Drug misuse, intoxication and withdrawal: Alcohol: Pathology review

2,369views

00:00 / 00:00

Drug misuse, intoxication and withdrawal: Alcohol: Pathology review

End of Rotation™ exam review

Cardiovascular

Anatomy clinical correlates: Heart
Anatomy clinical correlates: Mediastinum
Aortic dissections and aneurysms: Pathology review
Coronary artery disease: Pathology review
Peripheral artery disease: Pathology review
Cardiovascular disease screening: Clinical sciences
Carotid artery stenosis screening: Clinical sciences
Abdominal aortic aneurysm: Clinical sciences
Acute coronary syndrome: Clinical sciences
Acute limb ischemia: Clinical sciences
Acute mesenteric ischemia: Clinical sciences
Aortic dissection: Clinical sciences
Approach to chest pain: Clinical sciences
Approach to dyspnea: Clinical sciences
Approach to syncope: Clinical sciences
Ischemic colitis: Clinical sciences
Chronic mesenteric ischemia: Clinical sciences
Coronary artery disease: Clinical sciences
Peripheral arterial disease and ulcers: Clinical sciences
Venous insufficiency and ulcers: Clinical sciences
ACE inhibitors, ARBs and direct renin inhibitors
Adrenergic antagonists: Alpha blockers
Adrenergic antagonists: Beta blockers
Adrenergic antagonists: Presynaptic
Calcium channel blockers
Cholinomimetics: Direct agonists
Cholinomimetics: Indirect agonists (anticholinesterases)
Class I antiarrhythmics: Sodium channel blockers
Class II antiarrhythmics: Beta blockers
Class III antiarrhythmics: Potassium channel blockers
Class IV antiarrhythmics: Calcium channel blockers and others
Lipid-lowering medications: Fibrates
Lipid-lowering medications: Statins
Miscellaneous lipid-lowering medications
Muscarinic antagonists
Positive inotropic medications
Sympatholytics: Alpha-2 agonists
Sympathomimetics: Direct agonists
Thiazide and thiazide-like diuretics

