Alcohol Related Problems

See related articles:

Alcoholism - Recognition and Assessment
Alcoholism and Alcohol Abuse - Management

Alcohol use is prevalent in the UK and it is estimated that 90% of adults consume alcohol.

The recommended maximum intake a week is 21 units for men and 14 units for women. In 2006 knowledge of daily benchmarks and measuring alcohol in units had increased among both men and women. The proportion of adults who had heard of daily benchmarks increased from 54% in 1997 to 69%.¹

The amount of alcohol consumed has increased over the years and the increase is greater in women. There is also a rise in binge drinking - usually in the younger adult, and the risk for alcohol dependence increases with binge drinking.^2,3,4

1 in 16 hospital admissions are due to alcohol related illnesses.² The more that is drunk, the greater the risk of illnesses such as oesophageal cancer. The risk especially increases once alcohol intake exceeds more than 3 drinks per day.⁴
70% of all admissions to A + E departments per year during busy episodes.⁵

Younger people were more likely than older people to exceed the daily benchmarks:¹

• Over 42% of young men aged 16 to 24 had exceeded 4 units on at least one day during the previous week.
• This compares with 16% of men aged 65 and over.
• 36% of women in the youngest age group had exceeded 3 units on at least one day compared with only 4% of those aged 65 and over.

The recent upward trend in heavy drinking among young women may have peaked. The proportion of 16 to 24 year old women who had drunk more than 6 units on at least one day in the previous week had fallen to 22% in 2005.

Alcohol misuse accounts for more than 20,000 premature deaths per year, this includes cancer, liver disease and accidental injury.
There were 8,724 alcohol related deaths in 2007, lower than 2006, but more than double the 4,144 recorded in 1991.⁶
The alcohol-death rate is on the increase with 13.4 deaths per 100,000 population in 2006, representing a doubling since 1991.⁶ The risk increases once intake exceeds more than 3 drinks per day.⁴

These result from continued use of excessive amounts of alcohol. Binge drinking and chronic drinking of alcohol are more likely to cause harm.⁷

Medical problems

• Liver: alcoholic hepatitis, cirrhosis, liver cancer.
• Gastrointestinal tract: oral cavity cancer, oesophageal neoplasm, oesophageal varices, pancreatitis.
• Cardiovascular system: atrial fibrillation, hypertension, strokes and cardiomyopathy with heart failure.
• Neurological system: acute intoxication with loss of consciousness, withdrawal, seizures, subdural haemorrhage, peripheral neuropathy, Wernicke-Korsakoff syndrome and cerebellar degeneration.

Psychiatric problems

• Alcohol dependence syndrome
• Suicidal ideation
• Depression
• Anxiety

Miscellaneous

• Loss of libido
• Fetal alcohol syndrome - see related record

• Impaired performance at work
• Relationship problems
• Violent crimes e.g. domestic violence and drink driving offences⁷
• Anti-social behaviour

Affects of alcohol on the liver

• Alcoholic liver disease includes fatty liver, alcoholic hepatitis and cirrhosis. These three conditions probably represent a spectrum of liver damage resulting from continued abuse of alcohol.⁸
  • In fatty liver there is an accumulation of fat within the hepatocytes. This is reversible with abstention from alcohol.
  • Alcoholic hepatitis presents as acute right upper quadrant (RUQ) pain with jaundice, fever and marked derangement of liver function tests. At a microscopic level there is inflammation of the liver.
  • In liver cirrhosis the hepatocytes are damaged so much that they are replaced by scar tissue which is permanent. Alcoholic hepatitis and cirrhosis may co-exist.⁹
  Alcoholic hepatitis and cirrhosis may lead to encephalopathy, portal vein hypertension and hepato-renal syndrome. This group of patients is also at increased risk of infections and they are usually also malnourished.
• Treatment involves abstinence from alcohol and good nutrition. There is no specific therapy for alcohol related hepatitis and cirrhosis. It is important to look for, and promptly treat, the complications which include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy and oesophageal varices.⁹
• Patients with ascites may need to be maintained on high doses of diuretics. Again, abstinence from alcohol is crucial.

