Alcoholism and Alcohol Abuse | Substance Abuse Problems

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Substance Abuse Problems

Table of Contents

1. Alcohol dependence
2. Health risks of alcohol use
3. Alcohol use disorder
4. Serum ketones test
5. Breath alcohol test
6. Helping a loved one with a drinking problem
7. Alcohol withdrawal
8. Beriberi
9. When you are drinking too much - tips for cutting back
10. Alcoholic ketoacidosis
11. Deciding to quit drinking alcohol
12. Delirium tremens
13. Alcoholic liver disease
14. Central pontine myelinolysis
15. Alcoholic neuropathy
16. Pellagra
17. Wernicke-Korsakoff syndrome
18. Ethanol poisoning

01.- Alcohol dependence

For most adults, moderate alcohol use is probably not harmful. However, about 18 million adult Americans have an alcohol use disorder. This means that their drinking causes distress and harm. It includes alcoholism and alcohol abuse.
Alcoholism, or alcohol dependence, is a disease that causes
• Craving - a strong need to drink
• Loss of control - not being able to stop drinking once you've started
• Physical dependence - withdrawal symptoms
• Tolerance - the need to drink more alcohol to feel the same effect
With alcohol abuse, you are not physically dependent, but you still have a serious problem. The drinking may cause problems at home, work, or school. It may cause you to put yourself in dangerous situations, or lead to legal or social problems.
Another common problem is binge drinking. It is drinking about five or more drinks in two hours for men. For women, it is about four or more drinks in two hours.
Too much alcohol is dangerous. Heavy drinking can increase the risk of certain cancers. It can cause damage to the liver, brain, and other organs. Drinking during pregnancy can harm your baby. Alcohol also increases the risk of death from car crashes, injuries, homicide, and suicide.
If you want to stop drinking, there is help. Start by talking to your health care provider. Treatment may include medicines, counseling, and support groups.
NIH: National Institute on Alcohol Abuse and Alcoholism

02.- Health risks of alcohol use

Beer, wine, and liquor all contain alcohol. If you are drinking any of these, you are using alcohol. Your drinking patterns may vary, depending on who you are with and what you are doing.
You probably already know that drinking too much can cause many health problems. But even responsible drinking patterns can lead to health issues and other problems in your everyday life.

Alternative names

Alcoholism - risks; Alcohol abuse - risks; Alcohol dependence - risks; Risky drinking - risks

Alcohol use and your health

Long-term use of alcohol increases your chances of:
• Bleeding from the stomach or esophagus (the tube the food travels through from your mouth to your stomach).
• Swelling and damage to the pancreas. Your pancreas produces substances your body needs to work well.
• Damage to the liver. When severe, liver damage often leads to death.
• Poor nutrition.
• Cancer of the esophagus, liver, colon, head and neck, breasts, and other areas.
Even responsible drinking can lead to high blood pressure in some people.
• If you already have high blood pressure, drinking can make it harder to control with medicines.
• Using alcohol for a long time can lead to high blood pressure, which can then cause the heart to weaken and become enlarged.
Alcohol can affect your thinking and judgment each time you drink. Long-term alcohol use damages brain cells. This can lead to lasting damage to your memory, thinking, and the way you behave.
Damage to nerves from alcohol use can cause many problems, including
• Numbness or a painful "pins and needles" feeling in your arms or legs.
• Problems with erections in men.
• Leaking urine or having a hard time passing urine.
Drinking during pregnancy can harm the growing baby. Severe birth defects or fetal alcohol syndrome (FAS) may occur.

How alcohol use can affect your life

Oftentimes, people drink to make themselves feel better or to block feelings of sadness, depression, nervousness, or worry. But alcohol can:
• Make these problems worse over time
• Cause sleep problems or make them worse
• Increase the risk of suicide
Families are often affected when someone in the home uses alcohol. Violence and conflict in the home is much more likely when a family member is abusing alcohol. Children who grow up in a home where alcohol abuse is present are more likely to:
• Do poorly in school
• Be depressed and have problems with anxiety and low self-esteem
• Have marriages that end in divorce
Drinking too much alcohol even once can harm you or others. It can lead to:
• Car accidents
• Risky sex habits, which may lead to unplanned or unwanted pregnancy, sexually transmitted infections (STIs), and sexual assault or rape
• Falls, drowning, and other accidents
• Suicide
• Violence and homicide

What you can do

First, ask yourself what type of drinker you are?
Even if you are a responsible drinker, drinking too much just once can be harmful.
Be aware of your drinking patterns. Learn ways to cut back on drinking.
If you cannot control your drinking or if your drinking is becoming harmful to yourself or others, seek help from:
• Your doctor
• Support and self-help groups for people who have drinking problems

References

American Psychiatric Association.Diagnostic and statistical manual of mental disorders
National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder: a comparison between DSM-IV and DSM-5. November 2013. http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.pdf.Accessed on May 11, 2014.
O'Connor PG. Alcohol abuse and dependence. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine
Sherin K, Seikel S. Alcohol use disorders. In: Rakel RE, Rakel DP, eds.Textbook of Family Medicine

03.- Alcohol use disorder

Alcohol use disorder is when your drinking causes serious problems in your life, yet you keep drinking. You may also need more and more alcohol to feel drunk. Stopping suddenly may cause withdrawal symptoms.

Causes

No one knows what causes problems with alcohol. Health experts think that it may be a combination of a person's:
• Genes
• Environment
• Psychology, such as being impulsive or having low self-esteem
Drinking a lot of alcohol can put you at risk for alcohol problems if:
• You are a man who has 15 or more drinks a week, or often have 5 or more drinks at a time
• You are a woman who has 12 or more drinks a week, or often have 4 or more drinks at a time
One drink is defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1 1/2-ounce shot of liquor.
If you have a parent with alcohol use disorder, you are more at risk for alcohol problems.
You also may be more likely to have problems with alcohol if you:
• Are a young adult under peer pressure
• Have depression, bipolar disorder, anxiety disorders, or schizophrenia
• Can easily obtain alcohol
• Have low self-esteem
• Have problems with relationships
• Live a stressful lifestyle
If you are concerned about your drinking, it may help to take a careful look at your alcohol use.

Symptoms

Doctors have developed a list of symptoms that a person has to have in the past year to be diagnosed with alcohol use disorder.
Symptoms include:
• Times when you drink more or longer than you planned to
• Wanted to, or tried to, cut down or stop drinking, but could not
• Spend a lot of time and effort to get alcohol, use it, or recover from its effects
• Crave alcohol or have a strong urge to use it
• Alcohol use is causing you to miss work or school, or you do not perform as well because of drinking
• Continue to drink, even when relationships with family and friends are being harmed
• Stop taking part in activities that you used to enjoy
• While or after drinking, you get into situations that can cause you to get hurt, such as driving, using machinery, or having unsafe sex
• Keep drinking, even though you know it is making a health problem caused by alcohol worse
• Need more and more alcohol to feel its effects or to get drunk
• You get withdrawal symptoms when the effects of alcohol wear off

Exams and Tests

Your health care provider will:
• Examine you
• Ask about your medical and family history
• Ask about your alcohol use, and if you have any of the symptoms listed above
Your provider may order tests to check for health problems that are common in people who use alcohol. These tests may include:
• Blood alcohol level (This shows if you have recently been drinking alcohol. It does not diagnose alcohol use disorder.)
• Complete blood count
• Liver function tests
• Magnesium blood test

