Alcohol and the Physician – Sri Lankan context

This review focuses on chronic alcoholism in Sri Lanka and its contribution to the increased burden of disease, deaths and health costs. The burden of alcoholism is unquestionably rising in Sri Lanka. The review traces briefly the history of alcohol consumption from early times to the present day. It discusses the demographic characteristics, the pattern of drinking and the types of indigenous spirits. It describes the main clinical disorders relating to the liver, heart, nervous system, pancreas and the role of alcohol in the development of cancer. Lastly, it is the physician’s duty not only to treat the patient but also to devote himself to addressing the problem of alcoholism and related disorders. He has to remain in close contact with the patient and with those in policy making positions.


Historical perspective
The deleterious effects of alcohol have been known from very early times. In the book of Genesis it is said that 'Noah planted a vineyard and he drank of the wine and became drunk and lay uncovered in the tent'. In an admirable study of Sri Lankan Alcohol Industry, Dayaratne 1

Summary
This review focuses on chronic alcoholism in Sri Lanka and its contribution to the increased burden of disease, deaths and health costs. The burden of alcoholism is unquestionably rising in Sri Lanka. The review traces briefly the history of alcohol consumption from early times to the present day. It discusses the demographic characteristics, the pattern of drinking and the types of indigenous spirits. It describes the main clinical disorders relating to the liver, heart, nervous system, pancreas and the role of alcohol in the development of cancer. Lastly, it is the physician's duty not only to treat the patient but also to devote himself to addressing the problem of alcoholism and related disorders. He has to remain in close contact with the patient and with those in policy making positions.
Key words: chronic alcoholism, indigenous spirits, kasippu, chronic liver disease, cardiomyopathy, advocacy lism from early times to the present day. According to him people have been consuming intoxicating beverages and liquor derived from the coconut flower and recalls anecdotal evidence about drinking toddy and toddy tapping has been occurring for a very long time. As early as the 19 th century arrack made out of toddy was exported to India.
In Sri Lanka the majority of the people are Buddhists. Lord Buddha had cautioned his disciples about deleterious effects of alcohol and advised to abstain from drinking alcohol 2 . The Portuguese (1505-1658) and the Dutch (1640-1796) occupied Sri Lanka and these two periods were the most disastrous years for promoting the drinking habit 1,2 .
When the British troops occupied Kandy in 1815 they found no arrack 3 . Besides making infusions decoctions and extracts for medicinal purposes, the people of Ceylon were well acquainted with distillation which they practised to obtain distilled water for medical purposes but more usually to obtain intoxicating liquor 3 .
During the last 1½ centuries arrack has become a common drink among the poorer classes especially in the low country districts. During the British period licences to open taverns were issued liberally encouraging the drinking habit and privately owned imported foreign liquor outlets were created in the large cities 1 .

Prevalence and demographic characteristics
In 2002 among those who consumed alcoholic beverages, 53.1% were males and 6.4% females 4 and the prevalence of current drinking was 32.9% in urban areas and 20.8% in rural areas 5 . Another study done in 2014 showed that alcohol consumption has increased to 26% among males between the ages 17-64 years 6 . A hospital study in 1986 revealed a strong family history in 56% of the cases and majority were in the lower socio-economic group who drank illicit manufactured brews with high alcohol content 7 . Hazardous drinking was closely associated with low levels of education and age above 70 years 8 . Michelle Ruth Gambard an American anthropologist used the term 'breaking the ashes' -rekindling the kitchen fire, to refer to the urge for a morning drink in those Sri Lankans with an alcoholic problem 9 .
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Types of beverages
According to Somatunga et al 6 the most common types of alcohol consumed is beer (4.8%) followed by spirits (51.5%), wine (25.8%), kasippu (22.2%), palmyrah toddy (16.9%), toddy (16.8%) and other types (5.3%). They are totally different in their alcoholic content, in the numerous additives (congenors) and the process of manufacture, so are the patterns of drinking. Arrack is distilled from fermented toddy or sugar. The fermented liquor consumed contains 4-5% of alcohol whereas distilled liquor contains 30-40%. Owing to the cost of foreign liquor which contains 20-30% alcohol, arrack, locally manufactured beer and gin are the main alcoholic drinks of the middle class. Average Sri Lankan beer has 4-8% alcohol increasing to 8% compared to 4.2% in American and British beer and in the West it is as low as 3.3% 10 . There are several beverages which are prepared illicitly by fermentation or distillation. The term kasippu indicates a generic term for of illicit brew. According to Dayaratna an estimated 60% of the total alcohol market is illicit kasippu brewed by about 5000 producers nationwide and only 30% is legal hard liquor and about 5% beer 11 . Some of them have local names and several ingredients go into their manufacture (Table  1) including methyl alcohol, spirits of chloroform, spirits of wine, and parts of torch batteries, metallic copper, formalin and medicinal herbs of various sorts. There is little knowledge about the toxic effects of these botanical additives. Ethanol, congenors or contaminants in alcoholic beverages may each be the cause of the toxicity.

