Case History 15: Alcohol and the Digestive Tract

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Chief Complaint: 62-year-old man with esophageal bleeding

History: Vincent Miller, a 62-year-old accountant, has had a "drinking problem" throughout most of his adult life. He drinks about a half-case of beer each day. He has lost several jobs over the years for drinking at the workplace or showing up for work drunk. He lost his driver's license for drunk-driving, and his drinking has placed a considerable strain on his marriage. He has tried several self-help programs as well as Alcoholic's Anonymous, all with little success. He has been hospitalized on several occasions over the years. Vincent has a severe tremor in his hands (probably a result of excessive alcohol intake), which makes it very difficult for him to use a spoon, fork, and knife to eat. It's your first day on the job as an occupational therapist, and you are consulted by his physician to see if there is any way to help Vincent use eating utensils. Not knowing anything about him, you open up his past medical records, which, incidentally, are quite thick.

First Hospitalization:

You note that Vincent was hospitalized at age 32 with a complaint of vomiting up blood after a drinking binge that lasted seven days and was marked by excessive and repeated vomiting episodes. The vomitus was bright red.

The hospital chart lists a diagnosis of "Upper GI bleed" due to a Mallory-Weiss tear. You look up "Mallory-Weiss tear" in an internal medicine textbook and see that it is defined as "a longitudinal tear in the mucosa at the gastroesophageal junction -- i.e. in the area of the lower esophageal sphincter -- caused by repeated vomiting."


Questions:

1. Why was the blood bright red, rather than the color of "coffee grounds"?

Answer

2. Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa?

Answer


Second Hospitalization

At age 36, Vincent was hospitalized again, this time with complaints of abdominal pain in the upper epigastric region (i.e. just below the xiphoid process of the sternum) and "coffee-grounds" emesis. He also complained of "heartburn" (a burning sensation in the area of the sternum) which was partially relieved with antacids. A diagnosis of "upper GI bleed due to gastritis and reflux esophagitis" is noted in the chart.

Questions:

1. What is causing the pain in the upper epigastric region ? What barrier(s) normally protect the stomach lining from its own acid?

Answer

2. What is reflux esophagitis?

Answer

3. Can you think of any treatments for Vincent's problems? Explain the mechanisms for those treatments, based upon your knowledge of the regulation of gastric secretions.

Answer

Third Hospitalization

At age 41, Vincent entered the hospital with complaints of a high fever, nausea, loss of appetite, and a dull, continual pain in the left side of the back. In addition, he had diarrhea of a particularly foul odor and yellow color . He had also lost 15 pounds over the last month and a half. Unfortunately, the page in the chart is torn, so you cannot read the diagnosis! But your memory of an anatomy and physiology course you took in college helps you figure out the possible causes of Vincent's problem.

Questions:

1. Excessive exposure to alcohol can cause inflammation of certain digestive organs, such as the stomach. Inflammation of which organ(s) might be causing Vincent's back pain?

Answer

2. Based upon the location of this pain, would you guess that the organ in question is a retroperitoneal organ or an organ attached to the abdominal wall by a broad sheet of mesentery? Explain your answer.

Answer


3. Based upon the function of the organ in question, what is causing the "steatorrhea" and weight loss?

Answer

Fourth Hospitalization

As you read on, you note that Vincent was hospitalized again at age 49 with dull pain in the right, upper quadrant of the abdomen, intermittent fever of 3 weeks duration, and a yellowing of the skin and the whites of the eyes. A diagnosis of "alcohol-induced hepatitis" is listed in the chart.

Questions:

1. Is the diagnosis consistent with the location of the abdominal pain? Explain your answer.

Answer

2. How are the liver and gallbladder connected to each other and to the duodenum?

Answer

3. If Vincent's liver disorder resulted in the production of a "gallstone," what danger might that present for his pancreas?

Answer

4. Why are Vincent's skin and eyes tinged yellow? What is this condition called?

Answer

Fifth Hospitalization

At age 58, Vincent was rushed to the emergency room with severe vomiting of bright red blood. On examination, he had a blood pressure of 60 mmHg / 30 mmHg. The bleeding and vomiting started abruptly while Vincent was eating some hard, dry French bread. An endoscope (i.e. a flexible tube equipped with a camera) was placed down Vincent's esophagus, and a diagnosis of esophageal varices was quickly made.

Questions:

1. What are esophageal varices?

Answer

2. Where are esophageal varices typically located? (Be specific.)

Answer

3. On the hospital chart you see two other "secondary diagnoses" listed:
(1) cirrhosis of the liver, and (2) portal hypertension.
Does this additional information help explain why Vincent developed esophageal varices? Explain your answer.

Answer

4. Why is bleeding particularly dangerous for Vincent?

Answer

 

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