Gastrointestinal and nutritional

Anatomy clinical correlates: Anterior and posterior abdominal wall
Anatomy clinical correlates: Inguinal region
Anatomy clinical correlates: Peritoneum and diaphragm
Anatomy clinical correlates: Viscera of the gastrointestinal tract
Anatomy clinical correlates: Other abdominal organs
Appendicitis: Pathology review
Colorectal polyps and cancer: Pathology review
Diverticular disease: Pathology review
Eating disorders: Pathology review
Esophageal disorders: Pathology review
Gallbladder disorders: Pathology review
Gastrointestinal bleeding: Pathology review
GERD, peptic ulcers, gastritis, and stomach cancer: Pathology review
Inflammatory bowel disease: Pathology review
Jaundice: Pathology review
Pancreatitis: Pathology review
Colorectal cancer screening: Clinical sciences
Acute pancreatitis: Clinical sciences
Approach to acute abdominal pain (pediatrics): Clinical sciences
Approach to the acute abdomen (pediatrics): Clinical sciences
Approach to biliary colic: Clinical sciences
Approach to upper abdominal pain: Clinical sciences
Anal cancer: Clinical sciences
Anal fissure: Clinical sciences
Approach to chronic abdominal pain (pediatrics): Clinical sciences
Approach to vomiting (acute): Clinical sciences
Appendicitis: Clinical sciences
Approach to constipation (pediatrics): Clinical sciences
Approach to vomiting (chronic): Clinical sciences
Approach to constipation: Clinical sciences
Approach to abdominal wall and groin masses: Clinical sciences
Approach to vomiting (newborn and infant): Clinical sciences
Approach to vomiting (pediatrics): Clinical sciences
Approach to diarrhea (chronic): Clinical sciences
Cholecystitis: Clinical sciences
Approach to diarrhea (pediatrics): Clinical sciences
Choledocholithiasis and cholangitis: Clinical sciences
Approach to hematochezia (pediatrics): Clinical sciences
Chronic pancreatitis: Clinical sciences
Approach to hematochezia: Clinical sciences
Colonic volvulus: Clinical sciences
Approach to hepatic masses: Clinical sciences
Colorectal cancer: Clinical sciences
Approach to jaundice (conjugated hyperbilirubinemia): Clinical sciences
Diverticulitis: Clinical sciences
Approach to jaundice (newborn and infant): Clinical sciences
Approach to jaundice (unconjugated hyperbilirubinemia): Clinical sciences
Esophageal cancer: Clinical sciences
Esophageal perforation: Clinical sciences
Approach to melena and hematemesis (pediatrics): Clinical sciences
Approach to melena and hematemesis: Clinical sciences
Fecal impaction: Clinical sciences
Femoral hernias: Clinical sciences
Approach to pancreatic masses: Clinical sciences
Gastric cancer: Clinical sciences
Approach to perianal problems: Clinical sciences
Approach to periumbilical and lower abdominal pain: Clinical sciences
Gastroesophageal reflux disease: Clinical sciences
Approach to pneumoperitoneum and peritonitis (perforated viscus): Clinical sciences
Gastroesophageal varices: Clinical sciences
Approach to postoperative abdominal pain: Clinical sciences
Hemorrhoids: Clinical sciences
Hepatocellular carcinoma: Clinical sciences
Ileus: Clinical sciences
Inflammatory bowel disease (Crohn disease): Clinical sciences
Inflammatory bowel disease (ulcerative colitis): Clinical sciences
Inguinal hernias: Clinical sciences
Intra-abdominal abscess: Clinical sciences
Ischemic colitis: Clinical sciences
Large bowel obstruction: Clinical sciences
Medication-induced constipation: Clinical sciences
Pancreatic cancer: Clinical sciences
Paraesophageal and hiatal hernia: Clinical sciences
Peptic ulcer disease: Clinical sciences
Perianal abscess and fistula: Clinical sciences
Pilonidal disease: Clinical sciences
Pyloric stenosis: Clinical sciences
Small bowel obstruction: Clinical sciences
Umbilical hernias: Clinical sciences
Ventral and incisional hernias: Clinical sciences
Acid reducing medications
Antidiarrheals
Laxatives and cathartics

Neurology

Anatomy clinical correlates: Cerebral hemispheres
Anatomy clinical correlates: Cerebellum and brainstem
Anatomy clinical correlates: Anterior blood supply to the brain
Anatomy clinical correlates: Posterior blood supply to the brain
Anatomy clinical correlates: Olfactory (CN I) and optic (CN II) nerves
Anatomy clinical correlates: Oculomotor (CN III), trochlear (CN IV) and abducens (CN VI) nerves
Anatomy clinical correlates: Trigeminal nerve (CN V)
Anatomy clinical correlates: Facial (CN VII) and vestibulocochlear (CN VIII) nerves
Anatomy clinical correlates: Glossopharyngeal (CN IX), vagus (X), spinal accessory (CN XI) and hypoglossal (CN XII) nerves
Anatomy clinical correlates: Spinal cord pathways
Anatomy clinical correlates: Vertebral canal
Adult brain tumors: Pathology review
Amnesia, dissociative disorders and delirium: Pathology review
Cerebral vascular disease: Pathology review
Traumatic brain injury: Pathology review
Carotid artery stenosis screening: Clinical sciences
Acute stroke (ischemic or hemorrhagic) or TIA: Clinical sciences
Approach to acute vision loss: Clinical sciences
Approach to aphasia: Clinical sciences
Approach to blunt cerebrovascular injury: Clinical sciences
Approach to diplopia: Clinical sciences
Approach to traumatic brain injury (pediatrics): Clinical sciences
Approach to traumatic brain injury: Clinical sciences
Subarachnoid hemorrhage: Clinical sciences
Anti-parkinson medications
Anticonvulsants and anxiolytics: Barbiturates
Anticonvulsants and anxiolytics: Benzodiazepines
Antiplatelet medications
General anesthetics
Local anesthetics
Medications for neurodegenerative diseases
Migraine medications
Neuromuscular blockers
Nonbenzodiazepine anticonvulsants
Osmotic diuretics
Thrombolytics

