Alcohol use disorder
Patients suffering from alcohol use disorder commonly present for medical evaluation, and many require emergent care and/or stabilization. The need for emergent care extends across the entire spectrum of alcohol use disorder, including patients seeking help and preventive care, acute management of alcohol intoxication, complications of acute intoxication (eg, trauma, severe electrolyte derangements, alcoholic / starvation ketoacidosis), and alcohol withdrawal syndrome.
Alcohol use disorder is a pattern of alcohol use leading to clinically significant impairment or distress, as manifested by multiple psychosocial, behavioral, or physiologic features. Formerly viewed as two distinct disorders, alcohol abuse and alcohol dependence, alcohol use disorder is now viewed as a single disorder, categorized as mild, moderate, or severe. In the United States, up to 29% of people meet the criteria for an alcohol use disorder in their lifetime. Risk factors include younger age, male sex, Native American race, and having a disability, mood disorder, or other . Genetic factors are also implicated in alcohol use disorder.
Patients present with a range of clinical findings that include dysarthria, gastrointestinal symptoms (ie, nausea, vomiting, abdominal pain), tachycardia, hypertension, sleep disturbance, hypoglycemia, nystagmus, tremor, memory impairment, and headache. Behavioral and psychosocial findings include cravings; difficulty quitting; interference with relationships and maintaining job, school, and home responsibilities; and incidences of risky behavior that may harm others or cause self-harm. Associated diagnoses include , , , , difficult-to-control , , , , seizures, and . Pregnant individuals face a greater risk of miscarriage and birth disorders due to . Severe intoxication with high levels of blood alcohol, or alcohol toxicity, is life-threatening and requires immediate medical attention.
Management is multifaceted and includes physiologic support, detoxification, residential rehabilitation treatment, cessation and withdrawal support, lifestyle changes, medications (eg, disulfiram, naltrexone, acamprosate), cognitive behavioral therapy, individual and group therapy, family therapy, and support programs.
Patients with this disorder may have an increased risk of various general medical conditions.
Cardiovascular effects: Acute and chronic alcohol consumption can have acute and chronic implications to the cardiovascular system. These include mechanical disturbances of the heart (eg, dilated cardiomyopathy) that produce dysrhythmias and exacerbation of coronary artery disease. In the emergent care setting, providers must be aware of signs of symptoms of heart failure (see alcoholic cardiomyopathy) as well as possible dysrhythmias, including supraventricular dysrhythmias (usually atrial fibrillation) and ventricular dysrhythmias (ie, transient ventricular tachycardia). Collectively, dysrhythmias can result in "holiday heart" due to heavy alcohol consumption. Acutely, providers should perform a detailed history and physical to evaluate for the cardiovascular effects of alcohol use disorder. This may include alcohol levels, blood glucose levels, blood chemistries, troponin levels, ECGs, and chest radiography. Management of alcohol-related cardiovascular effects will depend on the severity of the derangement but not uncommonly will result in hospitalization.
Pulmonary and infectious disease effects: Consuming drinks that contain 10-20 grams of alcohol is linked to an 8% increased risk of developing community-acquired pneumonia, with disproportionately high rates of Klebsiella pneumoniae infection. For patients with unexplained hypoxia, respiratory distress, cough, or other cardiopulmonary complaints, providers should assess for pneumonia with lung auscultation and chest radiography.
Gastrointestinal effects: The gastrointestinal effects of alcohol are among the most profound, common, and potentially life-threatening. Patients with alcohol use disorder have a higher incidence of gastritis, esophagitis, gastrointestinal-related malignancies, pancreatitis, and malabsorption issues, with many irreversible problems such as liver damage and cirrhosis. Alcohol-related liver disease is well recognized as a primary finding in patients with alcohol use disorder, manifesting in ways such as asymptomatic liver dysfunction, portal hypertension, platelet disorders, ascites, and hepatocellular carcinoma. Complications from portal hypertension include esophageal varices, liver fibrosis (which is not reversible but can be halted with alcohol cessation), and even hepatic encephalopathy. Gastrointestinal bleeding is among the most acute, life-threatening manifestations of alcohol use disorder, which can be a result of Mallory-Weiss tears, bleeding esophageal varices, erosive gastritis / esophagitis, or even Boerhaave syndrome. Alcoholic hepatitis is yet another gastrointestinal manifestation that results in patients presenting acutely with a range of symptoms and clinical presentations, including upper abdominal pain, tender liver, fever, jaundice, and abnormal liver function studies, and can even present as fulminant liver failure. The model for end-stage liver disease (MELD) score can be used to predict mortality in alcoholic hepatitis but may not be useful in the emergency setting.