Treatment

Many people with an alcohol problem need to completely stop using alcohol. This is called abstinence. Having strong social and family support can help make it easier to quit drinking.
Some people are able to just cut back on their drinking. So even if you do not give up alcohol altogether, you may be able to drink less. This can improve your health and relationships with others. It can also help you perform better at work or school.
However, many people who drink too much find they cannot just cut back. Abstinence may be the only way to manage a drinking problem.
DECIDING TO QUIT
Like many people with an alcohol problem, you may not recognize that your drinking has gotten out of hand. An important first step is to be aware of how much you drink. It also helps to understand the health risks of alcohol.
If you decide to quit drinking, talk with your health care provider. Treatment involves helping you realize how much your alcohol use is harming your life and the lives those around you.
Depending on how much and how long you have been drinking, you may be at risk for alcohol withdrawal. Withdrawal can be very uncomfortable and even life-threatening. If you have been drinking a lot, you should cut back or stop drinking only under the care of a doctor. Talk with your health care provider about how to stop using alcohol.
LONG-TERM SUPPORT
Alcohol recovery or support programs can help you stop drinking completely. These programs usually offer:
• Education about alcohol use and its effects
• Counseling and therapy to discuss how to control your thoughts and behaviors
• Physical health care
For the best chance of success, you should live with people who support your efforts to avoid alcohol. Some programs offer housing options for people with alcohol problems. Depending on your needs and the programs that are available:
• You may be treated in a special recovery center (inpatient)
• You may attend a program while you live at home (outpatient)
You may be prescribed medicines to help you quit. They are often used with long-term counseling or support groups. These medicines make it less likely that you will drink again or help limit the amount you drink.
Drinking may mask depression or other mood or anxiety disorders. If you have a mood disorder, it may become more noticeable when you stop drinking. Your health care provider will treat any mental disorders in addition to your alcohol treatment.

Support Groups

Support groups help many people who are dealing with alcohol use.
ALCOHOLICS ANONYMOUS (AA)
Alcoholics Anonymous is a self-help group of persons recovering from alcohol use. Meetings offer emotional support and specific steps toward recovery. The program is commonly called a "12-step" approach. There are local chapters throughout the U.S. AA offers help 24 hours a day.
AL-ANON
Family members of a person with an alcohol problem often benefit from talking with others. Al-Anon is a support group for people who are affected by another person's drinking problem.
Alateen provides support for teenage children of people with alcohol use disorder.
OTHER SUPPORT GROUPS
Several other support groups are available.
• SMART recovery teaches ways to change thoughts and behaviors to help people recover from alcohol use disorder.
• LifeRing recovery and Secular Organizations for Sobriety (SOS) are two non-religious programs that offer support for people with alcohol use disorder.
• Women for Sobriety is a self-help group just for women.
• Moderation Management is a program for those who want to reduce how much they drink. It recommends abstinence for people who cannot do this.

Outlook (Prognosis)

How well a person does depends on whether they can successfully cut back or stop drinking.
It may take several tries to stop drinking for good. If you are struggling to quit, do not give up hope. Getting treatment, if needed, along with support and encouragement from support groups and those around you can help you remain sober.

Possible Complications

Alcohol use disorder can increase your risk of many health problems, including:
• Bleeding in the digestive tract
• Brain cell damage
• A brain disorder called Wernicke-Korsakoff syndrome
• Cancer of the esophagus, liver, colon, and other areas
• Changes in the menstrual cycle
• Delirium tremens (DTs)
• Dementia and memory loss
• Depression and suicide
• Erectile dysfunction
• Heart damage
• High blood pressure
• Inflammation of the pancreas (pancreatitis)
• Liver disease, including cirrhosis
• Nerve damage
• Poor nutrition
• Sleeping problems (insomnia)
• Sexually transmitted infections (STIs)
Alcohol use also increases your risk for violence.
Drinking alcohol while you are pregnant can lead to severe birth defects in the baby. This is called fetal alcohol syndrome.

When to Contact a Medical Professional

Talk with your doctor if you or someone you know may have an alcohol problem.
Seek immediate medical care or call your local emergency number (such as 911) if you or someone you know has an alcohol problem and develops severe confusion, seizures, or bleeding.

Prevention

The National Institute on Alcohol Abuse and Alcoholism recommends:
• Women should not drink more than 1 drink per day
• Men should not drink more than 2 drinks per day

Alternative Names

Alcohol dependence; Alcohol abuse; Problem drinking; Drinking problem; Alcohol addiction

References

American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.
Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. CDC Vital Signs: Alcohol Screening and Counseling. January 2014. Available athttp://www.cdc.gov/vitalsigns/pdf/2014-01-vitalsigns.pdf
National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder: A Comparison Between DSM-IV and DSM-5. November 2013. Available at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.pdf
National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder. Available athttp://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders
O'Connor PG. Alcohol abuse and dependence. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine.
Sherin K, Seikel S. Alcohol use disorders. Rakel RE, Rakel DP, eds.Textbook of Family Medicine.
U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Available at http://www.uspreventiveservicestaskforce.org/uspstf12/alcmisuse/alcmisuserfinalrs.htm

04.- Serum ketones test

Ketones are substances produced in the liver when fat cells break down in the blood. A serum ketone test is a measurement of how many ketones are in the blood.

How the Test is Performed

Blood is most often drawn from a vein. The vein usually used is on the inside of the elbow or the back of the hand.
Theprocedure is done in the following way:
• The site is cleaned with germ-killing medicine (antiseptic).
• The health care provider wraps an elastic band around the upper arm to apply pressureto the area and make the vein swell with blood.
• The health care provider gently inserts a needle into the vein.
• The blood collects into an airtight vial or tube attached to the needle.
• The elastic band is removed from your arm.
• The needle is removed.
• The puncture site is covered to stop any bleeding.
In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it bleed. The blood collects into a small glass tube called a pipette, or onto a slide or test strip. Afterward, a bandage may be placed over the area if there is any bleeding.

How to Prepare for the Test

No preparation is needed.

How the Test Will Feel

When the needle is inserted to draw blood, you may feel slight pain or only a prick or stinging. Afterward, there may be some throbbing.

Why the Test is Performed

This test is used to diagnose ketoacidosis.

Normal Results

A normal test result would be negative, meaning there are no ketones in the blood.
Normal value ranges may vary slightly among different laboratories. Talk to your health care provider about the meaning of your specific test results.

What Abnormal Results Mean

A test result is positive if ketones are found in the blood. This may indicate:
• Alcoholic ketoacidosis
• Diabetic ketoacidosis
• Starvation
• Uncontrolled blood glucose in diabetics

Risks

Veins and arteries vary in size from one patient to another and from one side of the body to the other. Drawing blood from some people may be more difficult than from others.
Other risks associated with having blood drawn are slight but may include:
• Excessive bleeding
• Fainting or feeling light-headed
• Hematoma (blood accumulating under the skin)
• Infection (a slight risk any time the skin is broken)

Considerations

A diet low in carbohydrates can increase ketones.

Alternative Names

Acetone bodies; Ketones - serum; Nitroprusside test; Ketone bodies - serum; Ketones - blood

References

Khan MI, Weinstock RS. Carbohydrates. In: McPherson RA, Pincus MR, eds.Henry's Clinical Diagnosis and Management by Laboratory Methods
Seifter JL. Acid-base disorders. In: Goldman L, Schafer AI, eds.Goldman’s Cecil Medicine

05.- Breath alcohol test

A breath alcohol test determines how much alcohol is in your blood by measuring the amount of alcohol in the air you breathe out (exhale).

How the Test is Performed

There are various brands of breath alcohol tests. Each one uses a different method to test the level of alcohol in the breath. The machine may be electronic or manual.
One common manual tester requires you to blow up a balloon in one continuous breath until it is full, then release the air into a glass tube. The tube is filled with bands of yellow crystals. The bands in the tube change colors (from yellow to green), depending on the alcohol content. Carefully read the instructions before using the test to make sure you get an accurate result.
If an electronic alcohol meter is used, follow the instructions that come with the meter.

