Health Effects of Alcohol 15

The Health Effects of
Alcohol
JOY ANNE NICODEMUS, MD
A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

What Is This?
H H
H C C O
H
H H
(CH3-CH2-OH)
Ethanol
H H
H C C OH
H H
Ethyl Alcohol
Methanol
H C OH
H
Methyl Alcohol
Historical Development
Ø Beer
• 10,000 years ago – accident from grain?
• 1100 AD guild formed devoted to brewing
• 1722 – a nourishing drink for potters and
laborers created called Potter
Ø Wine
• 8,000 years ago –
• 5,000 years ago the vineyards
• 2,000 BC - Hammurabi ruler of Babylon sets
rules for the sale and purchase of wine
• 1,500 BC Greek god of wine – Dionysus /
Bacchus

Historical Awareness
Alcohol
Ø Alchemist of the 16th century saw alcohol
as the essence from distillation.
Ø The middle of the 18th century alcohol took
on its current meaning of the intoxicating
ingredient of many common beverages.

Ancient Awareness
"You will conceive and bear a son…now

then be careful to take no wine or
strong drink and to eat nothing
unclean".
Bible - Judges 13:3-4

Historical Perspective
’T is not the drinking that is to be

blamed, but the excess.
John Selden (1584–1654)

In “Table Talk” 1689

Ethanol
Mechanism of Toxicity
CNS depressant
Teratogen
Carcinogen

Lite Beer 2.5 - 3.5%
Beer 4.0 - 6.0%
Wine 10 - 18 %
Flavored Liquors 15 - 25%
Distilled Liquors 22 - 50%
Everclear 95%
Proof is double %

Ethanol Metabolism
One drink equals:

12 ounces beer
5 ounces wine
1.5 ounces distilled liquor
70 kg person metabolizes approximately one
drink/hour
7 calories per gram vs. fat @ 9 calories/gm

Highest serum level recorded with full recovery
in an adult - 1510 mg/dL
Legal limit for intoxication - 80mg/dL or 0.08
Odor threshold - 10 ppm

Alcohol and Alcoholism
Alcoholism
Addiction to alcohol or abuse of alcohol to a
degree that produces problems in one or more of
these areas:
● Health
● Social relationships
● Economic status
● Interpersonal relationships

ALCOHOLISM
Phases
Problem drinking
● Drinks to relieve stress
● Abstinence does not cause physical symptoms
Alcohol addiction
● Abstinence produces physical symptoms

Alcohol does NOT depend on type of EtOH
Alcoholism occurs in ALL social classes and age
groups
“Skid row bums” = 3 to 5% of alcoholics

Current Views
“Alcohol is the number one drug of

choice among our Nation’s youth. Yet
the seriousness of this issue does not
register with the general public or
policymakers.”
Enoch Gordis, M.D. Director, National Institute

on Alcohol Abuse and Alcoholism.

Some Current Facts
Ø 7.4% of adult population in U.S. alcoholic

Ø $185 Billion – cost of alcohol abuse in U.S.
Ø 100,000 deaths annual in U.S. related to
Ø $1.2 Billion spent on wine, beer and liquor
advertisements in U.S.

Acute Alcohol Effects
Hangover
Mild withdrawal with volume depletion
Treatment
● Fluids
● Tylenol for headache
● Not aspirin or ibuprofen

Stupor-Coma
Acute overdose
● Coma
● Depressed respirations
● Hypotension
● Hypothermia

Stupor-Coma
Hypoglycemia
● Inhibition of protein to sugar conversion in liver
(gluconeogenesis)
● D-stick all patients with altered LOC

Stupor-Coma
Trauma
● “Drunks fall down and hit their heads.”
● Concussion
● Subdural hematoma

Stupor-Coma
Mixed drug overdose
● Tranquilizers
● Barbiturates
● Anti-depressants

Worsening of other problems

Peptic ulcer disease
Liver disease
Pancreatic disease
Heart disease (decreased pump strength)

Acute Overdose Treatment
ABC’s
Oxygen, assisted ventilations
Intubate
IV, infuse fluid to support perfusion
Lavage if within 2 hours

Acute Overdose Treatment
DONT
Dextrose, Oxygen, Narcan, Thiamine
Glucose, thiamine (50-100mg)
Narcan may reduce respiratory depression but
not CNS depression (? Use)
Dialysis - removes 280mg/minute

