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Psychiatric Medicine > Substance misuse - alcohol > Flashcards

Substance misuse - alcohol Flashcards

1
Q

How does alcohol act as a drug?

A

https://www.youtube.com/watch?v=e5DxD6Tuxxw

  • Non-specific effects on neuronal cell wall fluidity and permeability
  • Enhancement of GABA-A transmission - anxiolytic effect
  • Release of dopamine in mesolimbic system - euphoriant and reward effects
  • Inhibition of NMDA-mediated glutaminergic transmission - amnesic effects
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2
Q

What is the physiology behind the anxiolytic effects of alcohol?

A

Enhancement of GABA-A Transmission

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3
Q

What is the physiology behind the euphoriant and rewarding effects of alcohol?

A

Dopamine release in the mesolimbic system

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4
Q

What is the physiology behind the amnesic effects of alcohol?

A

Inhibition of NMDA-mediated glutaminergic transmission

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5
Q

What are the steps in the pathway of alcohol breakdown?

A

Ethyl-alcohol -> alcohol dehydrogenase -> acetaldehyde -> acetaldehyde dehydrogenase -> Acetate

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6
Q

What are the acute effects of low doses of alcohol?

A
  • Euphoria
  • Reduced anxiety
  • Relaxation
  • Sociability
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7
Q

Where is alcohol absorbed in the GI tract?

A
  • Mouth
  • Stomach
  • Small intestine
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8
Q

What are the acute effects alcohol in low doses?

A
  • Elevated mood/Reduced anxiety
  • Sociability
  • Impaired judgment
  • Disinhibition
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9
Q

What are the acute effects of alcohol intoxication?

A
  • Impaired attention and judgement
  • Unsteadiness
  • Flushing
  • Nystagmus
  • Mood lability
  • Slurring
  • Dilated pupils
  • Stupor
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10
Q

Where is alcohol mostly oxidised in the body?

A

Liver

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11
Q

What are the three pathways for alcohol metabolism?

A
  • Alcohol dehydrogenase pathway
  • Microsomal ethanol oxidizing system (MEOS)
  • Catalase pathway - located in peroxisomes
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12
Q

When are peak blood ethanol concentrations achieved?

A

1 hour after ingestion

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13
Q

What factors influence the levels of alcohol attained in the blood after ingestion?

A
  • Speed of intake
  • Food cunsumed
  • Rate of gastric emptying
  • Body habitus
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14
Q

Why do women obtain higher blood ethanol concentrations than men after drinking the same amount of alcohol?

A

Primarily because their body water, and hence the compartment in which the ethanol distributes, is significantly smaller than in men. There may also be differences in gastric ADH activity between genders

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15
Q

What is the hourly rate of ethanol elimination from the body?

A

7-10g per hour

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16
Q

What is the rate limiting factor for ethanol metabolism?

A

Dissociation of NADH-NAD enzyme complex - ADH mediated oxidation of ethanol results in transfer of hydrogen to the co-factor NAD converting it to NADH. The rate at which the liver re-oxidizes NADH to NAD is the limiting factor

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17
Q

In chronic alcohol misuse, why does the metabolic rate of ehtnaol increase?

A

Increased action of MEOS system

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18
Q

What problems can occur if the redox hoemeostatic capacity of the liver is exceeded (i.e. capacity of liver to convert NADH to NAD)

A
  • Hypo/hyperglycaemia
  • Lactic acidosis
  • Ketoacidosis
  • Hyperuricaemia
  • Abnormal lipid metabolism
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19
Q

What range of blood alcohol concentration would produce definite impairment of cognitive function?

A

150-250 mg/100ml

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20
Q

What factors will influence the blood alcohol concentration required to produce intoxication?

A
  • Rate of increase in blood levels
  • Degree of tolerance
  • Simultaneous effects of other drugs
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21
Q

What are the affects of severe alcohol intoxication?

