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Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Alcoholism is a common substance-abuse disorder that affects virtually every organ system. Alcoholics are at increased risk for cirrhosis (shown), gastrointestinal (GI) bleeding, pancreatitis, cardiomyopathy, trauma, mental health disorders (eg, depression, blackouts, dementia), and a wide variety of cancers. Many alcoholics are in denial about their addiction and lack awareness of the short- and long-term complications of alcohol abuse.

Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Liver Disease and Associated Complications

Alcohol abuse is the second most common cause of cirrhosis in the United States, after hepatitis C.[1] Damage to the liver parenchyma over time from alcohol leads to progressive fibrosis, producing a nodular contour to the liver (white arrows). The scar tissue impairs portal vein blood flow,[2] which induces portal hypertension; this causes splenomegaly (yellow arrow), transudative ascites (red arrow), and varices. The computed tomography (CT) image shown demonstrates prominent esophageal varices (green arrow).

Image courtesy of Lars Grimm, MD, MHS.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

A 60-year-old woman presents for a new patient evaluation. She suffers from depression after the loss of her husband a year ago and admits to drinking approximately 60 g of alcohol daily. She recently presented to the emergency department (ED) for abdominal pain and underwent an abdominal CT scan (shown).

On review of her CT scan, which of the following changes could be attributed to her alcohol use?

  1. None; study is normal
  2. Alcoholic hepatic steatosis
  3. Alcoholic hepatitis
  4. Alcoholic cirrhosis
  5. Hepatocellular carcinoma (HCC)
Image courtesy of Lars Grimm, MD, MHS.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Answer: B. Alcoholic hepatic steatosis.

Ingestion of more than 60 g of alcohol daily causes morphologic changes to the liver. The first change is fatty replacement of the liver, or hepatic steatosis, due to an increase in fatty acids and glycerol 3-phosphate.[4]

The ultrasound image shows that the liver is more echogenic (ie, brighter) (red arrow) than the kidney (blue arrow) due to increased fat content. MRI is an excellent means of evaluating for subsequent complications such as portal hypertension, ascites, and HCC.[5] Newer imaging techniques, such as dual-energy CT, can quantify the degree of steatosis.[6] Hepatic steatosis is reversible, but if ingestion of alcohol is not decreased, it progresses to alcoholic hepatitis, followed by alcoholic cirrhosis.[7]

Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Esophageal Damage

A 50-year-old man with a long-standing history of alcohol abuse and with esophageal varices diagnosed on a recent esophagogram (shown) presents to the ED with hematemesis. He was drinking heavily earlier in the day and started vomiting about 1 hour ago. Initial vital signs include heart rate 90 beats/min, blood pressure 115/73 mm Hg, and normal respiratory rate. While sitting in the waiting room, he has filled two cups with bloody fluid.

After the administration of intravenous (IV) fluids, what is the most appropriate next step in management?

  1. Watchful waiting
  2. Repeat esophagogram
  3. CT of the chest, abdomen, and pelvis
  4. GI consult for endoscopy
  5. Interventional radiology consult for angiography
Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Answer: D. GI consult for endoscopy.

The patient's history suggests either a bleeding esophageal varix or a Mallory-Weiss tear, both of which can be diagnosed with endoscopy. Management with endoscopy is also possible in some cases, but surgery or angiotherapy may be required to stop the bleeding.[9]

Varices develop secondary to cirrhotic changes in the pressure and flow gradients of the liver vasculature. As varices grow, the risk of rupture and hemorrhage increases dramatically, with a 70% chance of rebleeding. Clinical signs include blood in vomit; black, tarry, or bloody stools; lightheadedness; rapid heart rate; and loss of consciousness.[8]

In contrast, Mallory-Weiss tears are longitudinal mucosal lacerations at the esophagogastric junction or gastric cardia (shown) that develop from a sudden rise in intragastric pressure. The classic presentation is protracted vomiting after alcoholic binge drinking followed by hematemesis. Hemodynamic instability and shock develop in as many as 10% of cases.

Pathology specimen with large HCC; image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Hepatocellular Carcinoma

HCC is one of the most common causes of cancer-related death, and roughly 30% of HCCs are due to excessive alcohol use.[10] In patients with 10 years of chronic alcohol abuse, the HCC risk is increased fivefold. Up to 75% of HCC are multifocal at diagnosis and the overall prognosis is poor, with a 5-year survival rate of 21%.[11] However, multiple treatment options are available for unresectable HCC, including transarterial chemoembolization, drug-eluting embolization, and radioembolization.[12] Patients at high risk for HCC can undergo US screening every 6 months.

Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Esophageal Cancer

Alcohol use is one of the leading causes of esophageal cancer in the United States.[13] Among patients who drink more than 30 g of ethanol daily, the risk ratio for squamous cell carcinoma is 4.61 compared with abstainers. Dysphagia with solids and eventually with liquids is the classic presentation. Endoscopy allows direct visualization and tissue biopsy. A barium swallow can indicate a mass lesion and provide functional information. The image shows a mid-esophageal endoluminal mass on barium swallow in a patient with esophageal cancer.

Surgical excision is the best option for curative therapy; nonoperative treatment is reserved for palliation of dysphagia. The overall 5-year relative survival rate for all stages of esophageal cancer is approximately 21% but the survival rate for late-stage cancer is about 6%.[14,15]

Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Stroke

The brain CT scan in the slide demonstrates two areas of intracerebral hemorrhage in the right lentiform nucleus.

