Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

92 III. SUBSTANCES OF ABUSETransaminase levels rarely exceed 500 international units (IU), with a typicalratio of aspartate aminotransferase to alanine aminotransferase of 2:1 to 5:1.Liver biopsy can be helpful in distinguishing fatty liver from hepatitis and fromcirrhosis. Ascites, encephalopathy, high bilirubin levels, and prolongation ofthe prothrombin time are poor prognostic indicators that portend an increasedmortality. Treatment consists of abstinence and nutritional support. Treatmentwith steroids, propylthiouracil, and colchicines has yielded mixed results. Thereis a relative-risk increase of 14–20 for individuals who drink more than fivedrinks per day, although wine drinkers are at a lower risk than beer or liquordrinkers (Becker, Gronbaek, Johansen, & Sorensen, 2002). Women have ahigher incidence of alcoholic hepatitis and cirrhosis than men, although themechanisms underlying these gender differences is not known. Alcoholiccirrhosis develops as a result of prolonged hepatocyte damage, leading tocentrilobular inflammation and fibrosis. The latter pathology causes portalhypertension and the development of varices. Esophageal varices may bleedspontaneously, or bleeding may be precipitated by respiratory tract infections,nonsteroidal anti-inflammatory drugs, and alcohol. Cirrhosis also leads toascites, clotting deficiencies, secondary malnutrition, and hepatic encephalopathy(Sutton & Shields, 1995).NutritionAlcoholics are especially susceptible to deficiencies of thiamine, folate, Bvitamins, and ascorbic acid. Alcohol intake leads to negative nitrogen balance,increased protein turnover, and inhibition of lipolysis (Bunout, 1999).Deficiencies in folate, vitamin B 6, and vitamin B 12play a role in elevated levelsof homocysteine, which in turn promotes atherosclerosis and thrombosisformation (Cravo & Camilo, 2000). Ethanol can suppress appetite through itseffect on the CNS. Gastric, hepatic, and pancreatic disease my furtherdecrease enteral intake and contribute to maldigestion or malabsorption.Signs of malnutrition include thinning of the hair, ecchymosis, glossitis,abdominal distention, peripheral edema, hypocalcemic tetany, and neuropathy.Nutritional management consists of abstinence and institution of a wellbalanceddiet and multivitamins, plus thiamine and vitamin B supplementswhen indicated.Cardiovascular SystemIt is well established that alcoholic heart muscle disease is a complication oflong-term alcoholism and not malnutrition or other possible causes of dilatedcardiomyopathy. In a dose-dependent fashion, left ventricular systolic functiondeclines, implicating alcohol in at least 30% of all dilated cardiomyopathies(Lee & Regan, 2002). The contractility of heart muscle is decreased through