Alcoholism

Presentation

Appropriate Tests

 

Diagnosis is based on clinical assessment.

Laboratory tests include: Full blood count, Blood film, Prothrombin time, Gamma glutamyltransferase, Urate, Triglycerides, as appropriate. Ethanol testing is helpful in detecting recent alcohol ingestion.

In chronic alcoholism, macrocytosis, thrombocytopenia, prolonged PT, elevated GGT, hyperuricaemia or hypertriglyceridaemia may be found. The most specific indicator of chronic excessive alcohol ingestion is Carbohydrate-deficient transferrin but it has a low sensitivity.

Alcoholic liver disease

Aspartate aminotransferase, Alanine aminotransferase, Alkaline phosphatase, Bilirubin, Albumin, Protein, INR. An AST/ALT ratio of >2 suggests liver disease is due to alcohol. Protein electrophoresis or immunoglobulin quantitation may assist in establishing chronicity. Liver biopsy, if indicated.

Fatty liver

 

Alcoholic hepatitis

See Hepatitis

Cirrhosis

 

Hepatic failure

 

Hepatocellular carcinoma

 

Portal Hypertension

 

Pancreatitis

 

Acute metabolic disorders

 

Hypoglycaemia

Glucose, Glucose urine.

Ketoacidosis

Electrolytes. Hydroxybutyrate, Urinalysis ketones.

Lactic acidosis

Electrolytes. L-Lactate.

Hypoalbuminaemia

Protein (serum)

Hyperlipidaemia

Cholesterol, Lipids (serum)

Malnutrition

Protein (serum), Full blood count

Wernicke-Korsakoff syndrome

If confirmation is required, blood must be collected for vitamin B1 assay prior to therapy.

Central pontine myelinolysis

A demyelinating syndrome associated with rapid sodium fluxes. Electrolytes.

Peripheral neuropathy

Biopsy for histological examination, Erythrocyte sedimentation rate; C-Reactive protein

Cardiomyopathy

Biopsy for histological examination

Infection

 

Pneumonia

Aspiration of respiratory tract bacteria (eg, MCS bronchoalveolar lavage) especially Streptococcus pneumoniae and Klebsiella pneumoniae. Alcoholism also predisposes to infection with Legionella pneumophila.

Bacteraemia / Septicaemia

Inability of the liver to deal with bacteria coming from the gastrointestinal tract in the portal system predisposes to septicaemia caused by Gram-negative bacilli, eg Escherichia coli, Klebsiella pneumoniae.

2 Blood culture sets (one aerobic and one anaerobic bottle collected before antibiotic use = “set”).

Peritonitis

Primary infection with Streptococcus pneumoniae or Gram-negative bacilli, eg Escherichia coli. Diagnosis established by aspiration of peritoneal fluid for microscopy and culture (Peritoneal fluid examination).

Tuberculosis

Culture for MTB, acid fast stain of aspirate with > 5 white cells/L. Mycobacteria testing.

Pancytopenia

Multifactorial; likely cause(s) indicated by blood film findings and red cell indices. Bone marrow aspiration occasionally indicated, particularly if severe, unexplained anaemia, pancytopenia.

Full blood count.

Anaemia

Full blood count.

Alcohol marrow toxicity

Bone biopsy, bone marrow aspirate; Full blood count; Ethanol level serum or urinary.

Blood loss

Full blood count (Hb and RBC differential)

Iron deficiency

Full blood count (MCV)

Folate deficiency

Folate levels prior to treatment

Hypersplenism

 

Bleeding

Full blood count, Prothrombin time, APTT, Thrombin time, Fibrin degradation products (D Dimer), Fibrinogen.

Failure of coagulation factor synthesis

 

Vitamin K deficiency

 

Hepatocellular failure

See Hepatic failure

Thrombocytopenia

Bone biopsy, bone marrow aspiration may be appropriate. Platelet count on peripheral blood sample.

  • Alcohol marrow toxicity

 

  • Hypersplenism

 

  • DIC (usually low grade)
 

Fibrinolysis

Primary fibrinolysis may occur and is usually low grade.

Dysfibrinogenaemia

In severe liver disease, especially with hepatocellular carcinoma. Thrombin time. Reptilase time.