How to Prepare for the Test

Wait 15 minutes after drinking an alcoholic beverage and 1 minute after smoking before starting the test.

How the Test Will Feel

There is no discomfort.

Why the Test is Performed

When you drink alcohol, the amount of alcohol in your blood goes up. This is called your blood-alcohol level.
When the amount of alcohol in the blood reaches 0.02 to 0.03%, you may feel a relaxing "high."
When that percentage reaches 0.05 to 0.10%, you have:
• Reduced muscular coordination
• A longer reaction time
• Impaired judgment
Driving and operating machinery under the influence of alcohol is dangerous. A person with an alcohol level of 0.08% and above is considered legally intoxicated (drunk) in most states. (Some states have lower levels than others.)
The alcohol content of exhaled air accurately reflects the alcohol content of the blood.

Normal Results

Normal is when the blood alcohol levels are not elevated.

What Abnormal Results Mean

When 1 band is green, it means that the blood-alcohol level is 0.05% or lower. 2 green bands mean levels of 0.05% to 0.10%. 3 green bands indicate levels between 0.10% and 0.15%.

Risks

There are no risks.

Considerations

The test does not take into account the driving abilities of the test subject. Driving abilities vary among people with the same blood-alcohol levels. Some people with blood-alcohol levels below 0.05% may not be able to safely drive. For occasional drinkers, judgment problems occur at blood-alcohol levels of just 0.02%.
The breath alcohol test helps you to know how much alcohol it takes to raise the blood-alcohol level to a dangerous level. Each person's response to alcohol varies. The test may help you make better decisions about driving after drinking.

Alternative Names

Alcohol test - breath

References

Bitterman RA. Medicolegal issues and risk management. In: Marx JA, ed.Rosen's Emergency Medicine: Concepts and Clinical Practice

06.- Helping a loved one with a drinking problem

If you think a loved one has a drinking problem, you may want to help but do not know how. You may not be sure it really is a drinking problem. Or, you might be afraid that your loved one will get angry or upset if you say something.
If you are concerned, DO NOT wait to bring it up. The problem is likely to get worse, not better, if you wait.

When is Drinking a Problem?

Drinking problems are not measured by the amount someone drinks or how often they drink. What matters most is how drinking affects the person's life. Your loved one may have a drinking problem if they:
• Regularly drink more than they intended
• Cannot cut back on drinking
• Spend a lot of time getting alcohol, drinking alcohol, or recovering from the effects of alcohol
• Have trouble at work, home, or school because of alcohol use
• Have trouble with relationships because of drinking
• Miss important work, school, or social activities because of alcohol use

Learn About Alcohol Abuse

Start by learning all you can about alcohol abuse. You can read books, look online, or ask your health care provider for information. The more you know, the more information you will have ready to help your loved one.

Get Support for Yourself

Alcohol abuse takes a toll on everyone. You cannot help your loved one if you do not take care of yourself and get support.
• Make your family's health and safety your top priority.
• Ask other family members or friends for support. Be honest about your feelings and tell them what they can do to help.
• Consider joining a group that supports family and friends of people with alcohol problems, such as Al-Anon. In these groups, you can talk openly about your struggles and learn from people who have been in your situation.
• Consider seeking help from a counselor or therapist who deals with alcohol problems. Even though your loved one may be the drinker, drinking affects the entire family.

What Not to Do

It is not easy to be involved with a person who has a drinking problem. It takes a lot of patience and love. You also need to set certain boundaries for your own actions so you do not encourage the person's behavior or let it affect you.
• DO NOT lie or make excuses for your loved one's drinking.
• DO NOT take on responsibilities for your loved one. This will only help the person avoid consequences for not doing the things they should.
• DO NOT drink with your loved one.
• DO NOT argue when your loved one has been drinking.
• DO NOT feel guilty. You did not cause your loved one to drink, and you cannot control it.

How to Talk About Alcohol Use

It is not easy, but it is important to talk with your loved one about the drinking. Find a time to talk when the person is not drinking.
These tips may help make the conversation go more smoothly:
• Express your feelings about your loved one's drinking. Try to use "I" statements. This helps keep the focus on how the drinking affects you.
• Try to stick with the facts about your loved one's alcohol use, such as specific behaviors that have you worried.
• Explain that you are concerned for your loved one's health.
• Try not to use labels like "alcoholic" when talking about the problem.
• DO NOT preach or lecture.
• DO NOT try to use guilt or bribe the person to stop drinking.
• DO NOT threaten or plead.
• DO NOT expect your loved one to get better without help.
• Offer to go with the person to see a doctor or addiction counselor.
Remember, you cannot force your loved one to get help, but you can offer your support.

Getting Help

It may take a few tries and several conversations before your loved one agrees to get help. There are many places to get help for an alcohol problem. You can start with your family health care provider. The provider may recommend an addiction treatment program or specialist. You can also check with your local hospital, insurance plan, or employee assistance program (EAP).
You can play an important role by continuing to show your support. Offer to go with your loved one to doctor's appointments or meetings. Ask what else you can do, such as not drinking when you are together and keeping alcohol out of the house.

When to Call Your Doctor

If you feel that your relationship with this person is becoming dangerous or is threatening your health, get help for yourself right away. Talk with your health care provider or a counselor.

References

Friedmann PD. Clinical practice. Alcohol use in adults.N Engl J Medwww.ncbi.nlm.nih.gov/pubmed/23343065
Moyer VA; U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement.Ann Intern Medwww.ncbi.nlm.nih.gov/pubmed/23698791
National Council on Alcoholism and Drug Dependence. Helping a Family Member or Friend. Available at: www.ncadd.org/index.php/for-friends-and-family/helping-someone. Accessed April 29, 2014.
National Council on Alcoholism and Drug Dependence. Intervention -- Tips and Guidelines. Available at: www.ncadd.org/index.php/for-friends-and-family/intervention. Accessed April 29, 2014.
National Institute on Aging. Older Adults and Alcohol. June 2011. Available at: www.nia.nih.gov/health/publication/older-adults-and-alcohol/whats-inside. Accessed April 29, 2014.
National Institute on Alcohol Abuse and Alcoholism. Rethinking Drinking. 2010. Available at: rethinkingdrinking.niaaa.nih.gov. Accessed April 29, 2014.

07.- Alcohol withdrawal

Alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol.

Causes

Alcohol withdrawal occurs most often in adults, but it may occur in teenagers or children.
The more you drink every day, the more likely you are to develop alcohol withdrawal symptoms when you stop drinking.
You may have more severe withdrawal symptoms if you have certain other medical problems.

Symptoms

Alcohol withdrawal symptoms usually occur within 8 hours after the last drink, but can occur days later. Symptoms usually peak by 24 - 72 hours, but may persist for weeks.
Common symptoms include:
• Anxiety or nervousness
• Depression
• Fatigue
• Irritability
• Jumpiness or shakiness
• Mood swings
• Nightmares
• Not thinking clearly
Other symptoms may include:
• Clammy skin
• Enlarged (dilated) pupils
• Headache
• Insomnia (sleeping difficulty)
• Loss of appetite
• Nausea and vomiting
• Pallor
• Rapid heart rate
• Sweating
• Tremor of the hands or other body parts
A severe form of alcohol withdrawal called delirium tremens can cause:
• Agitation
• Fever
• Seeing or feeling things that aren't there (hallucinations)
• Seizures
• Severe confusion

Exams and Tests

Your health care provider will perform a physical exam. This may reveal:
• Abnormal eye movements
• Abnormal heart rhythms
• Dehydration (not enough fluids in the body)
• Fever
• Rapid breathing
• Rapid heart rate
• Shaky hands
Blood and urine tests, including a toxicology screen, may be done.