Preoperative and postoperative care

Acid-base disturbances: Pathology review
Adrenal insufficiency: Pathology review
Coronary artery disease: Pathology review
Deep vein thrombosis and pulmonary embolism: Pathology review
Diabetes mellitus: Pathology review
Drug misuse, intoxication and withdrawal: Alcohol: Pathology review
Drug misuse, intoxication and withdrawal: Hallucinogens: Pathology review
Drug misuse, intoxication and withdrawal: Other depressants: Pathology review
Drug misuse, intoxication and withdrawal: Stimulants: Pathology review
Electrolyte disturbances: Pathology review
Heart blocks: Pathology review
Heart failure: Pathology review
Obstructive lung diseases: Pathology review
Supraventricular arrhythmias: Pathology review
Thrombosis syndromes (hypercoagulability): Pathology review
Valvular heart disease: Pathology review
Ventricular arrhythmias: Pathology review
Acute coronary syndrome: Clinical sciences
Adrenal insufficiency: Clinical sciences
Alcohol use disorder: Clinical sciences
Alcohol withdrawal: Clinical sciences
Aortic stenosis: Clinical sciences
Approach to a postoperative fever: Clinical sciences
Approach to acid-base disorders: Clinical sciences
Approach to ascites: Clinical sciences
Approach to bradycardia: Clinical sciences
Approach to hypercalcemia: Clinical sciences
Approach to hyperkalemia: Clinical sciences
Approach to hypernatremia: Clinical sciences
Approach to hypocalcemia: Clinical sciences
Approach to hypokalemia: Clinical sciences
Approach to hyponatremia: Clinical sciences
Approach to lower limb edema: Clinical sciences
Approach to metabolic acidosis: Clinical sciences
Approach to metabolic alkalosis: Clinical sciences
Approach to nosocomial infections: Clinical sciences
Approach to postoperative abdominal pain: Clinical sciences
Approach to postoperative acute kidney injury: Clinical sciences
Approach to postoperative hypotension: Clinical sciences
Approach to postoperative respiratory distress: Clinical sciences
Approach to postoperative wound complications: Clinical sciences
Approach to respiratory acidosis: Clinical sciences
Approach to respiratory alkalosis: Clinical sciences
Approach to tachycardia: Clinical sciences
Asthma: Clinical sciences
Atrial fibrillation and atrial flutter: Clinical sciences
Atrioventricular block: Clinical sciences
Central line-associated bloodstream infection: Clinical sciences
Chronic obstructive pulmonary disease: Clinical sciences
Congestive heart failure: Clinical sciences
Coronary artery disease: Clinical sciences
Deep vein thrombosis: Clinical sciences
Delirium: Clinical sciences
Diabetes mellitus (Type 1): Clinical sciences
Diabetes mellitus (Type 2): Clinical sciences
Diabetic ketoacidosis: Clinical sciences
Essential hypertension: Clinical sciences
Hyperosmolar hyperglycemic state: Clinical sciences
Hypovolemic shock: Clinical sciences
Medication-induced constipation: Clinical sciences
Opioid intoxication and overdose: Clinical sciences
Opioid use disorder: Clinical sciences
Opioid withdrawal syndrome: Clinical sciences
Pressure-induced skin and soft tissue injury: Clinical sciences
Pulmonary embolism: Clinical sciences
Right heart failure (cor pulmonale): Clinical sciences
Substance use disorder: Clinical sciences
Surgical site infection: Clinical sciences
Tobacco use: Clinical sciences
Ventricular tachycardia: Clinical sciences
Acetaminophen (Paracetamol)
Anticoagulants: Direct factor inhibitors
Anticoagulants: Heparin
Anticoagulants: Warfarin
Antiplatelet medications
Cell wall synthesis inhibitors: Cephalosporins
DNA synthesis inhibitors: Metronidazole
Glucocorticoids
Insulins
Laxatives and cathartics
Miscellaneous cell wall synthesis inhibitors
Non-steroidal anti-inflammatory drugs
Opioid agonists, mixed agonist-antagonists and partial agonists
Protein synthesis inhibitors: Aminoglycosides

