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Jan 10

Chronic Alcohol Abuse: Complications and Consequences

Slide 1

Alcoholism is a common substance-abuse disorder that leads to significant medical complications. Alcohol affects virtually every organ system, and alcoholics are at increased risk for cirrhosis, gastrointestinal (GI) bleeding, pancreatitis, cardiomyopathy, trauma, mental health disorders, and a wide variety of cancers. Patients frequently have very poor insight into their addiction—a state commonly referred to as denial—and must be made aware of the numerous devastating short- and long-term complications of alcohol abuse. The computed tomography (CT) scan seen here demonstrates an unresectable pancreatic adenocarcinoma, a malignancy that is more common in alcoholics, surrounding the superior mesenteric artery (sma).


Slide 2

Liver disease and associated complications

Alcohol abuse is the second most common cause of cirrhosis in the United States, after hepatitis C.[1] Damage to the liver parenchyma from alcohol leads to progressive fibrosis, producing a nodular contour to the liver (white arrows). The subsequent increased resistance to portal blood flow induces portal hypertension, which may cause splenomegaly (yellow arrow), transudative ascites (red arrow), and varices. The CT image shown here demonstrates very prominent esophageal varices (green arrow).


Slide 3

A 60-year-old woman presents for a new patient evaluation. She has been suffering from depression after the loss of her husband a year ago. She admits to drinking approximately 60 g of alcohol daily. She has recently undergone abdominal CT scanning, seen here, in the course of a visit to the emergency department (ED) for pain.

On review of her CT scan, which of the following changes do you suspect to be present secondary to her alcohol use?

  1. None; study is normal
  2. Alcoholic hepatic steatosis
  3. Alcoholic hepatitis
  4. Alcoholic cirrhosis
  5. Hepatocellular carcinome


Slide 4

Answer: B. Alcoholic hepatic steatosis.

Ingestion of more than 60 g of alcohol daily results in morphologic changes to the liver. The first such change is fatty replacement of the liver, or hepatic steatosis. Alcoholic fatty liver is believed to be due to an increase in fatty acids and glycerol 3-phosphate.[2] With regard to diagnostic imaging, the liver will appear to be much lower in attenuation than the spleen on CT scans (see the previous slide), to be more echogenic (red arrow) than the kidney (blue arrow) on ultrasonography (US), and to lose signal on out-of-phase sequences on magnetic resonance imaging (MRI). Hepatic steatosis is reversible, but if ingestion of alcohol is not decreased, alcoholic hepatitis will develop, followed by alcoholic cirrhosis.

Slide 5

Varices develop secondary to cirrhosis, which changes the pressure and flow gradients of the vasculature. The classic locations for cirrhotic varices are the esophagus, the rectum, the stomach, and the abdominal wall.[3] As varices grow in size, the risk of rupture and hemorrhage increases dramatically. The image seen here demonstrates prominent esophageal varices visible on upper GI endoscopy, with some punctate areas of active hemorrhage (arrow). Patients who have bled from esophageal varices have a 70% chance of rebleeding, and roughly one third of episodes are fatal

Slide 6

Esophageal damage

A 50-year-old man who has a long-standing history of alcohol abuse with known esophageal varices (red arrow) diagnosed on recent esophagography presents to the ED with hematemesis. His friend reports that the man was drinking heavily earlier in the day and started vomiting about 1 hour ago. The patient’s initial vital signs show a heart rate of 90 beats/min, a blood pressure of 115/73 mm Hg, and a normal respiratory rate. While sitting in the waiting room, he has filled two cups with reddish fluid.

After intravenous (IV) administration of fluids has been initiated, which of the following is the most appropriate next step in management?

  1. Watchful waiting
  2. Repeat esophagography
  3. CT scan of the chest, abdomen, and pelvis
  4. GI consult for endoscopy
  5. Interventional radiology consult for angiography

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