Relevant Physical Examination and Laboratory Findings
Medical illness is a common consequence of heavy drinking and may be present in the absence of physical dependence. Early in the course individuals with alcoholism may show no physi-cal or laboratory abnormalities. But as it progresses, it is widelymanifested throughout most organ systems. A thorough physical examination is indicated if, in the history, there is evidence of medical problems. The physical examination provides essential information about the presence and extent of end-organ damage, and should be focused on the systems most vulnerable to devel-oping alcohol-related pathology: the cardiovascular system, the gastrointestinal system, and the central and peripheral nervous systems. The physician should also be alert to other acute alcohol-related signs, including alcohol withdrawal or delirium, intoxica-tion or withdrawal from other drugs, and the acute presentation of psychiatric symptomatology. Other systemic or nonspecific health problems associated with alcoholism include malnutrition, muscle wasting, neuritis, specific vitamin deficiencies, infectious diseases (such as tuberculosis, dermatitis, pediculosis, and hepa-titis) and trauma secondary to fights and accidents.
Laboratory testing can assist the clinician in providing ob-jective, nonjudgmental feedback to alcoholic patients on the nega-tive physical consequences of excessive drinking. Laboratory de-terminations should be repeated biweekly at the initial phase of treatment, and monthly during the aftercare. Results should be graphically presented to the patient in an easy-to-comprehend for-mat with reference to normal values. This allows the patient to ap-preciate the declining and eventual stabilization of laboratory in-dexes thereby enhancing his/her motivation to maintain sobriety.
Laboratory tests can also help to detect relapse to the extent they are sensitive to heavy drinking. Early identification of re-lapse can prevent the reinstatement of alcohol dependence. It can diminish adverse consequences of heavy drinking by promoting modifications to the original treatment plan and by prompting more aggressive therapeutic interventions. Finally, laboratory markers of drinking can be used to evaluate effectiveness of spe-cific therapeutic interventions and provide funding agencies with objective treatment outcome information.
Several laboratory tests, particularly those related to he-patic function (e.g., serum transaminases, bilirubin, prothrombin time and partial thromboplastin time) have been commonly used by clinicians. Other laboratory tests (e.g., gamma-glutamyl transpeptidase [GGTP], mean corpuscular volume [MCV]) of erythrocytes can be used as objective indicators of heavy drink-ing. Elevation in GGTP occurs in approximately three-fourths of alcoholics before there is clinical evidence of liver disease. It is often considered to be the earliest indication of heavy alcohol con-sumption and is widely available clinically. GGTP levels usually return to normal limits after 4 to 5 weeks of abstinence. As with GGTP, elevations of the transaminases serum glutamic oxaloace-tic transaminase (SGOT) and serum glutamic pyruvic transami-nase (SGPT) are common in other liver diseases. However, elevations in the transaminases are less sensitive indicators of heavy drinking, with SGOT being elevated in 32 to 77% of alco-holics, while elevations in SGPT have been observed in 50% of alcoholics. In contrast to the use of absolute values of SGPT and SGOT, the ratio of SGPT to SGOT may provide a more accurate indicator of heavy drinking. A ratio greater than 2 is more likely to be related to heavy alcohol consumption whereas a ratio below 1 would suggest a different etiology. Elevation of MCV, which has also been associated with folate deficiency, is more prominent in alcoholics, especially among those who are smokers. Though MCV can assist clinicians in identifying patients who are drink-ing excessively, particularly when this marker is used in combi-nation with GGTP or carbohydrate-deficient transferrin (CDT), this is not an efficient indicator of relapse because of the 2- to 4-month period of abstinence that is needed for its normalization
CDT is more sensitive than most routine laboratory tests for the identification of heavy alcohol consumption. In contrast to GGTP, CDT elevations are associated with few conditions other than heavy drinking. CDT and GGTP appear to identify two dif-ferent subsets of alcoholic patients. Elevations in GGTP values detect alcoholics with hepatic damage secondary to heavy drink-ing, whereas CDT appears to be more directly related to heavy drinking. Whenever possible, CDT and GGTP should be used together by classifying as a case individuals who have elevated scores in either test. This approach increases the likelihood of identifying individuals experiencing alcohol use disorders. CDT appears to detect relapse to heavy drinking among patients in alcohol treatment more accurately than other laboratory tests.
In a clinical setting where laboratory results are generally not immediately available, the alcohol breath test, which meas-ures the amount of alcohol in expired air (providing an estimate of venous ethanol concentration), is valuable. Although its accu-racy depends on the patient’s cooperation (which in an intoxi-cated patient is often problematic), the alcohol breath test can be a reliable and inexpensive method for assessing recent alcohol consumption. Venous blood levels should be obtained if danger-ously high levels of intoxication are suspected, when a patient is comatose, or for medical–legal purposes. A BAL greater than 150 mg/dL in a patient showing no signs of intoxication (i.e., no dys-arthria, motor incoordination, gait ataxia, nystagmus, or impaired attention) can be interpreted to reflect physiological tolerance. In nontolerant individuals, a BAL in excess of 400 mg/dL can result in death, and 300 mg/dL indicates a need for emergency care.
Another laboratory evaluation that is indicated in alcoholics is a urine toxicology screen. To identify drug use that the patient may not recognize or which he or she denies is a problem, the screen should include opiates, cocaine, cannabis and benzodiazepines. Routine urinalysis, blood chemistries, hepatitis profile, complete blood count and serologic test for syphilis and (for the female pa-tient) serum testing for pregnancy should also be obtained.