A
  • Drowsiness
  • Coma
  • Hypotension
  • Hypothermia
  • Decreased respiratory effort - shallow and sterterous
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22
Q

How can death occur in alcohol acute alcohol intoxication?

A
  • Respiratory depression
  • Vomit aspiration
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23
Q

What blood alcohol is often regarded as being a fatal level?

A

>450 mg/100ml

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24
Q

What is the recommend alcohol intake for males and females?

A

14 units per week

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25
Q

How many grams of alcohol are in 1 unit?

A

8g

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26
Q

What volume of 3-4% beer contains 1 unit of alcohol?

A

284 ml - 1/2 pint

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27
Q

What volume of average strength table wine would contain 1 unit of alcohol?

A

125ml - a single small glass

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28
Q

What volume of spirit would contain 1 unit of alcohol?

A

25 ml - single measure

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29
Q

What is the defintion of alcohol dependence?

A

Harmful use + established dependence syndrome:

  • DEPENDENCE SYNDROME
    • Cravings
    • Difficulty controlling use
    • Primacy
    • Increased tolerance
    • Psychological withdrawal on reduction of intake
    • Persitence despite harmful consequences
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30
Q

What is regarded as harmful use of alcohol?

A

Non-dependent pattern of use causing damage to physical or mental health for > 1 month, or repeatedly over 12 months

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31
Q

In men, how many units per week would be classed as harmful?

A

50 units

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32
Q

In women, how many units per week is regarded as drinking harmfully?

A

35 units per week

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33
Q

What percentage of harmful drinkers will develop liver cirrhosis?

A

20%

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34
Q

What are acute physical effects/problems of alcohol intoxication?

A
  • Accident/injury
  • Acute alcohol poisoning
  • Aspiration pneumonia
  • Oesophagitis
  • Mallory-Weiss tear
  • Gastritis
  • Pancreatitis
  • Cariac Arrhythmias
  • CVA
  • Neupraxia
  • Myopathy/Rhabdomyolysis
  • Hypoglycaemia/hypokalaemia
  • Respiratory depression
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35
Q

What systems are most commonly affected through chronic alcohol misuse?

A
  • Hepatic/Gastrointestinal
  • Malignancy
  • Cardiovascular
  • Respiratory
  • Neurological
  • GU
  • Musculoskeletal
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36
Q

What percentage of alcohol misusers develop pancreatitis?

A

15%

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37
Q

What are the cutaneous/superficial signs suggestive of chronic alcohol misuse?

A
  • Spider naevi
  • Telangiectasia
  • Facial mooning
  • Parotid enlargement
  • Palmar erythema
  • Dupuytren’s contracture
  • Gynaecomastia
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38
Q

What is this, and what might it indicate?

A

Spider naevi - chronic alcohol misuse

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39
Q

What is the distribution of spider naevi?

A

Only in the distribution of the superior vena cava - most commonly face and anterior chest wall

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40
Q

How do spider naevi occur?

A

Failure of the sphincteric muscle surrounding a cutaneous arteriole. The central red dot is the dilated arteriole and the red “spider legs” are small veins carrying away the freely flowing blood.

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41
Q

What is this, and what does it indicate?

A

Telangiectasia - chronic alcohol misusue

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42
Q

What is telangiectasia?

A

Broken veins - commonly occur on the face

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43
Q

What is this, and what could cause it?

A

Sialadenosis (Parotid hypertrophy) - palpable as a soft, bilateral, symmetrical and non-tender enlargement of the parotid glands. Thought to be caused by cellular hypertrophy and disturbed fat metabolism

Found in chronic alcohol misuse

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44
Q

What is the following, and what might it indicate?

A

Palmar erythema - chronic alcohol misuse - specifically alcohol related liver disease

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45
Q

What is the following, and what is it associated with?

A

Dupuytren’s contracture - chronic alcohol misuse

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46
Q

What is this, and what does it indicate?

A

Gynaecomastia - chronic liver disease

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47
Q

Why does gynaecomastia occur in cirrhotic liver disease?