Pot arrack
Fermented toddy, sweet toddy Distillation or treacle to which jaggery or sugar is added

Clinical
A number of abnormalities have been shown to occur in some alcoholics who appear to be in good physical health. Besides mild abnormalities of liver function, water metabolism may be disturbed as alcohol inhibits production of antidiuretic hormone (ADH) and dysproteinaemias are not uncommon as alcohol influences the production of immunoglobulins 12 . Alcoholics in poor general health may have an extraordinary variety of conditions. These conditions have been well recognised since antiquity. Hepatic, pancreatic, neurological, psychiatric and cardiac manifestations are well known. Haematological abnormalities have been recognised so are those affecting primarily the muscles (Table 2).
Furthermore, the association of alcoholism with common conditions such as myocardial infarction, peptic ulcer, appendicitis, pulmonary tuberculosis, depressive states or hypertension may cause serious difficulties in diagnosis and treatment. General nutritional deficiencies are not uncommon among chronic alcoholics. Disturbances of tryptophan metabolism, hypomagnesaemia, hypokalaemia, zinc deficiency, phosphate deficiency, protein and vitamin deficiencies especially folic acid, thiamine and B6 are not infrequently found. Alcohol is strongly linked with domestic violence, suicide, trauma and accidents. In the United States 40% of car accident deaths involve alcohol 13   Alcohol and the Physician -Sri Lankan context

I. Hepatic
The metabolism of alcohol generating acetaldehyde is carried out by enzymes, alcohol dehydrogenase, cytochrome P459 2E1, to a lesser extent catalase 14 and by bacterial metabolism in the gastrointestinal tract 15 . Acetaldehyde is deleterious to the hepatocytes and generates radical oxygen species (ROS) damaging intestinal mucosal barrier 15 . Five sequential phases of hepatic injury have been seen in alcoholics; namely subcellular alterations, fatty liver, alcoholic hepatitis, cirrhosis and hepatoma. One of the conditions we would like to make special mention of is acute alcoholic hepatitis. Identification of this portion of the spectrum of alcoholic liver disease is important because of its prognostic implications. It's reported mortality rate ranges from 58%-78% at one year 16 . Portal endotoxaemia and cytokines induced in the liver have an important role in it's development 14 . It should be remembered that 'drunkenness' is not essential for its development. Although its occurrence in the alcoholic has long been recognised it has received scant attention in Sri Lanka, either it is not thought of even in a known alcoholic or frequently mistaken for some other condition. Clinically the condition may be associated with constitutional disturbances such as fever with chills, loss of appetite, abdominal pain, nausea, vomiting and jaundice of varying degree. It therefore sometimes closely simulates hepatic amoebiasis, a condition commonly met with in this country. In one study the biochemical and haematological data were normal or near normal in this group with normal or near normal serum bilirubin, with normal or slightly elevated alkaline phosphatase, transaminases and a polymorphonuclear leucocytosis. In this study all the patients had been treated initially as amoebic hepatitis 17 .

