Alcohol

1
Alcohol

• With a nod towards the liver

2
Alcohol in the news Guardian yesterday

• Alcoholics may have benefits withdrawn from them
  unless they agree to go on a government treatment
  programme, the work and pensions secretary, James
  Purnell, suggested yesterday.
• The government is already piloting plans to
  require drug addicts to go on treatment
  programmes or lose benefit, but this previously
  unpublicised idea is likely to prove more
  controversial.
• Purnell has asked Glasgow University to work up
  practical proposals on how to define alcoholism,
  what treatment alcoholics would be required to
  take and how to judge whether they were taking it
  seriously.

3

• Use
• Misuse
• social
• Occasional
• self-medication
• dependence

4
Some pathophysiology

• 40-60 of risk of alcohol misuse is explained by
  genes
• Some help, - ALDH22 allele which increases
  sensitivity to alcohol
• Some worse GABRA2 receptor variations
• 2-10 excreted through the lungs, urine and
  sweat, remainder via AHD and then to CO2 and
  water via ALDH, at about 1 unit/hour (and about
  40 Japanese, Korean and Chinese have an inactive
  ALDH either homo or heterozygous

5
Random Facts

• The survey Crime in England and Wales 2001/2
  found that domestic violence victims reported
  that 45 of perpetrators were under the influence
  of alcohol at the time of assault.
• In England and Wales 6 of women and 5 of men
  suffered some of domestic violence in 2003-2004.
  Women were subjected to 12.9 million incidents
  per year and men 2.5 million incidents.

6
Medical conditions

• Cancers
• Mouth, throat, breast
• Liver disease
• Heart disease
• Mental health
• Trauma

7
Alcohol dependence

• Dependence
• 1 year prevalence of 3-5 in industrialised
  nations and lifetime prevalence of 13-16
• Harmful drinking
• 15-40

8
Other random facts

• Abstinence? yes in USA, increasingly in UK
• 20-30 without help become long-term problem-free
  (new partner, more responsibilities, maturity)
• 80 of people with alcohol-misuse do NOT have
  cirrhosis
• Even low doses of alcohol enhance activity in the
  inhibitory ?-aminobutyric acid systems throughout
  the brain, causing muscle relaxation, somnolence
  and intoxicated feelings

9
Yet more

• Cancer is 2nd leading cause of early death (even
  after controlling for smoking)
• 75 of head and neck cancers misuse alcohol
• Alcohol doubles oesophagus, rectum and breast
• (alcohol-induced damage of immune system?

10
Pharmacological treatments

• Strychnine, atropine, hydrochloric acid, insulin
  coma therapy, lysergic acid
• Promote abstinence attenuate drinking
  acamprosate (a synthetic GABA analogue)
• Alcohol sensitising agents
• Opioid anatagonists naltrexone
• http//www.alcoholconcern.org.uk/files/20031016_14
  1411_version202201920Aug2003.pdf

11
Brief intervention

• Twice as likely to reduce over 6-12 months
• NNT about 8 (better than smoking)

12
A 40 year old woman presents with a five year
history of tiredness. She is a teacher and drinks
alcohol occasionally.

• Her LFTs are
• Bilirubin 14 (0-17 µmol/l)
• Alk phos 245 (40-125 IU/l)
• ALT34 (0-35 IU/l)
• GGT 110 (0-40 IU/l)
• IgG 12 (6.9-14 g/l)
• IgA 3 (0.88-4.1 g/l)
• IgM 6.6 (0.34-2.1 g/l)
• Antinuclear antibody neg
• Anti-mitochondrial antibody positive (1400)
• Anti-smooth muscle antibody neg

• Which one of the following statements is correct?
  
• An ultrasound scan is likely to be diagnostic
• Tiredness is not likely to be related to the
  liver disease
• Autoimmune hepatitis is the most likely diagnosis
• Primary biliary cirrhosis is the most likely
  diagnosis
• Alcoholic liver disease is the most likely
  diagnosis

13
What is the commonest cause of abnormal LFTs in
pregnancy (in the UK)?
14
You see a 33 year old man with a three week
history of malaise and jaundice. On examination
he has a low grade pyrexia and cervical
lymphadenopathy. Here are his results What test
ought you to carry out?

• Bilirubin 48 (0-17 µmol/l)
• Alk phos 118 (40-125 IU/l)
• ALT 188 (0-35 IU/l)
• AST 170 (0-35 IU/l)
• GGT 62 (0-40 IU/l)
• Haemoglobin 13.6 g/l
• White cell count 10.8 x 1012 / l
• Neutrophils 4.6 x 1012 / l
• Eosinophils 0.2 x 1012 / l
• Lymphocytes 5.8 x 1012 / l
• Basophils 0.2 x 1012 / l
• Platelets 196 x 109 / l

• Blood film
• Occasional atypical lymphocytes seen
• Paul Bunell test Negative
•  
• Hepatitis A IgG and IgM negative
• Hepatitis B Surface antigen negative
• Hepatitis C Antibody negative
• CMV IgM negative
• CMV IgG positive

15
A 70 year old man has a history of weight loss
and increasing urinary frequency. He does not
drink and has previously been well. He takes no
regular medication.

• The results of tests show
• Bilirubin 9 (0-17 µmol/l)
• Alk phos 636 (40-125 IU/l)
• ALT 36 (0-35 IU/l)
• GGT 35 (0-40 IU/l)

• What is the likely diagnosis?
• Primary biliary cirrhosis
• Gallstone disease
• Metastatic carcinoma of the prostate
• Primary sclerosing cholangitis
• SIADH

16
A 40 year old woman has a 12 month history of
tiredness. She works as a bartender and drinks
about 5 pints of lager two days a week. She has
never used intravenous drugs and hasn't travelled
abroad recently.

