MEDICAL COMPLICATIONS

OF ALCOHOL USE
MODERATOR: DR SPOORTHY
PRESENTER: DR NEETHU
SCHEME

 INTRODUCTION

ADVERSE EFFECTS IN
 NERVOUS SYSTEM
 GASTROINTESTINAL SYSTEM
 CARDIOVASCULAR SYSTEM
 HAEMATOPOETIC SYSTEM
 GENITOURINARY SYSTEM
 CANCERS
 TERATOGENECITY
 OTHERS
 CONCLUSION
 INTRODUCTION
 Alcohol is the most common substance abuse.

 Alcohol is a psychoactive drug that depresses the central nervous system.

 Acts on GABA A receptors

 Alcohol cause both acute and chronic changes in almost all neurochemical systems.

 Several preexisting psychiatric diagnosis including antisocial personality , bipolar and

schizophrenic disorder includes the risk of later alcohol use disorder.

 most affected systems: liver , respiratory and cardiovascular

NERVOUS SYSTEM
 ACUTE INTOXICATION
 ALCOHOLIC BLACK OUT
 ALCOHOLIC DEMENTIA
 DELIRIUM TREMENS
 WITHDRAWAL SEIZURES
 WERNICKE’S ENCEPHALOPATHY
 KORSAKOFF’S PSYCHOSIS
 PERIPHERAL NEUROPATHY
 STROKE
 CEREBELLAR DEGENERATION
 AMBLYOPIA
 CENTRAL PONTINE MYELINOSIS
 MARCHIFAVA - BIGNAMI DISEASE
 Alcohol intoxication
acute intoxication
pathological intoxication
blackouts
 Alcohol withdrawal syndromes
tremors,
hallucinosis ,
seizures ,
delirium tremens.
 Nutritional defects:
Wernicke’s encephalopathy,
Korsakoff’s syndrome,
peripheral neuropathy
cerebellar degeneration,
amblyopia.
 ACUTE ALCOHOL INTOXICATION
 A reversible syndrome caused by recent ingestion of alcohol
 Effects of alcohol are sensitive to dose.
 Early effects produce elation, excitement
Physiological signs of intoxication :
slurred speech
dizziness
incoordination
unsteady gait
nystagmus
impairment in attention / memory
BLOOD LEVEL IMPAIRMENT
20-30 mg/dl Slowed motor performance &
decreased thinking ability.

30-80 mg/dl Increases in motor & cognitive

problems
80-200 mg/dl Increase in incoordination &
judgement errors, mood
lability,deterioration in cognition

200-300 mg/dl Nystagmus, marked slurring of

speech and alcoholic blackouts.

>300 mg/dl impaired vital signs & possible

death
PATHOLOGICAL INTOXICATION

 Abrupt irrational combative behaviour , after taking small amounts of

Alcohol that would have minimal behavioural effects on most persons.
 Its is called as acute alcohol paranoid state/idiosyncratic
intoxication/manie a potu
ALCOHOLIC BLACKOUTS

 Dense amnesia for significant events that have occurred during a drinking
episode.
 Alcohol interferes with the transfer of information from short term to long
term storage
WITHDRAWAL SEIZURES

 Alcohol can precipitate seizures in a person suffering from epilepsy .

 Withdrawal seizures : 12-48hr of the termination of long continued bout.
 Usually generalized tonic clonic seizures.
 EEG-abnormal at time of seizures.
 High risk of progression to delirium tremens.
DELIRIUM TREMENS
 Delirium tremens is the most severe form alcohol withdrawal .
 MEDICAL EMERGENCY
 Hospitalise
 Full blown DT: profound confusion, vivid hallucinations, marked tremor,
agitation, sleeplessness and autonomic disturbances.
 Presence of hallucination with two of the following: confusion and
disorientation, tremulousness, increased PMA, fearfulness and signs of
autonomic disturbance.
Risk factors

 Daily heavy and prolonged ethanol consumption

 Severe withdrawal symptoms at presentation
 Intense craving for alcohol
 Older age
 Past history of DT
 Withdrawal seizures
 Presence of acute medical comorbidity, especially infections
etiology

 A primary disorder of the reticular formation is strongly suggested by the

clinical components of profound inattention coupled with alertness,
overactivity and insomnia.

 Cerebral blood flow studies :

increased CNS excitability during the course of delirium.

 Withdrawal of alcohol
treatment

 Best treatment is prevention.