Questions

USMLE® Step 1 style questions USMLE

0 of 9 complete

A 1-day-old male infant is brought to the newborn nursery two hours after birth. He was born via vaginal delivery at 38 weeks gestation. The infant’s mother did not receive prenatal care. Family history is unremarkable for hereditary disorders. Weight and length are at the 5th percentile. Vitals are within normal limits. Physical examination reveals microcephaly, short palpebral fissures, a thin vermillion border, and a smooth philtrum. A harsh holosystolic murmur is heard at the lower left sternal border on cardiac auscultation. This infant’s physical exam findings are most likely secondary to in-utero exposure to which of the following?  

Transcript

Watch video only

Two individuals are brought into the emergency department, one night. One is 28 year old Brian who was brought in by his friend with complaints of altered consciousness and vomiting.

The friend recalls that Brian had a habit of binge drinking on weekends. On examination, he was disoriented, and had slurring of speech, loss of coordination, and nystagmus.

The second is 2 year old Michelle who’s brought by the mother who reported a seizure episode an hour ago.

Upon further questioning, the mother reveals that Michelle was born 2 months prematurely, was always crying and irritable, and was slow in reaching developmental milestones.

On examination, Michelle has reduced height and weight, a small eye opening, smooth philtrum, and thin lips. A neurological exam shows reduced muscle tone and coordination.

When you obtain a more focused history regarding the mother's pregnancy, she reported drinking 3-5 glasses of wine each night during the 1st and 2nd trimester.

Okay, both Brian and Michelle’s symptoms are due to alcohol. Alcoholic drinks contain the chemical ethanol, which mainly acts in two ways in the brain, one, it acts as an agonist to GABA, which is the brain’s major inhibitory neurotransmitter; and two, it acts as an antagonist of glutamate, which is an excitatory neurotransmitter.

Both these actions produce an overall inhibitory action on the brain’s neuronal circuits. Now, ethanol’s effects vary based on the blood alcohol concentration, or BAC, which is the percentage of ethanol in a given volume of blood.

At a blood alcohol concentration of 0.0 to 0.05%, ethanol produces a relaxed and happy feeling, along with slurred speech and some difficulty with coordination and balance.

At a blood alcohol concentration of 0.06 to 0.15%, there is increased impairment to speech, memory, attention, and coordination, and some individuals can get aggressive and even violent.

Complex tasks like driving can become dangerous, which is why it is illegal to drive in some countries with a blood alcohol concentration of 0.08% or higher.

At a blood alcohol concentration of 0.16 to 0.30%, individuals can experience alcohol poisoning where they blackout or experience periods of amnesia.

Finally, at a blood alcohol concentration above 0.31%, the effect of alcohol can severely suppress breathing and even lead to death.

Now, the use of alcohol can be assessed by direct and indirect tests. Direct tests measure the alcohol content in bodily fluids like blood, urine, saliva and the air breathed out.

In contrast, the indirect tests assess the effect of alcohol on organs like the liver. Cellular damage causes the release of liver enzymes into the blood.

Gamma-glutamyltransferase, or GGT, is the most sensitive indicator of alcohol use. In addition, aspartate aminotransferase or AST, alanine aminotransferase or ALT, are also elevated in chronic alcohol use, although AST values rise to about twice as much as ALT.

