Introduction

Alcohol excess is best diagnosed by taking a history and screening for alcoholism is best done using the CAGE and AUDIT questionnaires. Men and women are now advised to drink no more than 14 units in one week. This should be spread over three or more days with some alcohol-free days. Even the most accurate laboratory tests may only pick up as much as 50% of patients with alcohol excess and physical features of chronic alcoholism will only become apparent after the sequelae of alcoholism begin to appear.

Epidemiology

  • Incidence: 200.00 cases per 100,000 person-years
  • Peak incidence: 40-50 years
  • Sex ratio: more common in males 2:1
Condition Relative
incidence
Alcohol excess1
Vitamin B12 deficiency0.05
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Symptoms:
  • Many patients with alcoholism will also be experiencing a mental health disorder such as anxiety or depression. Others may have an antisocial personality type.
  • The AUDIT questionnaire (3) has 10 questions which assess for symptoms of alcohol-related problems and should be used for any new patients joining a GP or any at-risk patients
  • People who score in the AUDIT questionnaire may be suffering from alcohol dependence. This can be diagnosed in patients experiencing more than three of the following symptoms in the last 12 months: 1. Tolerance, 2. Withdrawal symptoms, 3. Craving, 4. Loss of control, 5. Salience, 6. Continued use despite harm.

Sometimes on examination of patients, we can identify signs of chronic alcoholism. These may include:
  • Palmar erythema (red palms)
  • Enlarged breasts in men (gynaecomastia)
  • Spider naevi (swollen blood vessels with a central red spot and spider web type appearance typically seen on the face, neck or upper arms)
  • Dupuytren's contractures (nodules and pitting on ligaments of the hand which can prevent the fingers from straightening properly)
  • Testicular atrophy
  • Usually a small shrunken liver, but this may be enlarged earlier in the disease
  • An enlarged spleen
  • A hepatic flap may occur in severe liver disease
  • Polyneuropathy, sensory ataxia and cerebellar signs
  • Sometimes people with chronic alcohol misuse may develop ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion which indicates Wernicke's encephalopathy which is due to exhaustion of thiamine stores. If untreated this can progress into Korsakoff's syndrome which presents as irreversible anterograde and retrograde amnesia with confabulation.

With increasing levels of acute alcohol intoxication, signs develop in the following manner:
  • Slurred speech and delayed reaction time
  • Increased confidence and chattiness with decreased inhibitions
  • Poor judgement and memory. Reduced balance, visual disturbances and drowsiness.
  • Confusion
  • Incontinence, uncontrolled vomiting, reduced breathing and gag reflexes. Blue-tinged skin and seizures
  • Coma
  • Death

Investigations

Investigations:
  • As above, the AUDIT questionnaire should be the first point of investigation
  • gamma-GT only picks up 50% of patients so is not good for screening but biochemical measures including LFTs can be used to assess the severity of the alcohol-related liver disease. For abnormal results, we must exclude alternative causes of liver disease. Then refer the patient to a specialist to confirm a clinical diagnosis of alcohol-related liver disease.
  • Perform a thorough neurological examination.
  • Routine blood tests to rule out vitamin deficiencies which are common secondary to chronic alcoholism.

Diagnosis

Diagnosis

ICD-10 definition - 3 or more needed
  • compulsion to drink
  • difficulties controlling alcohol consumption
  • physiological withdrawal
  • tolerance to alcohol
  • neglect of alternative activities to drinking
  • persistent use of alcohol despite evidence of harm

Management

Nutritional support
  • SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be deficient'

Drugs used
  • benzodiazepines for acute withdrawal
  • disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis
  • acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials

Screening and prevention

Screening

AUDIT
  • 10 item questionnaire, please see the link
  • takes about 2-3 minutes to complete
  • has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems
  • minimum score = 0, maximum score = 40
  • a score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption
  • a score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence
  • AUDIT-C is an abbreviated form consisting of 3 questions

FAST
  • 4 item questionnaire
  • minimum score = 0, maximum score = 16
  • the score for hazardous drinking is 3 or more
  • with relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
  • if the answer to the first question is 'never' then the patient is not misusing alcohol
  • if the response to the first question is 'Weekly' or 'Daily or almost daily' then the patient is a hazardous, harmful or dependent drinker. Over 50% of people will be classified using just this one question

1MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
2How often during the last year have you been unable to remember what happened the night before because you
had been drinking?
3How often during the last year have you failed to do what was normally expected of you because of drinking?
4In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or
suggested you cut down?

CAGE
  • well known but recent research has questioned it's value as a screening test
  • two or more positive answers is generally considered a 'positive' result

CHave you ever felt you should Cut down on your drinking?
AHave people Annoyed you by criticising your drinking?
GHave you ever felt bad or Guilty about your drinking?
EHave you ever had a drink in the morning to get rid of a hangover (Eye opener)?