A

Increased secretion of androgenic hormones from the adrenal gland, which is converted to oestrogen. Levels of free testosterone also decrease

48
Q

How can Mallory-Weiss tears occur from alcohol consumption?

A

Violent vomiting which causes a tear in the cardio-oesophageal junction, with often profuse GI bleeding as a result

49
Q

How can alcohol cause GORD, and what are the outcomes of the development of GORD?

A

Alcohol reduces sphincter pressue at both ends of the oesophagus and impedes persitalsis. In chronic misusers -> GORD develops

This leads to oesophagitis, distal oesophageal ulceration and Barrett’s oesophagus

50
Q

How would a patient present if they had acute alcohol induced gastritis?

A
  • Nausea
  • Vomiting
  • Epigastric pain

SYMPTOMS DISAPPEAR 48-72 hrs after

51
Q

What symptom associated with the small intestine can be associated with either acute or chronic alcohol misuse and reflects changes in small intenstinal permeability and motor activity?

52
Q

Chronic alcohol misuse is associated with what defective process in the small intestine?

A

Absorption of nutrients, glucose, amino acids, vitamins

53
Q

Why does progressive, irreversible damage to the pancreas occur in chronic alcohol misuse?

A

Chronic alcohol misuse cause pancreatic inflammation, acinar atrophy, and ultimately fibrosis resulting in endo- and exocrine insufficiency

54
Q

How would someone with alcohol-related pancreatitis present?

A

Acute episode on top of chronic pancreatitis

  • Epigastric pain which radiates to the back
  • Nausea and vomiting
  • Profound metabolic abnormalities
  • Malabsorption
  • Diabetes
55
Q

What changes in the liver will occur in the majority of those who misuse alcohol?

A

Hepatic steatosis - Fatty changes in the liver which occur due to altered fat metabolism linked to excess hydrogen ions generated ib ethanol oxidation

56
Q

What is the mechanism behind the development of palmar erythema in liver disease?

A

Increased perfusion to the hands, mainly caused by increased oestrogen levels, increased oestrogen-to-testosterone ratios or raised circulating free oestrogens. Oestrogen is thought to increase capillary density in the palms, similar to its effects on the endometrium.

Other factors that may play a role include:

  • disordered hepatic metabolism of bradykinin and other vasoactive substances
  • abnormal cutaneous vasoconstrictor/vasodilator reflexes.
57
Q

What proportion of individuals who chronically misuse alcohol develop alcoholic hepatitis?

58
Q

What are the signs/symptoms of alcoholic hepatitis?

A

Alcohol use, plus:

  • Asymptomatic, or
  • Symptomatic
    • Tender hepatomegaly +/- Jaundice
    • Ascites
    • Encephalopathy
    • Malnutrition -> Anorexia
    • Malaise
    • Decompensated hepatic function
59
Q

What factors determine whether an individual with alcoholic hepatitis will develop alcoholic liver cirrhosis?

A
  • Drinking behaviour
  • Gender
  • Severity of histiological lesions
60
Q

What are signs and symptoms of alcoholic liver cirrhosis?

A

Chronic alcohol use, plus

  • Asymptomatic - compensated disease
  • Symptomatic - decompensated disease
    • Portal hypertension
    • Jaundice
    • Fluid retention
    • Abnormal bleeding
    • Hepatic encephalopathy
    • Variceal haemorrhage
61
Q

What is the outcome of patients with alcoholic liver cirrhosis determined by?

A
  • Degree of decompensation
  • Subsequent drinking behaviour
62
Q

What effects does alcohol have on the electrophysiology of the heart?

A
  • Depression of left ventricular function
  • Premature ventricular beats
  • AF - more severe intoxication
63
Q

What effects does alcohol have on blood pressure?

A

Increased systolic + diastolic pressure

64
Q

What effect does alcohol have on the heart muscle?