This is because alcohol use decreases ALT activity in the liver. And, that’s high yield! Over time, in people with prolonged alcohol consumption, neurons adapt by decreasing their number of GABA receptors, while increasing the number of NMDA glutamate receptors.

These individuals develop tolerance to the effects of alcohol, and therefore an increased dose is needed to achieve the original response.

Moreover, if the individual suddenly stops drinking, this receptor imbalance leads to overactivity of the central nervous system, which can result in withdrawal symptoms.

Eventually, the individual ends up requiring large amounts of alcohol just to function normally, which is known as alcohol use disorder, or alcoholism.

In the long run, alcohol use disorder can have a very deleterious effect on the body leading to several health problems.

It can cause inflammatory changes in the liver leading to steatohepatitis and cirrhosis. Similarly, the pancreas can also be affected, resulting in pancreatitis.

There can also be inflammation of the gastrointestinal mucosa resulting in esophagitis, gastritis, and gastric ulcers.

Now, it’s common to see vitamin deficiencies, especially that of B vitamins. This is due to a combination of decreased synthesis, absorption and storage as well as having poor eating habits.

Lack of vitamin B1, or thiamine, can lead to problems like Wernicke–Korsakoff syndrome which presents with ophthalmoplegia, ataxia, and altered mental status, severe and permanent memory impairment; confabulation, which is when the person creates stories to fill in the gaps in their memory which they believe to be true; and personality changes like apathy or indifference.

Another disease caused by thiamine deficiency is Beriberi. There’s “wet” Beriberi where the heart is the most affected, which leads to heart failure.

Common symptoms include lower limb edema and shortness of breath. In dry Beriberi the nervous system, especially the peripheral nervous system, is most affected.

The main symptoms include pain or loss of sensation in the limbs, weakness, decreased tendon reflexes, and muscle weakness. There could also be confusion and speech difficulties.

Thiamine deficiency is treated with intravenous thiamine supplementation foÍllowed by glucose infusion once thiamine levels normalize.

Chronic alcohol use is also associated with an increased risk of high blood pressure, dysregulated lipid metabolism, myocardial infarction, and cerebrovascular disease.

Alcoholism is associated with the risk of developing certain cancers, including mouth, esophagus, throat, liver, and breast cancer.

Now, consuming alcohol during pregnancy can result in ethanol, and toxic alcohol metabolites like acetaldehyde pass freely through the placenta and buildup in the fetus, interfering with the growth and development of various tissues.

The end result is known as fetal alcohol syndrome or FAS. For your exams, remember that this can present with growth retardation during the prenatal and postnatal period, resulting in low height and weight; along with typical dysmorphic facial features like short palpebral fissures, smooth philtrum, and thin vermillion border.

There may also be microcephaly and damage to the brain, including deficits in the corpus callosum, cerebellum, and basal ganglia leading to abnormal reflexes, tone, coordination, intellectual disabilities, and seizures. Additional features include limb dislocation and heart defects.

Now, individuals with alcohol use disorder can present with alcohol withdrawal symptoms when they abruptly stop drinking.

Sources

  1. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  2. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  3. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  4. "Robbins Basic Pathology" Elsevier (2017)
  5. "Diagnostic Immunohistochemistry" Elsevier (2021)
  6. "Bates' Guide to Physical Examination and History Taking" LWW (2017)
  7. "Atlas of Emergency Medicine" NA (2015)
  8. "ALCOHOL DEPENDENCE: A COMMENTARY ON MECHANISMS" Alcohol and Alcoholism (1996)
  9. "Alcohol and Cardiovascular Health: The Dose Makes the Poison…or the Remedy" Mayo Clinic Proceedings (2014)
  10. "Alcohol, Neurotransmitter Systems, and Behavior" The Journal of General Psychology (2006)