15. Alcoholism

📄 Definition

Chronic, harmful use of alcohol leading to physical, psychological, and social impairment. Strong association with liver disease, GI disorders, mental health conditions, and increased mortality.

🛡️ Risk Factors

  • Family history (genetic predisposition).

  • Mental health: depression, anxiety, trauma, social isolation.

  • Social: unemployment, deprivation, peer culture.

  • Biological: male sex, early onset drinking.

⚠️ Epidemiology (UK)

  • ~25% of adults drink above recommended limits (ONS, 2023).

  • Higher prevalence in men (2× risk).

  • ↑ Burden in Scotland & Northern England.

  • Ethnicity: ↑ risk in White British; lower in South Asian Muslim populations (religious abstinence).

  • Alcohol-related hospital admissions: >980,000/year in England.

🔬 Pathophysiology (simplified)

  1. Ethanol → metabolised in liver (alcohol dehydrogenase → acetaldehyde → acetate).

  2. Excess acetaldehyde → toxic to hepatocytes → oxidative stress, inflammation.

  3. Steatosis → steatohepatitis → fibrosis → cirrhosis → HCC.

  4. CNS effects: GABA agonism (sedation) + NMDA antagonism (withdrawal hyperexcitability).

  5. Dependence: altered reward pathways (dopamine, glutamate).

🔍 Clinical Features

🧠 Mnemonic: CAGE

  • Cut down (felt need to).

  • Annoyed by criticism.

  • Guilty about drinking.

  • Eye-opener drink in morning.

Other:

  • Tremor, sweating, agitation (withdrawal).

  • Jaundice, hepatomegaly, ascites (liver disease).

  • Peripheral neuropathy, Wernicke’s (thiamine deficiency).

  • Social/occupational impairment.

🔬 Investigations (Stepwise PARA Focus)

StepInvestigationPurpose
1️⃣ InitialFBC (macrocytosis, anaemia, thrombocytopenia)Detect alcohol-related marrow/liver effects
 LFTs (↑GGT, ↑AST>ALT, ↑bilirubin, ↓albumin)Suggests alcoholic liver disease
 U&E, glucose, clotting (INR)Assess systemic impact
2️⃣ ScreeningAUDIT-C, CAGEIdentify hazardous drinking
3️⃣ ImagingUSS liverFatty infiltration, cirrhosis
4️⃣ AdvancedFibroscan, liver biopsyStage fibrosis if indicated

💊 Management (NICE CG115 / SIGN 74)

StepInterventionNotes
1️⃣ Acute withdrawalBenzodiazepines (e.g. chlordiazepoxide) taperPrevent delirium tremens/seizures
 Thiamine (Pabrinex IV if malnourished; oral prophylaxis otherwise)Prevent Wernicke’s
2️⃣ Relapse preventionAcamprosate,  naltrexone, disulfiramSpecialist initiation
3️⃣ SupportiveDetox programmes, CBT, motivational interviewingCommunity or inpatient
4️⃣ Liver diseaseAlcohol abstinence = only proven therapyConsider transplant in end-stage cirrhosis
5️⃣ Social supportAA, community alcohol services, safeguardingMultidisciplinary input

⚠️ Complications

  • Acute: Withdrawal seizures, delirium tremens, Wernicke’s encephalopathy.

  • Chronic: Cirrhosis, HCC, GI bleeding (varices), pancreatitis, cardiomyopathy, neuropathy, depression, suicide.

📅 Follow-up

  • Monitor abstinence: LFTs, CDT/PEth testing if needed.

  • GP / alcohol services follow-up.

  • Screen for comorbidities: depression, malnutrition, liver cancer (US + AFP if cirrhotic).

  • Long-term relapse prevention programmes.

🔎 Key PARA Exam Traps

  • AST > ALT (usually ratio >2:1) = alcoholic liver disease.

  • Always give thiamine before glucose in suspected Wernicke’s.

  • Alcohol withdrawal = benzodiazepines (not antipsychotics).

  • Acamprosate/naltrexone = relapse prevention; disulfiram rarely first-line.

  • Do not “treat” asymptomatic raised GGT with drugs → investigate alcohol use.

📌 Guidelines referenced: NICE CG115 (Alcohol-use disorders), SIGN 74 (Management of harmful drinking), NICE NG50 (Cirrhosis).
🔒 PASSMAP ensures all content is PARA-aligned, exam-focused, and NICE-compliant.

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