 In terms of slow bolus dose of IV diazepam 5-10mg or IV lorazepam 2-4 mg
 CIWA-Ar >20: give bolus  monitor every 10-20 min  repeat every time till
CIWA-Ar <10
 CIWA-Ar <10: monitor every 1-2 hour for 12 hours
 Aim is to sedate the patient
 Antipsychotic medication should be avoided
 Supportive care:
Correct dehydration
Environmental reorientation measures.
 WERNICKE’S ENCEPHALOPATHY

 It is an acute complication due to severe thiamine deficiency.

 Characterised by nystagmus, abducens and conjugate gaze palsies,

ataxia of gait, and global confusional state.

 Role of thiamine:
Thiamine is phosphorylated to TPP, which acts as a coenzyme.
INVESTIGATIONS

 EEG: asynchronous slow waves and often also causes bisynchronous slow
waves.

 CSF: mild elevation of protein

 CT: symmetrical areas of decreased attenuation in the region of the

thalamus

 MRI: atrophy of the mamillary bodies

hyperintensities surrounding the third ventricle
TREATMENT

 Acute medical emergency.

 Pabrinex is usually employed intravenously in place of thiamine alone.
 Inj.Pabrinex(thiamine hydrochloride250 mg, nicotinamide 160 mg, ribofl
avine 4 mg,
pyridoxine hydrochloride 50 mg and ascorbic acid 500 mg) twice daily for
atleast 5 days.

 Oral vitamin supplements are usually continued for

several weeks after the acute illness has resolved .(3 months)
 If delayed nicotinic acid deficiency encephalopahy must be considered.
KORSAKOFF’S SYNDROME

 Korsakoff’s syndrome is an amnestic syndrome caused by thiamine

deficiency.

 Clinical features:
anterograde and retrograde amnesia., confabulation.

 Neuroimaging findings:

 CT: cortical shrinkage and ventricular dilatation.
atrophy in frontal sulcal and perisylvian areas
Contd..

 MRI: loss of grey matter in the medial temporal and orbitofrontal cortex

 FDG-PET : hypometabolism present in numerous cortical areas ,

involvement of the thalamus and basal ganglia

 Treatment:
thiamine replacement
iv thiamine 500mg,2-3 times/day for 3-5 days.
oral T.thiamine 100mg/day. Amnesia, apathy and may not improve
ALCOHOLIC COGNITIVE IMPAIRMENT

 Long term cognitive problem that can develop in course of AUD-alcohol

induced persisting dementia

 Global decrease in intellectual function, cognitive abilities and memory,

psychomotor speed, visuospatial competence and new learning ability.

 CT: enlarged ventricles and shrinkage of cerebral sulci, widening of gyri

and fissures.

 MRI: reduction in grey matter in medial temporal, superior frontal, and

parietal regions, sub cortical grey matter.
CEREBELLAR DEGENERATION

 Ataxia most common feature. Hands less involved. Nystagmus , dysarthria less
common.
 May be asymptomatic
 CT/ MRI: cerebellar cortical atrophy
 FDG-PET: hypometabolism in superior cerebellar vermis

STROKE
 Increase in LDL (type hyper lipidemia)
 Increase in cholesterol, triglycerides
 Increased BP
MARCHIFAVA– BIGNAMI DISEASE
 Cause: demyelination of corpus callosum.

 Clinical features:
ataxia, dysarthria ,epilepsy ,
severe impairment of consciousness.
• slowly progressive form :dementia and spastic paralysis of limbs.

 Investigation:
 CT & MRI: characteristic finding of demyelination in corpus callosum
CENTRAL PONTINE MYELINOSIS

 acute and often fatal complication of alcoholism.

 Clinical features:
obtundation ,bulbar palsy, quadriplegia &
loss of pain sensation in limbs and trunk.
Vomiting ,confusion ,disordered eye movements.

 Location: lesion at center of basis pontis

 MRI: focus of demyelination
PERIPHERAL NEUROPATHY

 Cause: deficiency of thiamine, pyridoxine and pantothenic acid.

 Clinical features: sensory ataxia, foot drop, cutaneous sensory loss.