• The results of tests show
• Bilirubin 8 (normal 0-17 µmol/l)
• Alk phos 135 (normal 40-125 IU/l)
• ALT 522 (normal range 0-35 IU/l)
• GGT 64 (normal range 0-40 IU/l)
• Total protein 90 (normal 65-85 g/l)
• Albumin 34 (normal 34-50 g/l)
• Hepatitis A IgM Negative
• Hepatitis B e and s antigen Negative
• Hepatitis C antibody Negative
• IgG 25 (normal range 6.9-14 g/l)
• IgA 3 (normal range 0.88-4.1 g/l)
• IgM 2 (normal range 0.34-2.1 g/l)

• Which is the likely diagnosis?
• a Alcoholic liver disease
• b Hepatitis B
• c Hepatitis C
• d Primary biliary cirrhosis
• e Autoimmune hepatitis

17
A 24 year old medical student has jaundice. He
had a recent episode of gastroenteritis, from
which he has recovered and is now asymptomatic.
He has not had alcohol for one month. Previously
he drank about 6 pints of lager five nights a
week. He has no history of travel, he does not
use intravenous drugs, and he has no family
history of note.

• The results of LFTs show
• Bilirubin 36 (0-17 µmol/l)
• Alk phos 112 (40-125 IU/l)
• ALT 23 (0-35 IU/l)
• GGT 20 (0-40 IU/l)

• What is the most likely diagnosis?
• Gallstones
• Gilbert's syndrome
• Viral hepatitis
• Autoimmune hepatitis
• Drug induced hepatitis

18
A 50 year old publican presented with a two week
history of jaundice. He had been drinking two
bottles of cider each day for at least two years.
He has no other risk factors for liver disease.
He is not on any medication.

• Blood tests showed
• Bilirubin 300 (0-17 µmol/l)
• Alk phos 145 (40-125 IU/l)
• ALT 60 (0-35 IU/l)
• AST 130 (0-35 IU/l)
• GGT 300 (0-40 IU/l)
• Prothrombin time
• 22 (11-13 sec)

• What is the most likely diagnosis?
• Obstructive jaundice secondary to pancreatic
  carcinoma
• Obstructive jaundice secondary to gallstones in
  the common bile duct
• Viral hepatitis
• Alcoholic hepatitis
• Autoimmune hepatitis

19
A 45 year old IT manager has been found to have
abnormal LFTs at a well person screening clinic.
He drinks two bottles of wine per week and does
not use intravenous drugs. In the clinic, his
body mass index was 35. He has no stigmata of
chronic liver disease.

• His LFTs are
• Bilirubin 12 (0-17 µmol/l)
• Alk phos 105 (40-125 IU/l)
• ALT 78 (0-35 IU/l)
• AST 30 (0-35 IU/l)
• GGT 108 (0-40 IU/l)
• and Chol. 6.8mmol/l

• Which one of the following statements is correct?
  
• These abnormalities are mild and do not need
  further investigation
• The ratio of AST to ALT suggests alcoholic liver
  disease
• The ratio of AST to ALT suggests non-alcoholic
  steatohepatitis
• Hepatitis C is likely
• Liver biopsy is essential for diagnosis

20
A minimal investigation set for such patients
might include......

• Serology for hepatitis B and C
• Autoantibodies
• Ferritin
• Immunoglobulins
• Copper studies (possibly).

21
This man is diagnosed with non-alcoholic
steatohepatitis after other forms of liver
disease are excluded by blood screening (normal
ferritin, viral markers, autoantibodies, copper
studies, and alpha1-antitrypsin levels).

• Which one of the following conditions is he NOT
  at increased risk of developing?
• Diabetes mellitus
• Hypertension
• Ischaemic heart disease
• Cryptogenic cirrhosis
• Drug induced hepatitis if he were to start on
  lipid lowering treatment

22
Resources for patients

• http//www.talktofrank.com/drugs.aspx?id166
• http//www.alcoholconcern.org.uk/servlets/home

23
Possible resources

• http//www.videojug.com/interview/alcohol-addictio
  n-defined-2

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Effects of High-Risk Drinking

• Numb, tingling toes.
• Painful nerves.
• Impaired sensation, leading to falls.
• Inflammation of the pancreas.
• Vitamin deficiency. Bleeding.
• Severe inflammation of the stomach. Vomiting.
• Diarrhea. Malnutrition.
• Cancer of throat and mouth .
• Premature aging. Drinker's nose.
• Weakness of heart muscle.
• Heart failure.
• Anemia.
• Impaired blood clotting.
• Breast cancer.
• In men
• Impaired sexual performance

• In women
• Risk of giving birth to deformed, retarded babies
  or low birth weight babies.
• Aggressive,irrational behaviour.
• Arguments. Violence.
• Depression. Nervousness.
• Frequent colds. Reduced resistance to infection.
• Increased risk of pneumonia.
• Alcohol dependence.
• Memory loss.
• Ulcer.
• Liver damage.
• Trembling hands.
• Tingling fingers.
• Numbness. Painful nerves.
• High-risk drinking may lead to social, legal,
  medical, domestic, job and financial problems. It
  may also cut your lifespan and lead to accidents
  and death from drunken driving.