Alcoholism - Diagnosis and Assessment

Alcohol use is prevalent in the UK and it is estimated that 90% of adults consume alcohol. 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 adults, and the risk for alcohol dependence increases with binge drinking.^1,2

1 in 16 hospital admissions are due to alcohol related illness.¹

Between 15,000 to 20,000 deaths per year are associated with alcohol; this includes cancer, liver disease and accidental injury.
The more that is drunk the more is the risk of illnesses e.g. oesophageal cancer. The risk increases once take more than three drinks per day.^1,2

The recommended maximum intake is 21 units for men and 14 units a week for a woman.

• Liver: alcoholic hepatitis, cirrhosis, liver cancer³
• 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, wernickes-Korsakoff syndrome and cerebellar degeneration
• Miscellaneous:
  • Loss of libido
  • Impaired performance at work
  • Damage to foetus in pregnant women
  • Psychiatric disorders e.g. alcohol dependence syndrome and suicide.

Key point: always ask about alcohol use in all settings and have a high index of suspicion.

In primary care and hospital settings - use the CAGE questionnaire, scoring one point for each:

• Do you feel the need to cut-down?
• Do you get angry if anyone comments on your alcohol intake?
• Do you feel guilty about drinking?
• Do you need an eye-opener?

If score > 2 then specificity is 90%, but as score increases the specificity improves but sensitivity reduces.⁴
There are also other questionnaires, such as AUDIT, a ten point scale to detect patients with excessive alcohol intake.⁵
Often routine blood results may show coincidental macrocytosis or abnormal LFTs which should make you suspicious.

This involves two main aspects:

• Is their alcohol intake a problem?
• Do they have any illnesses relating to their alcohol intake?

• Amount of consumption
• Are they dependent on alcohol? Do you need a drink everyday? What time to your first drink?
• Has any one expressed concerns about your alcohol intake?
• Alcohol dependence:
  • Strong desire to drink
  • Difficulty controlling alcohol intake
  • Physiological withdrawal when reduce intake
  • Tolerance; such that increasing amounts required to produce the same effect
  • Harm resulting from alcohol use e.g. work, relationships
• Alcohol withdrawal
  • Symptoms begin within few hours of not having a drink and can last beyond 48 hours.
  • Hyperactivity, anxiety and coarse peripheral tremor
  • Mild pyrexia, tachycardia and hypertension
  • Sweating, nauseas and retching
  • Seizures
  • Auditory and visual hallucinations
  • Delirium tremens is the severe end of the spectrum of withdrawal and consists of severe forms of the above symptoms and may be associated with circulatory collapse and ketoacidosis.⁶

• History - include features as above
• Examination:
  • General demeanour, ethanolic or hepatic foeter
  • Malnourishment
  • Signs of acute withdrawal such as coarse tremor and tachycardia
  • Signs of liver disease, such as, palmar erythema, gynaecomastia, spider naevi and jaundice⁷
  • Hepatomegaly (in chronic alcoholic liver disease the liver is shrunken)
  • Ascites, gonadal atrophy
  • Atrial fibrillation and cardiomyopathy
  • Wernicke-Korsakoff (ataxia, confusion, ophthalmoplegia), amnesic problems, peripheral neuropathy and dementia

• Alcohol level is useful in acute comatose state.
  • Alcohol level > 300 mg/100ml extreme intoxication (see drowsiness and then coma).
  • Levels > 400 mg/100ml may be fatal.
• Full blood count, clotting screen, renal and liver function tests:
  • Suspect excessive alcohol use if MCV raised and platelet count may be decreased or elevated liver enzymes. (Gamma GT is the best indicator of excessive alcohol consumption).
  • Chronic alcohol consumption may also be associated with dyslipidaemia, notably hypertriglyceridaemia.
  • Also check fasting glucose as chronic pancreatitis can lead to diabetes mellitus.

• Be honest and non-judgemental
• Many patients drink in secret and may not want to discuss the issue.
• Patient needs to accept that there is a problem before therapy can start.
• Detoxification should be discussed.
• Information regarding local alcoholic anonymous groups.

Some studies suggest that light drinking - small amounts infrequently, reduces the risk of coronary heart disease.^8,9 But these studies were confined to certain groups of patients and may not be easily generalised to include all patients. Other studies suggest that actually alcohol is harmful and increases cardiovascular risk.¹⁰