A

Can develop Alcoholic cardiomyopathy - >60 g daily for more than 10 years

65
Q

How could you reverse alcoholic cardiomyopathy?

A

Abstinence

66
Q

What cardiovascular problems are caused by alcohol intake?

A
  • Arrythmias - esp AF
  • Dilated cardiomyopathy
  • Hypertension
  • CVA
  • CHD
67
Q

What gastro-intestinal problems can be caused by alcohol use?

A
  • Gastritis
  • GORD -> barrett’s oesophagus
  • Mallory-Weiss tear
  • Peptic ulceration
  • Chornic diarrhoea
  • Chornic pancreatitis
68
Q

What cancers can alcohol use cause?

A
  • Hepatocellular
  • Oesophageal
  • Stomahc
  • Mouth
  • Tongue
  • Pharynx
69
Q

What respiratory problems can occur due to alcohol misuse?

A
  • Tuberculosis
  • Klebseilla/pneumococcal pneumonia
  • Aspiration pneumonia
70
Q

What neurological problems can occur with alcohol misuse?

A
  • Alcohoic dementia
  • Wernicke-Korsakoff syndrome
  • Peripheral neuropathy
  • Central pontine myelinolysis
  • Cerebellar degeneration
  • Optic atrophy
  • Alcoholic myopathy
71
Q

What genitourinary problems can occur from alcohol misuse?

A
  • Erectile dysfunciton
  • Hypogonadism in men
72
Q

What musculoskeletal problems can occur as a result of alcohol misuse?

A
  • Accidents/trauma - ​Saturday night palsy, fractures, lacerations, battered alcoholic syndrome etc.
  • Osteoporosis
  • Gout
  • Acute/Chronic myopathy
73
Q

Which type of stroke does chronic alcoholiosm increase the risk of?

A

Haemorrhagic stroke

74
Q

What is steatosis?

A

Non-alcoholic fatty liver disease (NAFLD) - recognised clinically by central obesity, dyslipidaemia and hypertension.

Caused by excess calorie intake and little exercise -> insulin resistance

Present in most patients with metabolic syndrome

75
Q

What is non-alcoholic steatohepatitis (NASH)?

A

Fatty changes in the liver + inflammation

Characterised by cellular swelling, Mallory’s hyaline and signs of inflammation. In contrast to NAFLD, this process causes cell death and fibrosis

1/4 of those with NASH progress to liver cirrhosis

76
Q

How would you investigate suspected alcoholic hepatitis?

A
  • History/examination - alcohol + acute liver signs
  • LFTs - raised bilirubin, raised GGT and AlkP
  • Exclude other causes - blockage etc.
77
Q

How would you treat alcoholic hepatitis?

A
  • Supportive
  • Abstinence
  • Nutritional treatment - thiamine (pabrinex), high energy feeds
78
Q

What are the different criteria assessed in the glasgow alcoholic hepatitis scoring system?

A
  • Age
  • WCC
  • Urea
  • INR
  • Bilirubin
79
Q

What score on the the glasgow alcoholic hepatitis scoring system would indicate the use of steroids to treat alcoholic hepatitis?

80
Q

What is spontaneous bacterial peritonitis?

A

The development of a bacterial infection in the peritoneum causing peritonitis, despite the absence of an obvious source for the infection. It occurs almost exclusively in people with portal hypertension (increased pressure over the portal vein), usually as a result of cirrhosis of the liver. Ascites has to be present for this to occur

81
Q

How does spontaenous bacterial peritonitis present?

A
  • Abdominal pain
  • Septic picture - Fever, Rigors
  • Renal impairment
82
Q

If you suspected spontaneous bacterial peritonitis, what investigations would you do?

A

Ascitic tap

  • Fluid protein and glucose
  • Cultures
  • WCC
83
Q

How would you treat someone with spontaenous bacterial periotnitis?

A
  • IV Abx
  • Ascitic drainage
  • IV Albumin infusion
84
Q

What is wernicke-Korsakoffs syndrome?

