ALCOHOLISM

  • Excessive amounts of alcohol can have adverse effects on physical, mental and social health.
  • Alcohol in the blood is metabolised to form a metabolite called acetaldehyde
  • Acetaldehyde is a potent oxidant that leads to the production of free radicals (unstable particles) that cause tissue damage and interfere with bio-chemical processes - this accounts for many of the damaging effects of alcohol in the body.

THE HISTORY

The issue of alcohol abuse in South Africa can be traced back to the early years of Dutch settlement.

Dutch farmers coming to the Cape implemented the 'dop' system (mostly in the Western Cape) in which 'African workers' were paid in alcohol in addition to their wages.

Through this mechanism South Africans became accustomed to heavy drinking and alcohol abuse.

As a result of its history, alcohol has become an important social aspect in the lives of many South Africans of various races and cultures, and consequently has raised many public health concerns.

In the early 1900's laws were made in attempt to control the drinking of the "natives" - with this came the increase of illegal shebeens which lead to "unmonitored drinking" and alcohol abuse.

Binge drinking is common practice in South Africa where people remain without drinking alcohol for a period of time only to drink excessively on weekends and at parties.

ALCOHOLIC LIVER DISEASE

  • In South Africa, one of the most common causes of cirrhosis is chronic (and excessive) alcohol consumption It is the 5th leading cause of death and kills approximately 25 000 people a year.
  • Cirrhosis refers to the irreversible damage to the liver which is defined by the abnormal regeneration of hepatocytes (liver cells) surrounded by fibrous tissue (dense collagen) - this results in the liver becoming 'nodular', hard and shrunken with over-all architectural disturbance.
  • Typical of alcoholic cirrhosis is the micronodular pattern - however macronodular cirrhosis associated with alcoholism can also occur.The fibrosis in the tissue results in intereference with the vascular communication between portal sytems and hepatic veins in the liver parenchyma. This leads to portal hypertension and portosystemic shunts, which contribute to features such as: ascites, oesphageal varices, congestive splenomegaly

ALCOHOLIC CIRRHOSIS

  • Specimen XVIII:viii:20


    Clinical: A 50 year old man with a history of chronic alcoholism over 21 years. He had abdominal swelling that had started 2 years before his final admission to hospital.
    Macroscopic Pathology: The liver shows coarse granularity and on the cut surface the variably sized nodules of regeneration can be seen, some of which are bile stained.

ALCOHOLIC STEATOSIS OF THE LIVER

  • Specimen XVIII:viii:39


    Clinical: A 63-yr-old man; a chronic alcoholic; consuming 1 litre of whiskey per day and smoked 60 cigarettes a day. He was admitted to hospital with a 6-week history of jaundice and loss of weight.Post mortem findings were: Ascites and fatty liver with alcoholic cirrhosis.
    Macroscopic Pathology: The liver is enlarged and discoloured. There is marked fatty change and micronodular cirrhosis.
    Microscopically there is also loss of architecture with collapse, fibrosis and bile duct proliferation.

PANCREATITIS

  • Pancreatitis refers to inflammation of the pancreas and can occur as acute or chronic, both are commonly associated with alcohol abuse.
  • Characteristic of this disease is the irreversible destruction of the exocrine tissue (cells wich secrete digestive enzymes), with fibrosis, leading to malabsorbtion syndrome. At a later stage destruction of the endocrine tissue (islets of Langerhans) may be associated with the development of secondary diabetes mellitus.
  • The consequence of this damage is typically the decrease in size and number of the pancreatic (acinar) cells with dilation of the pancreatic ducts - macroscopically this leaves the pancrease shrunken and fibrosed and because of the release of digestive enzymes (particularly elastases) the elastic fibres of the blood vessels are 'auto digested', leading to haemorrhage into the adjacent tissue. (See specimen)
  • Specimen XXVII:ii:17


    Clinical: The patient was a 56-yr-old man who was a chronic alcoholic, admitted to hospital with pancreatitis.
    Macroscopic Pathology: Part of the normal stomach is present but its posterior wall and serosa of descending colon were involved in the haemorrhagic pancreatitis and fat necrosis. The pancreas shows many areas of fat necrosis varying in diameter.

ALCOHOLIC CARDIOMYOPATHY (ACM)

  • ACM (or dilated cardiomyopathy - DCM) is a degenerative condition of the heart muscle that results in dilatation of all four chambers and therewith contractile dysfunction, and leads to intractable congestive cardiac failure.
  • There is strong correlation between excessive alcohol consumption and DCM as alcohol and its metabolites are believed to have a direct toxic effect on the myocardium but the exact mechanism is unknown.
  • In DCM typical characteristics are:
    - Heavy, enlarged and sometimes 'flabby' heart
    - All four chambers dilated
  • Histologically: muscle cells are bigger/hypertrophied but flatter or stretched. May have endocardial and interstitial fibrosis.
  • Specimen II:ii:22


    Clinical: The patient presented with congestive cardiac failure. He had thiamine deficiency and found to have had a 2-year history of heavy alcohol consumption
    Macroscopic Pathology: The heart is grossly enlarged (600g) due to dilation of all four chambers. The ventricles are hypertrophied and dilated resulting in deep loculi between trabeculae; many of which contain smoothly rounded antemortem thrombi. Also note an acute fibrinous pericarditis and the abnormally 'thin' ventricular wall.

EFFECTS OF ALCOHOL ON THE CENTRAL NERVOUS SYSTEM

Wernicke-Korsakoff Syndrome - "Wet Brain"

This syndrome encompasses 2 separate conditions namely:

  1. Wernicke's Encephalopathy: brain injury as a result of thiamine deficiency. The commonest association is with alcoholism. Wernicke's is characterised by:
    • Ataxia - loss of muscle co-ordination (e.g. Leg tremors)
    • Nystagmus - abnormal back-and-forth eye movement
    • Opthalmoplegia
    • Mental Dysfunction - global confusion, apathy, listlessness and disorientation
  2. Korsakoff's Psychosis is characterised by:
    • 'retrograde amnesia' (moderate-severe memory impairment)
    • Inability to take in new information and make new memories
    • Confabulation - make up stories to disguise memory loss.
    • Hallucinations

Diagnosis is usually made based on clinical impression and can be confirmed with formal neuropsychological assessment

Morphology:

Wernicke's encephalopathy shows haemorrhagic foci with necrosis especially in the mamillary bodies (areas in the brain which are thought to play a role in memory). Early lesions have dilated capillaries with prominent endothelium which then leak red blood cells into the adjacent interstitium - hence the haemorrhages.

  • Specimen XII:v:8
    Wernicke's Encephalopathy


    The coronal slice of the cerebrum shows discolouration as a result of necrosis and haemorrhage of both mamillary bodies. This condition occurs as a result of thiamine deficiency and classically occurs in alcoholics but can also arise in other disease states that cause thiamine deficiency. The exact pathogenesis is still not known.

FOETAL ALCOHOL SYNDROME (FAS)

Is a condition that refers to children or babies born with irreversible mental dysfunction, physical and central nervous system abnormalities and growth retardation caused by maternal alcohol use during pregnancy. Alcohol consumed by the mother enters the blood and reaches the foetus within 20 minutes. As a consequence of the brain abnormalities children with FAS have learning disabilities, behavioural abnormalities and cognitive impairment.

FAS Facts:

  • There are at least 500 000 South African's suffering from FASD (foetal alcohol spectrum disorders).
  • South Africa with an incidence of 8-12% has the highest rate of FAS globally - De Aar having the highest prevalence of 12% in the country.
  • It is estimated that in Western Cape 70-80 babies per 1000 are born with FAS.