Treatment

The goal of treatment includes:
• Reducing withdrawal symptoms
• Preventing complications of alcohol use
• Therapy to get you to stop drinking (abstinence)
INPATIENT TREATMENT
People with moderate-to-severe symptoms of alcohol withdrawal may need inpatient treatment at a hospital or other facility that treats alcohol withdrawal. You will be watched closely for hallucinations and other signs of delirium tremens.
Treatment may include:
• Monitoring of blood pressure, body temperature, heart rate, and blood levels of different chemicals in the body
• Fluids or medications through a vein (by IV)
• Sedation using medication called benzodiazepines until withdrawal is complete
OUTPATIENT TREATMENT
If you have mild-to-moderate alcohol withdrawal symptoms, you can often be treated in an outpatient setting. You will need someone to commit to staying with you during this process and who can keep an eye on you. Daily visits to your health care provider are often needed until you are stable.
Treatment usually includes:
• Sedative drugs to help ease withdrawal symptoms
• Blood tests
• Patient and family counseling to discuss the long-term issue of alcoholism
• Testing and treatment for other medical problems linked to alcohol use
It is important that the patient goes to a living situation that helps support them in staying sober. Some areas have housing options that provide a supportive environment for those trying to stay sober.
Permanent and life-long abstinence from alcohol is the best treatment for those who have gone through withdrawal.

Support Groups

The following organizations are good resources for information on alcoholism:
• Alcoholics Anonymous - www.alcoholics-anonymous.org
• Al-Anon/Alateen - www.al-anon.org
• National Institute on Alcohol Abuse and Alcoholism - http://www.niaaa.nih.gov/alcohol-health
• Substance Abuse and Mental Health Services Administration - www.samhsa.gov

Outlook (Prognosis)

How well a person does depends on the amount of organ damage and whether the person can stop drinking completely. Alcohol withdrawal may range from a mild and uncomfortable disorder to a serious, life-threatening condition.
Symptoms such as sleep changes, rapid changes in mood, and fatigue may last for months. People who continue to drink a lot may develop health problems such as liver, heart, and neurological disease.
Most people who go through alcohol withdrawal make a full recovery. However, death is possible, especially if delirium tremens occurs.

When to Contact a Medical Professional

Alcohol withdrawal is a serious condition that may rapidly become life threatening.
Call your health care provider or go the emergency room if you think you might be in alcohol withdrawal, especially if you were using alcohol often and recently stopped. Call for an appointment with your health care provider if symptoms persist after treatment.
Go to the emergency room or call the local emergency number (such as 911) if seizures, fever, severe confusion, hallucinations, or irregular heartbeats occur.

Prevention

Reduce or avoid alcohol. If you have alcoholism, you should stop drinking completely.

Alternative Names

Detoxification - alcohol; Detox - alcohol

References

O'Connor PG. Alcohol abuse and dependence. In: Goldman L, Schafer AI, eds.Cecil Medicine
In the clinic. Alcohol use.Ann Intern Med
Schuckit MA. Alcohol-use disorders. Lancet

08.- Beriberi

Beriberi is a disease in which the body does not have enough thiamine (vitamin B1).

Causes

There are two major types of beriberi:
• Wet beriberi affects the cardiovascular system.
• Dry beriberi and Wernicke-Korsakoff syndrome affect the nervous system.
Beriberi is rare in the United States because most foods are now vitamin enriched. If you eat a normal, healthy diet, you should get enough thiamine. Today, beriberi occurs mostly in patients who abuse alcohol. Drinking heavily can lead to poor nutrition. Excess alcohol makes it harder for the body to absorb and store thiamine.
A rare condition known as genetic beriberi is inherited (passed down through families). People with genetic beriberi lose the ability to absorb thiamine from foods. This can happen slowly over time and symptoms occur when the person is an adult. However, because health care providers may not consider beriberi in nonalcoholics, this diagnosis is often missed.
Beriberi can occur in breastfed infants when the mother's body is lacking in thiamine. The condition can also affect infants who are fed unusual formulas that don't have enough thiamine.
Getting dialysis and taking high doses of diuretics raise your risk of beriberi.

Symptoms

Symptoms of dry beriberi include:
• Difficulty walking
• Loss of feeling (sensation) in hands and feet
• Loss of muscle function or paralysis of the lower legs
• Mental confusion/speech difficulties
• Pain
• Strange eye movements (nystagmus)
• Tingling
• Vomiting
Symptoms of wet beriberi include:
• Awakening at night short of breath
• Increased heart rate
• Shortness of breath with activity
• Swelling of the lower legs

Exams and Tests

A physical examination may show signs of congestive heart failure, including:
• Difficulty breathing with neck veins that stick out
• Enlarged heart
• Fluid in the lungs
• Rapid heartbeat
• Swelling in both lower legs
A person with late-stage beriberi may be confused or have memory loss and delusions. The person may be less able to sense vibrations.
A neurological exam may show signs of:
• Changes in the walk
• Coordination problems
• Decreased reflexes
• Drooping of the eyelids
The following tests may be done:
• Blood tests to measure the amount of thiamine in the blood
• Urine tests to see if thiamine is passing through the urine

Treatment

The goal of treatment is to replace the thiamine your body is lacking. This is done with thiamine supplements. Thiamine supplements are given through a shot (injection) or taken by mouth.
Other types of vitamins may also be recommended.
Blood tests may be done after you are given thiamine supplements to see how well you are responding to the medicine.

Outlook (Prognosis)

Untreated, beriberi is often deadly. With treatment, symptoms usually improve quickly.
Heart damage is usually reversible, and a full recovery is expected. However, if acute heart failure has already occurred, the outlook is poor.
Nervous system damage is also reversible, if caught early. If it is not caught early, some symptoms (such as memory loss) may remain even with treatment.
If a patient with Wernicke's encephalopathy receives thiamine replacement, language problems, unusual eye movements, and walking difficulties may go away. However, Korsakoff syndrome (or Korsakoff psychosis) tends to develop as Wernicke symptoms go away.

Possible Complications

• Coma
• Congestive heart failure
• Death
• Psychosis

When to Contact a Medical Professional

Beriberi is extremely rare in the United States. However, if you feel your family's diet is inadequate or poorly balanced, and you or your children have any symptoms of beriberi, call your health care provider.

Prevention

Eating a proper diet that is rich in thiamine and other vitamins will prevent beriberi. Nursing mothers should make sure that their diet contains all vitamins. When infants are not receiving breast milk, parents need to be sure that their baby's infant formula contains thiamine.
People who drink heavily should try to cut down or quit. They should take B vitamins to make sure their body is properly absorbing and storing thiamine.

Alternative Names

Thiamine deficiency; Vitamin B1 deficiency

References

Koppel BS. Nutrition and alcohol-related neurologic disorders. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine
Sachdev HPS, Shah D. Vitamin B complex deficiency and excess. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics
So YT, Simon RP. Deficiency diseases of the nervous system. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds.Bradley's Neurology in Clinical Practice

09.- When you are drinking too much - tips for cutting back

Alcohol - drinking too much; Alcohol use disorder - drinking too much; Alcohol abuse - drinking too much

Description

Doctors consider you to be drinking more than is medically safe when you drink:
• Many times a month or many times a week
• 3 to 4 drinks or more in one day
• 5 or more drinks on one occasion, on a monthly or weekly

Ways to cut back

Watch your drinking patterns more closely and plan ahead. This can help you cut back on your alcohol use. Keep track of how much you drink and set goals.
• Track how many drinks you have during the week on a small card in your wallet, on your calendar, or on your phone.
• Know how much alcohol is in a standard drink -- a 12-ounce can or bottle of beer, a 5-ounce glass of wine, a wine cooler, 1 cocktail, or 1 shot of hard liquor.
When you're drinking:
• Pace yourself. Have no more than 1 alcoholic drink per hour. Sip on water, soda, or juice in between alcoholic drinks.
• Eat something before drinking and in between drinks.
To control how much you drink:
• Stay away from people or places that influence you to drink when you do not want to drink, or tempt you to drink more than you should.
• Plan other activities that do not involve drinking for days when you have the urge to drink.
• Keep alcohol out of your home.
• Make a plan to handle your urges to drink. Remind yourself of why you do not want to drink, or talk to someone you trust.
• Create a polite but firm way of refusing a drink when you are offered one.