Associated Medical Problems

Head injury/subdural hematoma

Impaired clotting mechanisms
Frequent falls

Hepatic cirrhosis
Causes
● Alcohol toxicity
● Poor nutrition

Hepatic cirrhosis
Symptoms
● Ascites
● Jaundice
● Palmar erythema
● Spider angiomata, Caput medusa
● Gynecomastia (males)
“Lemon on toothpicks”
Hepatic Cirrhosis
Effects
● Impaired glucose metabolism,
hypoglycemia
● Portal hypertension, esophageal varices
● Coagulopathies
● Hepatic encephalopathy

Pancreatitis
Nausea, vomiting
Severe upper abdominal pain radiating to back
Hypovolemic shock
Secondary diabetes
Pancreatic necrosis and hemorrhage

Methanol/ethylene glycol poisoning

Sterno, antifreeze ingestion
Serve as EtOH substitutes
Produce
● profound metabolic acidosis
● hypocalcemia in ethylene glycol poisoning

Nutritional deficiencies
Wernicke’s syndrome
● Dizziness
● Confusion
● Apathy
● Ophthalmoplegia
● Ataxia

Korsakoff’s psychosis
● Memory loss
● Confusion

Beriberi
● Paresthesias, burning of feet
● Cardiovascular failure
– Peripheral vasodilation
– Biventricular myocardial failure
– Na+ and water retention

Respond to administration of thiamine (Vitamin
B1)

Cancer
Colon
Breast

Abstinence Syndrome

Abstinence Syndrome
Results from EtOH intake reduction

NOT necessarily result of complete withdrawal

Abstinence Syndrome
Stages
Tremulousness
● Shakes, jitters
● Fine tremors
● GI upset
● Restlessness
● Peaks at 24 hours
● Patient may feel “shaky” for up to 2 weeks

Abstinence Syndrome
Stages
Hallucinations
● Distorted vision
● Misinterpretation of visual stimuli (snakes, vermin)
● Auditory hallucinations
Seizures (“rum fits”)
● Usually in first 24 hours
● Major motor seizures in bursts of 2 to 6
● May progress to status epilepticus

Abstinence Syndrome
Stages
Delirium tremens
● 24 to 72 hours after reducing intake
● Restlessness, tremors, hallucinations, seizures
● Dilated pupils, flushed face, tachycardia, nausea,
vomiting
● 15% mortality from dehydration, electrolyte
imbalance, aspiration

Abstinence Syndrome
Management
Oxygen, monitor, IV (LR or NS)
Check blood sugar
Consider D50W and thiamine
Minimum stimulation
Sedation
● Phenobarbital
● Benzodiazepines

Antabuse (disulfiram)
Used in aversion therapy

Blocks EtOH metabolism
Causes buildup of acetaldehyde

Antabuse (disulfiram)
Exposure to EtOH while taking causes sudden,

severe vasodilation:
Hot, flushed face
Dizziness
Pounding heart, hypotension
Nausea, vomiting
Headache

Fetal Alcohol Syndrome (FAS)
Most common preventable cause of

adverse CNS development
4,000-12,000 infants per year in US
Characteristics
Growth retardation
Facial malformations
Small head
Greatly reduce intelligence
Fetal Alcohol Syndrome (FAS)
1 to 3 births per 1,000 world wide??
1968 first association by French

researchers at the University of Nantes
Early 1970’s FAS as condition –
University of Washington, Seattle WA,
USA

Fetal Alcohol Effect (FAE)
Milder form of FAS
Characteristics
Growth deficiency
Learning dysfunction
Nervous systems disabilities

Effects of Prenatal Alcohol

Effects of Prenatal Alcohol

A Child
FAS Small Dose of Toxicology (National Geographic, George Steinmetz, Feb 1992) A Small Dose of Alcohol – 2/16/04
Mouse – Scanning EM
A Small Dose of Toxicology (National Geographic, George Steinmetz, Feb 1992) A Small Dose of Alcohol – 2/16/04
Consumption
Have you ever drank

alcohol?
Why?
Have you ever drank
too much alcohol?

Health Effects
What are the pleasant

effects of alcohol?
The adverse effects

(toxicity)?

Acute Effects
• CNS Depressant
• Depression of inhibitory control
• Vasodilation, warm, flushed, reddish skin
• Emotional outbursts
• Decreased memory & concentration
• Poor judgment
• Decreased reflexes
• Decreased sexual response

Long Term Adverse Effects
Ø Obvious
• Alcoholism, death, cancer (oral cavity,
esophagus, liver), fetal effects (FAS)
Ø Alcoholism
• Cirrhosis of liver, appetite loss, poor
judgment
Ø Subtle
• Lost productivity, impaired performance,
motor impairment, cost to society