Patients with alcohol use disorder presenting with life-threatening manifestations very commonly get admitted to the hospital, especially when a diagnosis of cirrhosis is present that requires rapid emergent evaluation, care, and potentially stabilization. Providers must assess for the complications of alcohol use disorder, which commonly include laboratory values such as CBCs, complete metabolic panels including liver function studies (AST, ALT, PT-INR, PTT), lipase, ECGs, and ammonia and type and screen if bleeding is of concern. Gastrointestinal bleeding is among the most urgent and life-threatening manifestations of alcohol use disorder, and providers need to be prepared for rapid deterioration of a patient with gastrointestinal bleeding, including access to vitamin K and blood products, intravenous (IV) access for the patient, and emergent gastroenterology consultation.
Neurological effects: Acute alcohol ingestion lowers the seizure threshold. Neuropathy, Wernicke-Korsakoff syndrome, alcoholic cerebellar degeneration, and hepatic encephalopathy are among the most common and dangerous neurological manifestations of chronic alcohol use disorder. Neuropathy can manifest as symmetric sensorimotor polyneuropathy, usually located in the lower extremities due to the direct toxic effects of alcohol and vitamin B12 deficiency. Acute treatment for this may involve an electromyograph (EMG), IV or oral thiamine, and possibly even hospitalization.
Metabolic effects: People with alcohol use disorder frequently present acutely with symptomatic (or even asymptomatic) hypoglycemia; thus, intoxicated patients must have a blood glucose check done upon arrival. Hypoglycemia can cause seizures and further develop into alcoholic ketoacidosis, which is a common complication of alcohol use disorder that usually requires hospitalization. Alcoholic ketoacidosis is usually found after a patient binge drinks, followed by 1-3 days of nausea, vomiting, abstinence, and dehydration, and then the patient presents with abdominal pain, nausea, and vomiting. Blood pH may be normal or acidic, and electrolyte disturbances such as hypokalemia and hypomagnesemia may be present. All patients with alcohol use disorder who present with nausea and vomiting should receive a complete metabolic panel, and then receive thiamine and glucose. Lastly, patients with alcohol use disorder frequently have other metabolic derangements, such as hypocalcemia, hypomagnesemia, hypokalemia, hypophosphatemia, and hyponatremia. Hypomagnesemia is the most common electrolyte abnormality, and since most stores are intracellular, serum magnesium levels may be normal. Long-term treatment requires improved diet and nutrition and alcohol cessation.
Hematologic effects: Chronic alcohol use results in numerous hematologic effects, partly due to the toxic effects of alcohol and its metabolites, but also due to nutritional deficiencies, liver dysfunction, and bone marrow suppression. This can result in anemia, leukopenia, and thrombocytopenia. Megaloblastic anemia is common due to folate deficiency. Thus, it is reasonable to give thiamine and folic acid to all patients suffering from alcohol use disorder. Additionally, alcoholics frequently have chronic inflammatory diseases that result in anemia of chronic disease. Similarly, leukopenia is common, which can result in decreased inflammatory responses and poor recovery after illness.
Psychiatric effects: Alcohol use disorder and other substance use disorders are frequently associated with depression and antisocial personality disorder. Concurrent mental illness, including major depression and antisocial personality disorder, increase the risk for violence and suicidality. Treatment of concurrent mental illness is crucial for alcohol cessation.
Pregnancy effects: No safe level of alcohol consumption has been observed in pregnancy. Alcohol is a potent teratogen that can affect fetal growth and development at all stages of pregnancy. Additionally, alcohol freely passes through a lactating mother's milk; thus, mothers who consume alcohol should refrain from breastfeeding for up to 4 hours after moderate-to-high levels of alcohol consumption.
Trauma effects: Trauma is the leading cause of death in the United States for individuals between the ages of 1 and 44 years, and alcohol is a major risk factor for all types of traumatic injuries. Alcohol intoxication has several deleterious effects in the setting of trauma, including volume depletion, lower blood pressures, neurological suppression due to intoxication, cardiac depressant, and sensitivity to abdominal injuries due to liver dysfunction and splenomegaly. Additionally, people with chronic alcohol use disorder are at risk for acute and chronic subdural hematomas, epidural hematomas, concussions, spine fractures, and other long bone fractures. Intoxicated patients should be placed in a gown, and providers should perform a complete integumentary examination assessing for any signs of trauma. Intoxicated patients are a vulnerable population, and liberal use of radiography and CTs are warranted, especially if neurological changes or depression are present.
F10.20 – Alcohol dependence, uncomplicated
7200002 – Alcoholism
Differential Diagnosis & Pitfalls