Getting help from others

Make an appointment with your doctor to talk about your drinking. You and your doctor can make a plan for you to either stop or cut back on your drinking. Your doctor will:
• Explain how much alcohol is safe for you to drink
• Ask if you have often been feeling sad or nervous
• Help you figure out what else about your life may be causing you to drink too much
• Tell you where you can get more support for cutting back or quitting alcohol
Ask for support from people who may be willing to listen and help, such as a spouse or significant other, or non-drinking friends.
Your place of work may have a program where you can seek help without needing to tell anyone at work about your drinking.
Some other resources where you can seek information or support for alcohol problems include:
• Alcoholics Anonymous (AA) -- www.aa.org
• National Council on Alcoholism and Drug Dependence (NCADD) -- ncadd.org/index.php/learn-about-alcohol

References

American Psychiatric Association.Diagnostic and statistical manual of mental disorders
National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder: a comparison between DSM-IV and DSM-5. November 2013. http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.pdf.Accessed on May 11, 2014.
O'Connor PG. Alcohol abuse and dependence. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine
Sherin K, Seikel S. Alcohol use disorders. In: Rakel RE, Rakel DP, eds.Textbook of Family Medicine

10.- Alcoholic ketoacidosis

Alcoholic ketoacidosis is the buildup of ketones in the blood. Ketones are a type of acid that form when the body breaks down fat for energy.
The condition is an acute form of metabolic acidosis.

Causes

Alcoholic ketoacidosis is caused by excessive alcohol use. It is most often seen in a malnourished person who drinks large amounts of alcohol every day.

Symptoms

• Abdominal pain
• Agitation
• Changed level of alertness, which may lead to coma
• Confusion
• Fatigue
• Slow, sluggish, lethargic movement
• Irregular deep, rapid breathing (Kussmaul's sign)
• Loss of appetite
• Nausea and vomiting
• Symptoms of dehydration, such as dizziness, light-headedness, and thirst

Exams and Tests

• Arterial blood gases (measure the acid/base balance and oxygen level in blood)
• Blood alcohol level
• Blood chemistries, and liver function tests, such as CHEM-20
• CBC (complete blood count, measures red and whilte blood cells, and platelets, which help blood to clot)
• Prothrombin time (PT, a different measure of blood clotting, often abnormal from liver disease)
• Toxicology (poison) screening
• Urine ketones

Treatment

Treatment may involve fluids (salt and sugar solution) given through a vein. You may need to have your blood taken often. You may get vitamin supplements to treat nutritional deficiencies caused by excess alcohol use.
People with this condition are admitted to the hospital, often to the intensive care unit (ICU). Additional medications may be given to prevent alcohol withdrawal.

Outlook (Prognosis)

Prompt medical attention improves the overall outlook. How severe the alcoholism is, and the presence of liver disease or other complications also affect the outlook.

Possible Complications

This can be a life-threatening disorder. Complications can include:
• Coma and seizures
• Gastrointestinal bleeding
• Pancreatitis (inflammation of the pancreas)
• Pneumonia

When to Contact a Medical Professional

If you or someone else has symptoms of alcoholic ketoacidosis, seek emergency medical help.

Prevention

Limiting the amount of alcohol you drink may help prevent this condition.

Alternative Names

Ketoacidosis - alcoholic

References

Cho KC, Fukagawa M, Kurokawa K. Fluid and electrolyte disorders. In: McPhee SJ, Papadakis MA, eds.Current Medical Diagnosis and Treatment
DuBose TD Jr. Acidosis and alkalosis. In: Fauci A , Kasper D, Longo DL, et al, eds.Harrison's Principals of Internal Medicine
Wiener SW, Hoffman RS. Alcoholic ketoacidosis. In: Wolfson AB, Hendey GW, Ling LJ, et al, eds.Harwood-Nuss' Clinical Practice of Emergency Medicine

11.- Deciding to quit drinking alcohol

Alcohol use disorder - quitting drinking; Alcohol abuse - quitting drinking; Quitting drinking; Quitting alcohol

Description

Many people with drinking problems cannot tell when their drinking is out of control. You likely have a drinking problem when your body depends on alcohol to function and your drinking is causing problems with your health, social life, family, or job. Recognizing that you have a drinking problem is the first step toward being alcohol-free.
Talk with your doctor about your drinking. Your doctor can help you find the best treatment.

Are you ready to change?

You may have tried to stop drinking many times in the past and feel you have no control over it. Or you may be thinking about stopping, but you're not sure if you're ready to start.
Change takes place in stages and over time. The first stage is being ready to change. Important stages that follow include:
• Thinking about the pros and cons of stopping drinking
• Making small changes and figuring out how to deal with the hard parts, such as what to do when you are in a situation where you would normally drink
• Stopping drinking
• Living an alcohol-free life
Many people go back and forth through the stages of change several times before the change really lasts. Plan ahead for what you will do if you slip up. Try not to be discouraged.

Lifestyle changes that can help

To help you control your drinking:
• Stay away from people you normally drink with or places where you would drink.
• Plan activities you enjoy that do not involve drinking.
• Keep alcohol out of your home.
• Follow your plan to handle your urges to drink. Remind yourself why you decided to quit.
• Talk with someone you trust when you have the urge to drink.
• Create a polite but firm way of refusing a drink when you are offered one.

Getting help from others

After talking about your drinking with your doctor or an alcohol counselor, you will likely be referred to an alcohol support group or recovery program. These programs:
• Teach people about alcohol abuse and its effects
• Offer counseling and support about how to stay away from alcohol
• Provide a space where you can talk with others who have drinking problems
You can also seek help and support from:
• Trusted family members and friends who do not drink.
• Your place of work, which may have an employee assistance program (EAP). An EAP can help employees with personal issues such as alcohol use.
• Support groups such as Alcoholics Anonymous (AA): www.aa.org

Alcohol withdrawal

You may be at risk for symptoms of alcohol withdrawal if you stop drinking suddenly. If you are at risk, you will likely need to be under medical care while you stop drinking. Discuss this with your doctor.

References

American Psychiatric Association.Diagnostic and statistical manual of mental disorders
National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder: a comparison between DSM-IV and DSM-5. November 2013. http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.pdf.Accessed on May 11, 2014.
O'Connor PG. Alcohol abuse and dependence. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine
Sherin K, Seikel S. Alcohol use disorders. In: Rakel RE, Rakel DP, eds.Textbook of Family Medicine

12.- Delirium tremens

Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes.

Causes

Delirium tremens can occur when you stop drinking alcohol after a period of heavy drinking, especially if you do not eat enough food.
Delirium tremens may also be caused by head injury, infection, or illness in people with a history of heavy alcohol use.
It is most common in people who have a history of alcohol withdrawal. It is especially common in those who drink 4 - 5 pints of wine or 7 - 8 pints of beer (or 1 pint of "hard" alcohol) every day for several months. Delirium tremens also commonly affects people who have had an alcohol habit or alcoholism for more than 10 years.