Alcohol & Cancer
Ethanol consumption increases

risk of cancer
Oral Cavity
Pharynx and Larynx
Esophagus
Liver

Absorption
Ø Rapidly absorbed from stomach,

small intestine, and colon
Ø Maximal blood concentration within
30 to 90 minutes
Ø Can be absorbed through the lungs

Distribution
Ø Uniformly distributed throughout

tissues and body fluids
Ø Readily crosses placenta, to
exposure fetus

Elimination
Urinary Excretion
Exhalation
Metabolism

Metabolism I
H H H
ADH
H C C OH H C C =O
H H H H
Ethanol Acetaldehyde
(ADH – Alcohol Dehydrogenase)
Metabolism II
H H
ALDH
H C C =O H C C =O
H H H OH
Acetaldehyde Acetate
(ALDH – Acetaldehyde Dehydrogenase)

Metabolism III
Ø 80-90% Metabolized
Ø Rate is constant (not increased
by concentrations in the blood)
Ø About 30 ml (1 oz) in 3 hours

Gender Differences
Females higher blood alcohol levels

than males
Males have higher stomach

metabolism of alcohol than females

Genetic Variation in ALDH
Acetaldehyde Dehydrogenase (ALDH)

varies in Caucasians, Blacks and Asians.
50% of Asians have inactive ALDH
Elevated acetaldehyde cause increased

flushing, tachycardia (elevated heart rate),
nausea, vomiting & hyperventilation.
Disulfiram – inhibits ALDH

Alcoholism - Disulfiram
Alcoholism Treatment with Disulfiram
Inhibits acetaldehyde dehydrogenase

(ALDH)
Elevated acetaldehyde cause increased

flushing, tachycardia (elevated heart rate),
nausea, vomiting & hyperventilation.

Alcoholism – Alcohol Dependence
Characterized by the following:
• Craving: A strong need, or compulsion, to drink.

• Loss of control: The inability to limit one’s drinking
on any given occasion.
• Physical dependence: Withdrawal symptoms, such
as nausea, sweating, shakiness, and anxiety, occur
when alcohol use is stopped after a period of heavy
drinking.
• Tolerance: The need to drink greater amounts of
alcohol in order to “get high.”
(from: U.S. Alcohol & Drug Information - http://ncadi.samhsa.gov/)

Alcoholism – Alcohol Dependence
Approximately 14 million Americans—7.4 percent of the

population —meet the diagnostic criteria for alcohol
abuse or alcoholism
(from: U.S. Alcohol & Drug Information - http://ncadi.samhsa.gov/)

Alcohol Withdrawal Effects
• Tremor
• Nausea
• Irritability
• Agitation
• Tachycardia
• Hypertension
• Seizers
• Hallucinations

Ethanol as Antidote
Antidote for Poisoning by:

Methanol
Ethylene glycol
Diethylene glycol
Inhibits metabolic activation by
alcohol dehydrogenase (ADH)

U.S. Government Warning
The Alcoholic Beverage Labeling Act of 1988 requires

that the following health warning statement appear
on the labels of all containers of alcohol beverages
offered for sale or distribution in the United States:
U.S. GOVERNMENT WARNING: (1) According to the

Surgeon General, women should not drink alcoholic
beverages during pregnancy because of the risk of
birth defects. (2) Consumption of alcoholic
beverages impairs your ability to drive a car or
operate machinery, and may cause health problems.

Regulatory Status
• 1981 - U.S. Surgeon General first advised that
women should not drink alcoholic beverages
during pregnancy.
• 1988 - U.S. requires warning labels on all

alcoholic beverages sold in the United States.
• 1990 - U.S. Dietary Guidelines state that women

who are pregnant or planning to become
pregnant should not drink alcohol.
• 1998 - 19 states require the posting of alcohol

health warning signs where alcoholic beverages
are sold

THANK YOU FOR YOUR
ATTENTION!

Health Effects of Alcohol 15

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The Health Effects of

JOY ANNE NICODEMUS, MD

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

"You will conceive and bear a son…now

Bible - Judges 13:3-4

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

’T is not the drinking that is to be

John Selden (1584–1654)

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

One drink equals:

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

“Alcohol is the number one drug of

Enoch Gordis, M.D. Director, National Institute

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Ø 7.4% of adult population in U.S. alcoholic

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Worsening of other problems

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Head injury/subdural hematoma

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Methanol/ethylene glycol poisoning

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Results from EtOH intake reduction

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Used in aversion therapy

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Exposure to EtOH while taking causes sudden,

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Most common preventable cause of

4,000-12,000 infants per year in US

1 to 3 births per 1,000 world wide??

1968 first association by French

4,000-12,000 infants per year in US

A Small Dose of Toxicology A Small Dose of Alcohol – 2/16/04

Milder form of FAS