Affects of alcohol on the gastrointestinal tract

• Alcohol increases the risk of oral cancers. This is especially associated with spirits and the risk is increased with concomitant use of tobacco. Adenocarcinoma of the stomach and oesophagus is thought to be related to alcohol use - although some studies have failed to show a positive association.¹⁰
• Portal hypertension is a complication of cirrhosis and leads to a raised venous pressure in veins in the oesophagus and stomach. These swollen veins are superficial and bleed easily. Bleeding from oesophageal varices is serious and is associated with a high level of morbidity and mortality.¹¹
  Management of bleeding varices is a medical emergency and requires adequate resuscitation (patients may need to be intubated to protect their airway). Blood transfusions are necessary and correction of abnormal clotting with vitamin K and fresh frozen plasma (FFP) may also be required.
• Both acute and chronic pancreatitis are associated with excessive alcohol consumption.¹² The pathophysiology of alcohol related pancreatitis is not clearly understood. Patients usually present with epigastric pain with vomiting. The amylase is high in acute pancreatitis but may be normal in patients with chronic pancreatitis. Pancreatitis can be associated with a number of complications such as shock, sepsis and abscess formation. Long-term complications include diabetes mellitus and weight loss from steatorrhoea.

Affects of alcohol on the cardiovascular system

• Excessive alcohol use is associated with hypertension and subsequent target organ damage such as strokes, myocardial events and renal failure.³
• It is also associated with a dilated cardiomyopathy with heart failure and atrial fibrillation which may revert to sinus rhythm.³

Again, abstinence from alcohol is paramount.

Affects of alcohol on the nervous system

• Acute alcohol intoxication can present with blackouts, head injuries and subdural haemorrhages. Alcohol withdrawal is associated with fits which may be unresponsive to anti-epileptics.
• The Wernicke-Korsakoff syndrome results from lack of thiamine (commonly seen in alcoholics due to malnutrition). Wernicke's syndrome occurs acutely and patients present with confusion, visual impairment (diplopia) and ataxia. Korsakoff's syndrome occurs more chronically and is characterised by memory deficits and confabulation may occur.

Alcohol withdrawal occurs within a few hours of not having a drink and can last beyond 48 hours. Patients experience hallucinations, anxiety and a coarse peripheral tremor. On examination patients may be pyrexial, tachycardic and hypertensive. They may also develop seizures and auditory and visual hallucinations.³

Delirium tremens is the severe end of the spectrum of alcohol withdrawal and consists of a severe form of the above symptoms and may be associated with circulatory collapse and ketoacidosis.¹³

This is characterised by the following:

• A strong desire to drink.
• Difficulty controlling alcohol intake.
• Physiological withdrawal when intake reduced.
• Tolerance, such that increasing amounts are required to produce the same effect.
• Harm resulting from continued alcohol use e.g. work or relationship problems.

Treatment of alcohol dependence includes education, support and counselling. Patients may need to be admitted to hospital for detoxification.

1. National Statistics. Drinking. November 2006.
2. IAS Factsheet; Institute of Alcohol Studies;Alcohol and Health
3. Rehm J, Gmel G, Sempos CT, et al; Alcohol-related morbidity and mortality.; Alcohol Res Health. 2003;27(1):39-51. [abstract]
4. NICE/Health Development Agency; Prevention and reduction of alcohol misuse - Evidence briefing (2nd edition), March 2005
5. Alcohol Harm Reduction Strategy for England - Cabinet Office UK
6. Office for National Statistics; Alcohol Deaths; Jan 2008.
7. Burge SK, Schneider FD; Alcohol-related problems: recognition and intervention.; Am Fam Physician. 1999 Jan 15;59(2):361-70, 372. [abstract]
8. Mann RE, Smart RG, Govoni R; The epidemiology of alcoholic liver disease.; Alcohol Res Health. 2003;27(3):209-19. [abstract]
9. Marsano LS, Mendez C, Hill D, et al; Diagnosis and treatment of alcoholic liver disease and its complications.; Alcohol Res Health. 2003;27(3):247-56. [abstract]
10. Lagergren J; Adenocarcinoma of oesophagus: what exactly is the size of the problem and who is at risk? Gut. 2005 Mar;54 Suppl 1:i1-5. [abstract]
11. Samonakis DN, Triantos CK, Thalheimer U, et al; Management of portal hypertension.; Postgrad Med J. 2004 Nov;80(949):634-41. [abstract]
12. Schneider A, Singer MV; Alcoholic pancreatitis.; Dig Dis. 2005;23(3-4):222-31. [abstract]
13. McIntosh C, Chick J; Alcohol and the nervous system.; J Neurol Neurosurg Psychiatry. 2004 Sep;75 Suppl 3:iii16-21.