Symptoms

Symptoms most often occur within 48-96 hours after the last drink. However, they may occur up to 7 - 10 days after the last drink.
Symptoms may get worse quickly, and can include:
• Body tremors
• Changes in mental function
• Agitation, irritability
• Confusion, disorientation
• Decreased attention span
• Deep sleep that lasts for a day or longer
• Delirium
• Excitement
• Fear
• Hallucinations (seeing or feeling things that are not really there)
• Increased activity
• Quick mood changes
• Restlessness, excitement
• Sensitivity to light, sound, touch
• Stupor, sleepiness, fatigue
Seizures (may occur without other symptoms of DTs)
• Most common in first 12 - 48 hours after last drink
• Most common in people with past complications from alcohol withdrawal
• Usually generalized tonic-clonic seizures
Symptoms of alcohol withdrawal, including:
• Anxiety
• Depression
• Fatigue
• Feeling jumpy or nervous
• Feeling shaky
• Headache
• Insomnia (difficulty falling and staying asleep)
• Irritability or excitability
• Loss of appetite
• Nausea
• Pale skin
• Palpitations (sensation of feeling the heart beat)
• Rapid emotional changes
• Sweating, especially on the palms of the hands or the face
• Vomiting
Other symptoms that may occur:
• Chest pain
• Fever
• Stomach pain

Exams and Tests

Delirium tremens is a medical emergency.
The health care provider will perform a physical exam. Signs may include:
• Heavy sweating
• Increased startle reflex
• Irregular heartbeat
• Problems with eye muscle movement
• Rapid heart rate
• Rapid muscle tremors
The following tests may be done:
• Blood magnesium level
• Blood phosphate level
• Comprehensive metabolic panel
• Electrocardiogram (ECG)
• Electroencephalogram (EEG)
• Toxicology screen

Treatment

The goals of treatment are to:
• Save the person's life
• Relieve symptoms
• Prevent complications
A hospital stay is needed. The health care team will regularly check:
• Blood chemistry results, such as electrolyte levels
• Body fluid levels
• Vital signs (temperature, pulse, rate of breathing, blood pressure)
Symptoms such as agitation, seizures, and irregular heartbeat are treated with the following medications:
• Sedatives such as diazepam or lorazepam
• Anticonvulsants such as phenobarbital
The patient may need to be put into a sedated state for a week or more until withdrawal and DTs are finished. Benzodiazepine medications such as diazepam or lorazepam also help treat seizures, anxiety, and tremors.
Antipsychotic medications such as haloperidol may sometimes be needed for persons with severe psychotic symptoms, especially if they have an underlying problem such as schizophrenia. However, these drugs should be avoided if possible because they may contribute to seizures.
Long-term preventive treatment should begin after the patient recovers from immediate symptoms. This may involve a "drying out" period, in which no alcohol is allowed. Total and lifelong avoidance of alcohol (abstinence) is recommended for most people who go through withdrawal. The person should receive treatment for alcohol use or alcoholism, including:
• Counseling
• Support groups (such as Alcoholics Anonymous)
The patient should be tested, and if needed, treated for other medical problems that can occur with alcohol use. Such problems may include:
• Alcoholic cardiomyopathy
• Alcoholic liver disease
• Alcoholic neuropathy
• Wernicke-Korsakoff syndrome

Support Groups

For additional resources, see alcoholism support group.

Outlook (Prognosis)

Delirium tremens is serious and may be life-threatening. Some symptoms related to alcohol withdrawal may last for a year or more, including:
• Emotional mood swings
• Feeling tired
• Sleeplessness

Possible Complications

• Injury from falls during seizures
• Injury to self or others caused by mental state (confusion/delirium)
• Irregular heartbeat, may be life threatening
• Seizures

When to Contact a Medical Professional

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms. Delirium tremens is an emergency condition.

Prevention

Avoid or reduce the use of alcohol. Get prompt medical treatment for symptoms of alcohol withdrawal.
For more information, see: Alcoholism

Alternative Names

DTs; Alcohol withdrawal - delirium tremens

References

O'Connor PG. Alcohol abuse and dependence. In: Goldman L, Schafer AI, eds.Cecil Medicine


13.- Alcoholic liver disease

Alcoholic liver disease is damage to the liver and its function due to alcohol abuse.

Causes

Alcoholic liver disease occurs after years of heavy drinking. Alcohol can cause inflammation in the liver. Over time, scarring and cirrhosis can occur. Cirrhosis is the final phase of alcoholic liver disease.
Alcoholic liver disease does not occur in all heavy drinkers. The chances of getting liver disease go up the longer you have been drinking and more alcohol you consume. You do not have to get drunk for the disease to happen.
The disease seems to be more common in some families. Women may be more likely to have this problem than men.

Symptoms

Symptoms vary, based on how bad the disease is. You may not have symptoms in the early stages. Symptoms tend to be worse after a period of heavy drinking.
Digestive symptoms include:
• Pain and swelling in the abdomen
• Decreased appetite and weight loss
• Nausea and vomiting
• Fatigue
• Dry mouth and increased thirst
• Bleeding from enlarged veins in the walls of the lower part of the esophagus (tube that connects your throat to your stomach)
Skin problems such as:
• Yellow color in the skin, mucus membranes, or eyes (jaundice)
• Small, red spider-like veins on the skin
• Very dark or pale skin
• Redness on the feet or hands
• Itching
Brain and nervous system symptoms include:
• Problems with thinking, memory, and mood
• Fainting and lightheadedness
• Numbness in legs and feet

Exams and Tests

• Complete blood count (CBC)
• Liver biopsy
• Liver function tests
Tests to rule out other diseases include:
• Abdominal CT scan
• Blood tests for other causes of liver disease
• Ultrasound of the abdomen

Treatment

The most important part of treatment is to stop using alcohol completely. If liver cirrhosis has not yet occurred, the liver can heal if you stop drinking alcohol.
An alcohol rehabilitation program or counseling may be necessary to break the alcohol addiction. Vitamins, especially B-complex and folic acid, can help reverse malnutrition.
If cirrhosis develops, you may need to manage the complications of cirrhosis. You may need a liver transplant if there has been a lot of liver damage.

Support Groups

Many people benefit from joining support groups for alcoholism or liver disease.

Outlook (Prognosis)

Continued excessive drinking can shorten your lifespan. Your risk for complications such as bleeding, brain changes, and severe liver damage go up. The outcome will likely be poor if you keep drinking.

When to Contact a Medical Professional

Call your health care provider if:
• You develop symptoms of alcoholic liver disease.
• You develop symptoms after a long period of heavy drinking.
• You are worried that drinking may be harming your health.

Prevention

Talk to your doctor about your alcohol intake. The doctor can counsel you about how much alcohol is safe for you.

Alternative Names

Liver disease due to alcohol; Cirrhosis or hepatitis - alcoholic; Laennec's cirrhosis

References

O’Shea RS, Dasarathy S, McCullough AJ et al. AASLD Practice Guidelines: Alcoholic liver disease.HEPATOLOGY
Carithers RL, McClain C. Alcoholic liver disease. In: Feldman M, Friedman LS, Brandt LJ.Feldman: Sleisinger & Fordtran's Gastrointestinal and Liver Disease
Schuppan D, Afdhal NH. Liver cirrhosis. Lancet
Garcia-Tsao G, Lim JK; Members of Veterans Affairs Hepatitis C Resource Center Program. Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program.Am J Gastroenterol
Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Ausiello D, eds.Cecil Medicine

14.- Central pontine myelinolysis

Central pontine myelinolysis is brain cell dysfunction caused by the destruction of the layer (myelin sheath) covering nerve cells in the middle of the brainstem (pons).

