve compression at humeral head

Question 18

What are some features of acute myopathy?

Answer 18

After binge = myalgia, proximal weakness, swollen tender muscle, raised CK, recovers over weeks to months

Question 19

What are some features of chronic myopathy?

Answer 19

Develops over weeks to months = painless, proximal weakness and atrophy, normal CK, low K, PO4, incomplete recovery takes months

Question 20

What is Wernickes encephalopathy?

Answer 20

Thiamine deficiency and cytotoxic oedema in mamillary bodies

Question 21

What are some features of Wernickes encephalopathy?

Answer 21

Occular dysfunction (nystagmus to complete opthalmoparesis), ataxic gait, acute confusion

Question 22

How is Wernickes encephalopathy treated?

Answer 22

Urgent thiamine replacement (recovery within hours)

Question 23

What is Korsakoff Syndrome?

Answer 23

Cerebral atrophy resulting from Wernickes encephalopathy

Question 24

What are some features of Korsakoff syndrome?

Answer 24

Profound anterograde amnesia (unable to retain new info), variable retrograde amnesia (episodic memory), confabulation, generally lack insight

Question 25

What is confabulation?

Answer 25

Patient replaces memory with info they are able to retain at the time and believes this to be true

Question 26

How is Korsakoff syndrome treated?

Answer 26

Abstinence and nutrition (recovery chances low)

Question 27

What are some other neurological medical complications of alcohol?

Answer 27

Dementia, stroke (haemorrhagic), depression, head injury/SDH, cerebellar disease (acute intoxication/chronic cerebellar atrophy)

Question 28

How does alcohol impact coronary artery disease?

Answer 28

Increases BP and lipids

Question 29

How much alcohol needs to be consumed for a cardiomyopathy to develop?

Answer 29

Usually 8-9 units/day for 5+ years

Question 30

How does alcohol cause cardiomyopathies?

Answer 30

Alcohol impairs ventricular function (calcium homeostasis, mitochondrial effects, signal transduction)

Question 31

What can prolonged exposure to alcohol do in the heart?

Answer 31

Cause chronic inflammation and fibrosis of myofibrils

Question 32

What are some acute arrhythmias linked to alcohol?

Answer 32

AF, SVT known as "holiday heart" (usually resolves within 24 hours)

Question 33

What are some chronic arrhythmias linked to alcohol?

Answer 33

Long QT syndrome (due to electrolyte imbalance), dilated cardiomyopathy (atrial and ventricular arrhythmias)

Question 34

What is the 5th most common cause of death in the UK?

Answer 34

Liver disease

Question 35

What age group is most affected by liver disease?

Answer 35

Young working age people(<60)

Question 36

What does >30 units/week cause a rapid rise in?

Answer 36

Cirrhosis

Question 37

What is the progression of liver disease?

Answer 37

Regular heavy drinking-fat accumulation in hepatocytes-inflammation-fibrosis-cirrhosis

Question 38

What percentage of heavy drinkers develop cirrhosis?

Answer 38

Only 10-20%

Question 39

How does alcohol-related steatosis commonly present?

Answer 39

Abnormal LFTs

Question 40

What happens in alcoholic-related steatosis?

Answer 40

Hepatocytes swell with triglycerides

Question 41

Is alcoholic-related steatosis reversible?

Answer 41

It can be reversed with cessation

Question 42

What is alcohol-related hepatitis and how does it present?

Answer 42

Parenchymal inflammation and hepatocyte damage. Presents with jaundice, coagulopathy, liver failure, sick and often worsen during first few weeks of admission

Question 43

What are alcohol-related hepatitis patients at risk of?

Answer 43

Renal failure, bleeding, infections

Question 44

What is alcohol-related cirrhosis?

Answer 44

Progressive fibrosis causing architectural distortion then cirrhosis +/- portal hypertension

Question 45

What is compensated cirrhosis?

Answer 45

Normal liver function and physical function

Question 46

What is decompensated cirrhosis?

Answer 46

Impaired synthetic function, ascites, encephalopathy

Question 47

What are some features of portal hypertension?

Answer 47

Variceal bleeding, ascites, SBP

Question 48

How does hepatic encephalopathy arise?

Answer 48

Portosystemic shunting through collaterals-failure to clear toxins/ammonia from blood-crosses blood brain barrier

Question 49

What are some treatments for alcoholic liver disease?

Answer 49

Abstinence, vitamins, nutrition, endoscopic, pharmacological (beta blockers, lactulose, Rifaximin), TIPSS, transplant

Question 50

How much alcohol increases your risk of cancer?

Answer 50

1.5 units/day increases risk of breast cancer (5%), pharyngeal cancer (17%) and oesophageal small cell cancer (30%)

Question 51

Why is alcohol linked to cancer?

Answer 51

Its intermediate acetaldehyde is carcinogenic

Question 52

Where is most alcohol broken down into acetaldehyde?

Answer 52

In the liver by ADH

Question 53

Where else is ADH expressed?

Answer 53

Stomach and UGI mucosa

Question 54

Why does alcohol increase the risk of breast cancer?

Answer 54

Oestrogen levels are increased

Question 55

What are some co-carcinogens of alcohol?

Answer 55

Tobacco, HCV/HBV

Question 56

What other medical conditions can arise from alcohol?

Answer 56

Injuries, STI, unplanned pregnancy, suicide, pancreatitis, pneumonia, mental health disorders, obesity, TB, psoriasis

Question 57

What can clinicians do?

Answer 57

Raise awareness, prioritise patients, brief intervention (i.e identification and brief advice), alcohol support services

Question 58

What are the NICE recommendations for alcohol treatment?

Answer 58

Promote abstinence and reduce alcohol consumption

Question 59

What are some pharmacological interventions?

Answer 59

Acamprosate (reduces craving), Naltrexone (reduces desire for alcohol), Disulfiram (aversion therapy drug), Nalmefene (opioid antagonist)

Question 60

How have the government helped to reduce alcohol consumption?

Answer 60

Lowered drink-drive limit from 80 to 50mg/100 ml blood, increased taxation, minimum unit pricing