 Treatment: vitamin supplementation

AMBLYOPIA

 retrobulbar neuritis.
 Clinical features:
dimness of central vision ,especially for red & green.
 Acute blindness-methyl alcohol consumption
GASTROINTESTINAL SYMPTOMS

 ACUTE HAEMORRHAGIC GASTRITIS AND ESOPHAGITIS (acute)

 MALLORY- WEISS TEARS (acute)
 ACUTE PANCREATITIS
 CHRONIC PANCREATITIS
 STEATOHEPATITIS TO CIRRHOSIS TO HEPATIC ENCAPHALOPATHY (chronic)
 Most common cause of hemorrhagic gastritis

 Violent vomiting leads to longitudinal tear in mucosa in gastroesophageal

junction.

 Acute pancreatitis: abdominal pain radiating to back, nausea and

vomiting , anorexia . H/o binging on alcohol

 Chronic pancreatitis: most common cause of chronic pancreatitis in adults.

May occur After repeated bouts of acute pancreatitis. Pseudocyst may be
present, may lead to diabetes.
 Contd…

 Steatohepatitis: AST > ALT

decreased beta
impaired increased lactate fat deposition
oxidation of fatty
gluconeogenesis production inside hepatocytes
acid

 Alcoholic hepatitis: immunologically mediated, interleukins are implicated.

Severe alcoholic hepatitis treated with prednisone or prednisolone or
pentoxyphylline.
HEPATIC ENCEPHALOPATHY

 Etiology: brain edema, gut derived

neurotoxins and ammonia

 Impaired consciousness, personality

changes, sleep disturbances,
asterixis.

 Treatment: taking care of

precipitating factors: like GI bleed,
SBP, infections etc.
 lactulose, metronidazole,
neomycin, rifaximin, zinc
supplementation.
CARDIOVASCULAR SYSTEM

 MYOCARDIAL INFARCTION: increased risk of cardio vascular diseases due

to impaired lipid profile.

 CARDIOMYOPATHY: direct effect of alcohol on myocardium. Dilatation of

all the 4 chambers of heart leading to pump failure.

 PAROXYSMAL TACHYCARDIA: atrial or ventricular arrhythmias with no

apparent evidence of heart disease. Holiday heart syndrome
HAEMATOPOIETIC SYSTEM

 INCREASED MCV: folic acid deficiency, cholesterol deposition in rbc

membrane, sideroblastic changes in marrow

 DECREASED IMMUNE FUNCTIONS: decreased production of WBCs,

decreased granulocyte mobility and adherence. Decreased delayed
hypersensitivity reaction.

 THROMBOCYTOPENIA: idiopathic, hypersplenism

GENITOURINARY SYSTEM

 DECREASED ERECTILE CAPACITY : increased sexual drive, but decreased

erectile capacity

 TESITICULAR ATROPHY :even in absence of ALD, irreversible shrinkage of

testis, with shrinkage of seminiferous tubules, decreased ejaculate volume
and low sperm count.

 INFERTILITY IN WOMEN: decreased ovarian size and absence of corpora

lutea

 INCREASED RISK OF SPONTANEOUS ABORTIONS

CANCERS

 INCREASED RISK OF BREAST CANCER

 ESOPHAGEAL CANCER
 RECTAL CANCER
 STOMACH CANCER
 COLON CANCER
 LIVER CANCER
 CANCERS OF HEAD AND NECK
 LUNG CANCER

 Cancer promoting action of alcohol and acetaldehyde impairing immune

homeostasis
 FETAL ALCOHOL SYNDROME
 INCIDENCE: 0.2-1.5 cases per 1000 live
birth (in some studies)
 5% of children born to heavy drinking
mother.
 LOW IQ
 SMALL HEAD
 LBW WITH FACIAL ANOMALIES
 ASDs or VSDs

FETAL ALCOHOL SPECTRUM

DISORDER:
 MODEST COGNITIVE DEFICITS
 HYPERACTIVITE BEHAVIOR
 LOW IQ
OTHERS

 ALCOHOLIC MYOPATHY: direct effect of alcohol. Might not remit fully on

abstinence.
 HORMONAL CHANGES: increased cortisol levels, decreased T3 and T4.
 EFFECTS ON SKELETAL SYSTEM: low bone mineral density
 CATARACTS
 BERIBERI: thiamine deficiency
 HYPOGLYCEMIA
CONCLUSION

 Alcohol - one of the most common substance of abuse

 Complications can occur due to acute binge intake or chronic alcohol
intake and due to withdrawal.
 Affects various systems of the body
REFERENCES

 Kaplan & sadocks comprehensive textbook of psychiatry.10th edition.

 Lishman’s organic psychiatry.
 Harrison’s principles of internal medicine 19th edition.
THANK YOU