Causes

The destruction of the myelin sheath that covers nerve cells prevents signals from being properly transmitted from one nerve to another.
The most common cause of central pontine myelinolysis is a quick change in the body's sodium levels. This most often occurs when someone is being treated for low blood levels of sodium (hyponatremia) and the sodium is replaced too fast. It also can occasionally occur when high levels of sodium in the body (hypernatremia) are corrected too quickly.
This condition does not usually occur on its own. It is typically a complication of treatment for other conditions, or from the other conditions themselves.
Risks include:
• Alcoholism
• Liver disease
• Malnutrition from serious illnesses

Symptoms

• Confusion, delirium
• Balance problems
• Difficulty swallowing
• Hallucinations
• Reduced alertness, drowsiness or sleepiness, lethargy, poor responses
• Speech changes, poor enunciation
• Tremor
• Weakness in the face, arms, or legs, usually affecting both sides of the body

Exams and Tests

An examination may show:
• Abnormal reflexes
• Confusion
• Involvement of all four arms and legs (spastic quadriplegia)
• Weakness of the face, arms, and legs (upper motor neuron syndromes)
A head MRI scan may reveal a problem in the brainstem (pons). This is the main diagnostic test.
Other tests may include:
• Blood sodium levels and other blood tests
• Brainstem auditory evoked response (BAER)

Treatment

This is an emergency disorder. You will need to go to a hospital for diagnosis and treatment. However, most people with this condition are already in the hospital for another condition.
There is no known cure for central pontine myelinolysis. Treatment is focused on relieving symptoms.
Physical therapy may help maintain muscle strength, mobility, and function in weakened arms and legs.

Outlook (Prognosis)

The nerve damage caused by central pontine myelinolysis is usually long-lasting. The disorder can cause serious long-term (chronic) disability.

Possible Complications

• Decreased ability to interact with others
• Decreased ability to work or care for self
• Inability to move, other than to blink eyes ("locked in" syndrome)
• Permanent nervous system damage

When to Contact a Medical Professional

There is no real guideline on when to seek medical attention, because this condition is rare in the general community.

Prevention

Gradual, controlled treatment of low sodium levels may reduce the risk of nerve damage in the pons. Being aware of how some medications can change sodium levels can prevent these levels from changing too quickly.

Alternative Names

Osmotic demyelination syndrome

References

Rosenberg GA. Brain edema and disorders of cerebrospinal fluid circulation. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds.Bradley's Neurology in Clinical Practice
Skorecki K, Ausiello D. Disorders of sodium and water homeostasis. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine

15.- Alcoholic neuropathy

Alcoholic neuropathy is damage to the nerves that results from excessive drinking of alcohol.

Causes

The exact cause of alcoholic neuropathy is unknown. It likely includes both a direct poisoning of the nerve by the alcohol and the effect of poor nutrition associated with alcoholism. Up to half of long-term heavy alcohol users develop this condition.
In severe cases, nerves that regulate internal body functions (autonomic nerves) may be involved.
Risks of alcoholic neuropathy include:
• Long-term, heavy alcohol use
• Alcoholism that is present for 10 years or more

Symptoms

• Numbness in the arms and legs
• Abnormal sensations, such as"pins and needles"
• Painful sensations in the arms and legs
• Muscle weakness
• Muscle cramps or muscle aches
• Heat intolerance, especially after exercise
• Impotence (in men)
• Problems urinating, incontinence (leaking urine), feeling of incomplete bladder emptying, difficulty beginning to urinate
• Constipation
• Diarrhea
• Nausea, vomiting
Additional symptoms that may occur with this disease:
• Swallowing difficulty
• Speech impairment
• Loss of muscle function or feeling
• Muscle contractions or spasm
• Muscle atrophy
• Movement disorders
Changes in muscle strength or sensation usually occur on both sides of the body and are more common in the legs than in the arms. Symptoms usually develop gradually and become worse over time.

Exams and Tests

Your health care provider will perform a physical exam and ask about your symptoms. An eye exam may show eye problems.
Alcoholism often makes your body unable to use or store certain vitamins and minerals. Blood tests will be ordered to check for a deficiency (lack of):
• Thiamine (vitamin B1)
• Pyridoxine (vitamin B6)
• Pantothenic acid and biotin
• Vitamin B12
• Folic acid
• Niacin (vitamin B3)
• Vitamin A
Additional tests may be ordered to rule out other possible causes of neuropathy. Tests may include:
• Electrolyte levels
• Electromyography (EMG)
• Liver and kidney function tests
• Thyroid function tests
• Levels of vitamins and minerals in the body
• Nerve conduction tests
• Nerve biopsy
• Upper GI and small bowel series
• Esophagogastroduodenoscopy (EGD)
• Voiding cystourethrogram

Treatment

Once the alcohol problem has been addressed, treatment goals include:
• Controlling symptoms
• Maximizing ability to function independently
• Preventing injury
It is important to supplement the diet with vitamins, including thiamine and folic acid.
Physical therapy and orthopedic appliances (such as splints) may be needed to make sure muscle function and limb position are maintained.
Medicines may be needed to treat pain or uncomfortable sensations. Because persons with alcoholic neuropathy have alcohol dependence problems, they are advised to take the least amount of medicine needed to reduce symptoms to help prevent drug dependence and other side effects of chronic use.
Positioning or the use of a bed frame that keeps the covers off the legs may reduce pain for some people.
Light-headedness or dizziness when standing up (orthostatic hypotension) may require several different treatments before finding one that successfully reduces symptoms. Treatments that may help include:
• Wearing compression stockings
• Eating extra salt
• Sleeping with the head elevated
• Using medicines
Bladder problems may be treated with:
• Manual expression of urine
• Intermittent catheterization (male or female)
• Medicines
Impotence, diarrhea, constipation, or other symptoms are treated when necessary. These symptoms often respond poorly to treatment in people with alcoholic neuropathy.
It is important to protect body parts with reduced sensation from injury. This may include:
• Checking the temperature of bath water to prevent burns
• Changing footwear
• Frequently inspecting the feet and shoes to reduce injury caused by pressure or objects in the shoes
• Guarding the extremities to prevent injury from pressure
Alcohol must be stopped to prevent the damage from getting worse. Treatment for alcoholism may include counseling or social support such as Alcoholics Anonymous (AA), or taking medicines.

Outlook (Prognosis)

Damage to nerves from alcoholic neuropathy is usually permanent. It is likely to get worse if the person continues to use alcohol or if nutritional problems are not corrected. Alcoholic neuropathy is usually not life-threatening, but it can severely affect quality of life.

Possible Complications

• Disability
• Long-term (chronic) discomfort or pain
• Injury to extremities
• Falling, especially at night
• Urinary incontinence or retention

When to Contact a Medical Professional

Call for an appointment with your health care provider if you have symptoms of alcoholic neuropathy.

Prevention

The only way to prevent alcoholic neuropathy is not to drink alcohol.

Alternative Names

Neuropathy - alcoholic; Alcoholic polyneuropathy

References

Chopra K, Tiwari V. Alcoholic neuropathy: possible mechanisms and future treatment possibilities. Br J Clin Pharmacol
Katri B, Koontz D. Disorders of the peripheral nerves. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds.Bradley’s Neurology in Clinical Practice

16.- Pellagra

Pellagra is a disease that occurs when a person does not get enough niacin (one of the B complex vitamins) or tryptophan (an amino acid).

Causes

Pellagra is caused by having too little niacin or tryptophan in the diet. It can also occur if the body fails to absorb these nutrients. It may develop after gastrointestinal diseases or with alcoholism, HIV/AIDS, or anorexia.
The disease is common in parts of the world where people have a lot of corn in their diet.

Symptoms

Symptoms of pellagra include:
• Delusions or mental confusion
• Diarrhea
• Nausea (sometimes)
• Inflamed mucus membranes
• Scaly skin sores

Exams and Tests

Your health care provider will perform a physical exam. You will be asked about the foods you eat.
Tests that may be done include urine tests to check if your body has enough niacin. Blood tests may also be done.

