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Clinical Summary

It is estimated that between 4% and 40% of all medical and surgical patients experience problems related to alcohol. It well known that alcohol use contributes significant to morbidity and mortality, and it is estimated that roughly 1 in 10 deaths among working-age adults results from excessive alcohol use. DSM-5 characterizes alcohol use disorder as a problematic pattern of use leading to clinically significant impairment or distress, as manifested by multiple psychosocial, behavioral, or physiologic features. Clinical manifestations of alcohol abuse may present in all organ systems, although advanced liver disease is a hallmark of long-term alcohol abuse. Skin changes such as palmar erythema (Fig. 27.19) and spider angioma (Video 27.1) are thought to develop due to increased circulating levels of estrogen due to inadequate hepatic metabolism of steroid hormones. Asterixis, also coined “liver flap,” is a type of negative myoclonus seen in advanced liver disease (Video 27.2). Conjunctival icterus may be seen when circulating serum bilirubin levels rise above 3 mg/dL in the setting of liver disease (Fig. 27.21). Alcohol is an indirect γ-aminobutyric acid (GABA) agonist, and when removed, symptoms of central nervous stimulation dominate, including agitation, tremulousness, hypertension, diaphoresis, and, when severe, seizures.

FIGURE 27.19

Alcohol Use Disorder—Palmar Erythema. Patient with alcohol-related cirrhosis and palmar erythema. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.20

Alcohol Use Disorder—Spider Angioma. Spider angioma, typically located on the upper chest, are seen in patients with cirrhosis due to impaired estrogen metabolism and increased serum vascular endothelial growth factor. (Photo contributor: R. Jason Thurman, MD.)

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Video 27-01: Alcohol Use Disorder: Spider Angioma

(Video Contributor: Max Hensel, MD)

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Video 27-02: Alcohol Use Disorder: Asterixis

(Video Contributor: Lawrence B. Stack, MD)

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FIGURE 27.21

Alcohol Use Disorder—Conjunctival Icterus. Icterus (jaundice) is seen in this patient’s skin and conjunctiva due to advanced cirrhosis due to chronic alcohol use. (Photo contributor: Lawrence B. Stack, MD.)

Management and Disposition

Treatment for acute alcohol intoxication is largely supportive. Benzodiazepines are the mainstay of treatment for alcohol withdrawal, with diazepam as the preferred benzodiazepine due to its long half-life. Long-term alcohol abuse may affect all organ systems, and thus, therapy should be directed at the presenting symptoms and affected organ system. Long-term alcohol use is also associated with vitamin deficiencies. Folate and thiamine supplementation should be considered along with glucose supplementation in patients suspected of long-term alcohol abuse to prevent Wernicke encephalopathy.

Pearls

  1. Treatment for acute intoxication is supportive, addressing ...

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