A

The combined presence of Wernicke’s encephalopathy (WE) and Korsakoff’s syndrome - this develops in those who are thiamine deficient. These syndromes can also exist on their own

85
Q

What is wernicke’s encephalopathy, and what are it’s characteristic features?

A

https://www.youtube.com/watch?v=olpyoHDZZGM

The acute phase of werkicke-korsakoffs syndrome (single disease process). Wernicke’s can occur with classic Triad of presenting symptoms/signs:

  • Acute confusion
  • Ocular signs
  • Ataxia

Other signs include peripheral neuropathy, resting tachycardia, disorientation, disturbed memory.

86
Q

What occular signs can be seen in Wernicke’s encephalopathy?

A
  • Nystagmus
  • Gaze palsies/Opthalmoplegia - most commonly 6th nerve
87
Q

What percentage of those with wernicke’s encephalopathy have the classic triad of symptoms/signs?

A

10% - about 80% of cases present with just confusion

88
Q

What is the pathology of wernicke’s encephalopathy?

A

Haemorrhages and secondary gliosis in periventricular and periaqueductal grey matter. Areas involved include:

  • Mamillary bodies
  • Hypothalamus
  • Colliculi
  • Tegmentum of midbrain
89
Q

How does heavy drinking cause thiamine deficiency?

A
  • Poor calorie/nutritional intake
  • Reduced absorption
  • Impaired hepatic storage
90
Q

How would you manage someone with wernicke’s encephalopathy?

A
  • IV Pabrinex - parenteral
  • Treat alcohol withdrawal
91
Q

What is korsakoff’s syndrome?

A

Usually occurs after wernicke’s encephalopathy, but not always

An amnesic state in which there is profound impairment of both retrograde (previous) and anteretrograde (new) memory but relative preservation of other intellectual abilities. Working, emotional and procedural memory is also preserved. Other features include:

  • Confabulation
  • Nystagmus
  • Ataxia

These tend to indicate combined syndrome

92
Q

How would you treat someone with Korsakoff’s syndrome?

A

Oral thiamine and multivitamin supplementation - 2 years

OT assessment

Cognitive rehabilitation

93
Q

What percentage of heavy drinkers will have a fatty liver?

94
Q

What is alcoholic hallucinosis?

A

Substance induced psychotic illness which is a rare complication of prolonged heavy alcohol misuse. The sufferer experiences hallucinations - usually auditory - while sober. Can start as elemental hallucinations which progress to formed voices (usually derogatory) with continued alcohol use

95
Q

If an individual presented with hallucinations with prolonged alcohol misuse, what would be your differential diagnosis?

A
  • Alcoholic hallucinosis
  • Transitory hallucinatory/illusionary experiences while intoxicated
  • Delerium tremens
  • Psychotic illnesses
96
Q

What is Othello syndrome?

A

Pathological jealousy - monosymptomatic delusional disorder seen most commonly secondary to current or previous alcohol abuse. Content is a primary delusion in which the content is that the patient’s spouse or partner has been/is being unfaithful

97
Q

What is alcohol induced amnesia?

A

Transient amnesic episodes related to periods of intoxication. Characteristically report a gap in their memory lasting severeal hours with global or partial amnesia for their actions during that time

98
Q

What is alcohol withdrawal syndrome?

A

Sydrome that occurs when someone who is alcohol dependent stops consuming alcohol either substantially or completely.

99
Q

What are the different alcohol withdrawal syndromes?

A
  • Uncomplicated alcohol withdrawal
  • Alcohol withdrawal with seizures
  • Delerium tremens
100
Q

What are the characteristic features of uncomplicated alcohol withdrawal/alcohol withdrawal syndrome with seizures?

A

Occurs 4-12 hrs after last drink, peak at 48 hrs, and last 2-5 days

  • Coarse tremor
  • Sweating
  • Insomnia
  • Tachycardia
  • Nausea and vomiting
  • Psychomotr agitation
  • Generalised anxiety
  • Occasional hallucinations
  • Seizures
101
Q

What is delerium tremens, and what are the characterisitc features?