Treatment

The goal of treatment is to increase your body's niacin level. You will be prescribed niacin supplements. You may also need to take other supplements. Follow your provider's instructions exactly on how much and how often to take the supplements.
Symptoms due to the pellagra, such as skin sores, will be treated.
If you have conditions that are causing the pellagra, these will also be treated.

Outlook (Prognosis)

People often do well after taking niacin.

Possible Complications

Left untreated, pellagra can result in nerve damage, especially in the brain. Skin sores may become infected.

When to Contact a Medical Professional

Call your health care provider if you have any symptoms of pellagra.

Prevention

Pellagra can be prevented by following a well-balanced diet.
Get treated for health problems that may cause pellagra.

Alternative Names

Vitamin B3 deficiency; Deficiency - niacin; Nicotinic acid deficiency

References

Brown TM. Pellagra: an old enemy of timeless importance.Psychosomaticswww.ncbi.nlm.nih.gov/pubmed/20332283
Crook MA. The importance of recognizing pellagra (niacin deficiency) as it still occurs.Nutritionwww.ncbi.nlm.nih.gov/pubmed/24679717
Kumar N. Neurologic presentation of nutritional deficiencies.Neurol Clinwww.ncbi.nlm.nih.gov/pubmed/19932379
So YT, Simon RP. Deficiency diseases of the nervous system. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds.Bradley's Neurology in Clinical Practice

17.- Wernicke-Korsakoff syndrome

Wernicke-Korsakoff syndrome is a brain disorder due to thiamine (vitamin B1) deficiency.

Causes

Wernicke encephalopathy and Korsakoff syndrome are different conditions. Both are due to brain damage caused by a lack of vitamin B1.
Lack of vitamin B1 is common in people with alcoholism. It is also common in persons whose bodies do not absorb food properly (malabsorption), as sometimes occurs with a chronic illness or after obesity (bariatric) surgery.
Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernicke symptoms go away. Wernicke encephalopathy causes brain damage in lower parts of the brain called the thalamus and hypothalamus. Korsakoff psychosis results from permanent damage to areas of the brain involved with memory.

Symptoms

Symptoms of Wernicke encephalopathy include:
• Confusion and loss of mental activity that can progress to coma and death
• Loss of muscle coordination (ataxia) that can cause leg tremor
• Vision changes such as abnormal eye movements (back and forth movements called nystagmus), double vision, eyelid drooping
• Alcohol withdrawal
Symptoms of Korsakoff syndrome:
• Inability to form new memories
• Loss of memory, can be severe
• Making up stories (confabulation)
• Seeing or hearing things that are not really there (hallucinations)

Exams and Tests

Examination of the nervous/muscular system may show damage to many nerve systems:
• Abnormal eye movement
• Decreased or abnormal reflexes
• Fast pulse (heart rate)
• Low blood pressure
• Low body temperature
• Muscle weakness and atrophy (loss of tissue mass)
• Problems with walk (gait) and coordination
The person may appear poorly nourished. The following tests are used to check a person's nutrition level:
• Serum albumin (relates to person's general nutrition)
• Serum vitamin B1 levels
• Transketolase activity in red blood cells (reduced in people with thiamine deficiency)
Liver enzymes may be high in people with a history of long-term alcohol abuse.
Other conditions that may cause vitamin B1 deficiency include:
• AIDS
• Cancers that have spread throughout the body
• Extreme nausea and vomiting during pregnancy (hyperemesis gravidarum)
• Heart failure (when treated with long-term diuretic therapy)
• Long periods of intravenous (IV) therapy without receiving thiamine supplements
• Long-term dialysis
• Very high thyroid hormone levels (thyrotoxicosis)
A brain MRI may show changes in the tissue of the brain. But if Wernicke-Korsakoff syndrome is suspected, treatment should start immediately. Usually a brain MRI exam is not needed.

Treatment

The goals of treatment are to control symptoms and to prevent the disorder from getting worse. Some people may need to stay in the hospital early in the condition to help control symptoms.
Monitoring and special care may be needed if the person is:
• Comatose
• Lethargic
• Unconscious
Vitamin B1 may be given by injection into a vein or a muscle, or by mouth. It may improve symptoms of:
• Confusion or delirium
• Difficulties with vision and eye movement
• Lack of muscle coordination
Vitamin B1 usually does not improve loss of memory and intellect that occur with Korsakoff psychosis.
Stopping alcohol use can prevent more loss of brain function and damage to nerves. Eating a well-balanced, nourishing diet can help, but it is not a substitute for stopping alcohol use.

Outlook (Prognosis)

Without treatment, Wernicke-Korsakoff syndrome gets steadily worse, and can be life-threatening. With treatment, it is possible to control symptoms (such as uncoordinated movement and vision difficulties). This disorder can also be slowed or stopped.
Some symptoms, especially the loss of memory and thinking skills, may be permanent. Other disorders related to alcohol use may also occur.

Possible Complications

• Alcohol withdrawal
• Difficulty with personal or social interaction
• Injury caused by falls
• Permanent alcoholic neuropathy
• Permanent loss of thinking skills
• Permanent loss of memory
• Shortened life span

When to Contact a Medical Professional

Call your health care provider or go to the emergency room if you have symptoms of Wernicke-Korsakoff syndrome, or if you have been diagnosed with the condition and your symptoms get worse or return.

Prevention

Not drinking alcohol or drinking in moderation and getting enough nutrition reduce the risk of developing Wernicke-Korsakoff syndrome. If a heavy drinker will not quit, thiamine supplements and a good diet may reduce the chance of getting this condition, but the risk is not eliminated.

Alternative Names

Korsakoff psychosis; Alcoholic encephalopathy; Encephalopathy - alcoholic; Wernicke's disease

References

So YT, Simon RP. Deficiency diseases of the nervous system. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds.Bradley's Neurology in Clinical Practice.

18.- Ethanol poisoning

Ethanol poisoning is caused by drinking too much alcohol.
This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or 1-800-222-1222 for a local poison control center.

Poisonous Ingredient

Ethanol

Where Found

Alcoholic beverages, including:
• Beer
• Gin
• Vodka
• Wine
• Whiskey

Symptoms

• Abdominal pain
• Coma
• Intestinal bleeding
• Slowed breathing
• Slurred speech
• Stupor
• Unable to walk normally
• Vomiting

Home Care

If you can wake an adult who has drunk too much alcohol, move the person to a comfortable place to sleep off the effects. Make sure the person won't fall or get hurt.
Place the person on their side in case they throw up (vomit). DO NOT make the person throw up unless told to do so by a health care professional or Poison Control.
Check the person frequently to make sure their condition does not get worse.
If the person is not alert (unconscious) or only somewhat alert (semi-conscious), emergency assistance may be needed. When in doubt, call for medical help.

Before Calling Emergency

Determine the following information:
• Patient's age, weight, and condition
• Name of the drinks consumed (ingredients and strengths if known)
• Time it was swallowed
• Amount swallowed
However, DO NOT delay calling for help if this information is not immediately available.

Poison Control

In the United States, call 1-800-222-1222 to speak with a local poison control center. This hotline number will let you talk to experts in poisoning. They will give you further instructions.
This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. You can call 24 hours a day, 7 days a week.

What to Expect at the Emergency Room

The health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure. The patient may receive:
• Breathing and airway support
• Fluids by IV
• Medicines to treat symptoms

Outlook (Prognosis)

Survival over 24 hours past the drinking binge usually means the person will recover.

References

Goldfrank LR, ed.Goldfrank's Toxicologic Emergencies
Publication authorized by the website: MedlinePlus
Disclaimer: The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.