Each year, more than 795,000 people in the United States have a stroke, and it is the fifth leading cause of death in the United States.[16,17] Although low-to-moderate alcohol use is associated with a reduced risk of stroke, heavy alcohol use (chronic or irregular) significantly increases the risk of both ischemic and hemorrhagic stroke.[18,19] Alcohol also has an anticoagulant effect, which is partly responsible for the increased risk of hemorrhagic stroke at higher levels of alcohol consumption.

Image courtesy of Wikimedia.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Pancreatitis

Alcohol abuse is the second most common cause of acute pancreatitis, after gallstones.[20] However, moderate alcohol use is protective against all forms of pancreatitis.[21] Pancreatitis may develop from an isolated episode of binge drinking or from habitual abuse. Injury to the pancreatic acinar cells creates an inflammatory cascade, leading to pancreatic damage.

Signs and symptoms of acute pancreatitis include dull abdominal pain that gradually becomes more severe, nausea, vomiting, and diarrhea.[22]

Classic physical examination findings of acute pancreatitis include the Cullen sign (edema and bruising in the periumbilical subcutaneous fatty tissue) and the Grey-Turner sign (shown), which is discoloration of the flanks from retroperitoneal hemorrhage. The most serious complications are pancreatic necrosis, pseudocyst, and infection of inflammatory fluid collections.

Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

The CT scan in the slide demonstrates extensive calcification of the pancreas (red arrow) and a large pancreatic pseudocyst (black arrow).

In chronic pancreatitis, progressive pancreatic damage results in impaired exocrine and endocrine function. The main symptom is abdominal pain, usually epigastric.[23] Pseudocyst formation is the most common complication and may lead to intestinal obstruction, abscess, pseudoaneurysm, or fistula. The 10-year mortality in patients with chronic pancreatitis is 30%.[24] Alcoholism is implicated in 70% of cases of chronic pancreatitis, and the incidence of chronic pancreatitis is rising throughout the world.[25]

Image courtesy of Lars Grimm, MD, MHS.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Pancreatic Cancer

A 70-year-old man with a long-standing history of alcohol abuse presents with painless jaundice, malaise, and weight loss. A CT scan of the abdomen reveals a mass in the head of the pancreas (red arrow), presumably representing a pancreatic adenocarcinoma. The patient asks if the cancer is treatable.

Which of the following is the most important factor influencing this patient's survival?

  1. Degree of pancreatic dilation
  2. Invasion of the superior mesenteric vein
  3. Invasion of the celiac artery
  4. Age
Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Answer: C. Invasion of the celiac artery.

The endoscopic US image demonstrates a pancreatic carcinoma (mass) obstructing the common bile duct (CBD) but not invading the portal vein (PV) or superior mesenteric vein (SMV). Pancreatic cancer is a frequently occult malignancy that is diagnosed in an advanced stage in half of patients. Chronic inflammation is a major predisposing factor, and patients with chronic pancreatitis from alcohol abuse have a higher incidence of pancreatic cancer and an earlier age of onset.[26] The classic presentation is painless jaundice from a pancreatic head mass.

Surgical excision offers the best chance of cure, but recurrence is very common.[27] Newer surgical techniques may allow resection of the superior mesenteric or portal veins, but arterial involvement is an absolute contraindication for surgical treatment. The 5-year survival rate is only 12.5%. Pancreatic cancer is responsible for 3.3% of all new cancer cases but 8.3% of all cancer deaths in the United States.[28]

Image from Medscape.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Cardiac Disease

Although low-to-moderate alcohol intake can provide cardiovascular protection, high alcohol use for an extended period can cause hypertension, coronary artery disease, peripheral artery disease, and dilated cardiomyopathy, among other conditions.[29,30] Alcohol's toxic effects directly weaken the heart muscle; alcohol also increases blood pressure, oxidative stress, and the risk of thrombosis, while negatively impacting the conductive system (resulting in arrhythmias).[17]

In dilated cardiomyopathy, the ventricular wall thickness remains normal but the ventricular chambers become enlarged (shown). Subsequent systolic dysfunction may result in arrhythmias, thromboembolism, and sudden death.

The term holiday heart syndrome refers to the development of rhythm disturbances, most commonly atrial fibrillation, after alcohol use in patients without structural heart disease.[31] Alcohol can also unmask or exacerbate Brugada syndrome, a hereditary cardiac channelopathy that increases risk for sudden death.[32,33] Brugada syndrome is thought to be responsible for 4-12% of all sudden cardiac deaths and 20% of sudden deaths in patients with structurally normal hearts.[34]

Image from the National Institute on Alcohol Abuse and Alcoholism.

Alcohol Abuse: Don’t Drink to That

Lars Grimm, MD, MHS | November 16, 2023 | Contributor Information

Neurologic Disorders

The coronal brain scans of a 60-year-old man with alcoholism demonstrate thinning of the corpus callosum and enlargement of the ventricles (on MRI), as well as reduced delineation of the white matter tracts (on diffusion tensor imaging [DTI]).

Alcohol causes direct neurotoxic effects. In addition, indirect damage from alcohol abuse includes associated thiamine deficiency, cerebrovascular disease, hepatic encephalopathy, and head trauma.[35]

Delirium tremens is a severe form of alcohol withdrawal that can occur in chronic alcohol abuse. When alcohol use ceases, the loss of inhibitory regulation of excitatory neurotransmitters and neuroreceptors can lead to tremors, diaphoresis, tachycardia, anxiety, delirium, and seizures.[36]

Thiamine deficiency in chronic alcohol abusers can lead to Wernicke encephalopathy, which is characterized by ataxia, ophthalmoplegia, and confusion. Another neurologic complication, Korsakoff syndrome, which often follows Wernicke encephalopathy, involves anterograde and retrograde amnesia, frequently accompanied by confabulation.[37]

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