A

Acute confusional state secondary alcohol withdrawal, which has the features of uncomplicated withdrawal, plus:

  • Clouding of consciousness
  • Disorientation
  • Amnesia - recent events
  • Hallucinations - tactile, visual, auditory
  • Marked fluctuation hour by hour
  • Profound psychomotor agitation
102
Q

What are the characteristic hallucinations that those going through Delerium Tremens experience?

A

Lilliputian hallucinations - hallucinations of diminutive people or animals

103
Q

If someone developed symptoms/signs which pointed towards a diagnosis of delerium tremens, what else would you consider as part of a differential diagnosis?

A
  • Hepatic encephalopathy
  • Head injury
  • Pneumonia
  • Acute psychotic illness
  • Other cause of delerium
104
Q

How can death occur when someone is going through delerium tremens?

A
  • Sudden cardiovascular collapse
  • Infection
  • Hyperthermia
  • Self-injury
105
Q

How would you manage someone going through alcohol withdrawal?

A

Detox

  • Decide setting - inpatient vs outpatient
  • Psychological support
  • Benzodiazepines - withdrawal symptoms - reducing regimen
    • ​Chlordiazepoxide prefered
  • Observation
  • Nutritional supplementation
106
Q

What indications would make you think it would be safer to detox a patient as an inpatient?

A
  • PH of complicated withdrawals - seizures/DTs
  • Current confusional/delerious symptoms
  • Comorbidities
  • Symptoms of WKS
  • Severe vomiting/malnutrition
107
Q

What are the indications for prescribing a reducing regimen of benzodiazepines when treating alcohol withdrawal?

A
  • Clinical symptoms
  • History of dependence
  • Consumption > 10 units/day over the previous 10 days
108
Q

What are the components to the CAGE questionnaire?

A

Cut down - Have you tried to cut down?

Annoyed - Have you felt annoyed by people criticising your drinking?

Guilt - Have you felt guilty about drinking?

Eye-opener - have you felt the need to have an eye-opener in the morning

109
Q

What disorders would usggest underlying alcohol abuse?

A
  • Hepatitis
  • Cryptogenic cirrhosis
  • Seizures
  • Gastritis
  • Anaemia
  • Cardiomyopathy
  • TB
  • Head injury
  • Impotence
110
Q

What blood tests might indicate excess alcohol consumption?

A

Elevated:

  • MCV
  • GGT
  • CDT - carbohydrate-deficient transferrin
111
Q

How would you manage someone in an attempt to maintain abstinence?

A
  • Individual/group therapy - AA
  • Pharmacological support
  • Advise regarding relapse
  • Consideration for residential rehabilitation
112
Q

What Medications can be used to help those who are attempting to achieve alcohol abstinence?

A
  • Aversive drugs - Disulfiram (Antabuse)
  • Anticraving drugs - acamprosate, Naltrexone, Baclofen
113
Q

What are examples of anti-craving drugs used for alcoholics?

A
  • Acamprosate
  • Naltexone
  • Baclofen
114
Q

How does disulfiram work?

A

Irreversible inhibition of ALDH, leading to a build up of Acetaldehyde. This causes unpleasent symptoms of flushing, headache, nausea and vomiting, and tachycardia

115
Q

When managing severe alcohol intoxicaiton in hospital, how should the individual be monitored?

A
  • Assessed hourly
  • Continuous ECG monitoring
  • Urine output
  • Blood Glucose, Electrolytes and gases - every 4 hours
116
Q

How would you manage someone with severe acute alcohol intoxication?

A
  • IV fluids
  • Oral glucose/IV 5% or 10% dextrose as required
  • Assist ventilation
  • Haemodialysis - exceptionally high blood ethanol

Psychiatric Medicine (16 decks)

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