II. Neurological
The neurological complications include acute intoxication, withdrawal state, diseases associated with prolonged alcoholism and nutrient deficits and neurological states associated with alcoholism ( Table  2). Of particular interest in this country is prolonged coma often fatal following ingestion of indigenous distilled spirits. The patients we have seen were in coma for several days. They have marked rigidity of the trunk and extremities, unequal pupils and bilateral extensor plantar responses. Their posture resembled that seen with decerebrate rigidity. The diagnosis can be difficult and confusing. Those who recovered were not normal mentally. Those who died soon after consuming large quantities of indigenous spirits showed no gross pathology at autopsy so it was not possible to postulate the nature or site of the lesion. In a study of 5681 patients having immediate CNS effects and admitted to the medical wards over a period of 18 months, 42 had a history of acute alcoholic intoxication, alcoholic coma or delirium tremens; an incidence of 0.72% 18 .

III. Cardiac
The toxic effect of alcohol is now supported by experimental evidence that alcohol is undoubtedly cardio-toxic producing myocardial lesions. Alcohol consumption is associated with myocyte loss 19 and myocyte dysfunction 20 . Endomyocardial biopsy showed myocarditis with lymphocytic infiltration, myocyte degeneration and focal necrosis in about 30% of patients with alcoholic cardiomyopathy 21 . In a study of 27 Sri Lankan patients with alcoholic heart disease 22 there was only slight derangement of liver function tests, except in two cases with cirrhosis of the liver and one with alcoholic hepatitis. Serum cholesterol was low. The radiological features though characteristic were not diagnostic of the condition and consisted of an enlarged heart shadow with pulmonary congestion. The electrocardiogram showed tachycardia, arrhythmias, conduction defects, T wave changes and patterns simulating myocardial infarction. In a large number of cases of cardiomegaly of unknown origin in this country alcohol looms in the background.

IV. Pancreatic
Chronic alcoholism is an established factor in the causation of pancreatitis and pancreatic calcification in Western countries. In a study of 53 Sri Lankan patients with chronic alcoholism, the serum amylase levels were normal in 70% of the cases. However pancreatic calcification was found in two cases, an incidence of 2.4% 23 .

V. Cancer
Chronic alcoholism is closely linked with upper alimentary tract cancer including cancer of the oropharynx, larynx and the oesophagus 24 . Acetaldehyde is carcinogenic and mutagenic 24 and decreases DNA repair mechanisms leading to chromosomal aberrations 25 . In a study of 27 Sri Lankan patients with primary cancer of the liver, 75% of the males had consumed alcohol 26 . The diagnosis was made on the basis of the histopathology of the liver following percutaneous liver biopsy or autopsy.

Physicians obligations
Physicians are responsible for diagnosis and treatment. In Sri Lanka the diagnosis of alcoholism is Journal of the Ceylon College of Physicians Nagaratnam N, Ruwanpathirana S not as frequently made as it should be. Physicians are disinclined to make the diagnosis for two reasons. One is that they tend to underestimate the prevalence of alcoholism in the community and the other is that they tend to discount its contribution to many medical emergencies even though they are aware that the patient is an alcoholic. Among the reasons for this attitude are (1) a history of alcoholism is not easily obtainable, for alcoholics rarely speak the truth, (2) patients err greatly on the side of understatement unless they are subjected to persistent interrogation, (3) rather poor results of treatment and (4) the diagnosis is in turn related to the support of his family, his financial resources and his socio-economic status.
When alcoholism is unrecognised the dangers are obvious and the strength of the dependence can be under estimated or the associated illness missed or misdiagnosed. A variety of medical, social and economic consequences can result when alcoholism is untreated. A hospital study in 1999 showed that 24% of male deaths were alcohol related. Annually 20,000 die due to alcoholic consumption 27 . Apart from treating alcoholism the physician must be aware of the health burden, the annual cost of the damage caused by alcohol which is estimated at Rs 141 billion 28 . Doctors need practice in referring patients to specialised treatment services. In Sri Lanka there is a clinic in every hospital to treat addicts and there are six rehabilitation hospitals in this country 29 .
Physicians managing alcoholism and alcoholrelated complications should be able to liaise with the government and more so with those in policy making positions. The College of Physicians and the College of General Practitioners should play an active part to this end. About 5-10% of hospital admissions in Sri Lanka are directly or indirectly related to alcohol abuse 7 . Hence physicians are well placed to identify and manage patients for they are the first point of entry for patients presenting to hospital with alcohol related complications. They have the opportunity not only to manage these patients but also advise them about the harmful effects of alcohol and how it has contributed to their present problems 30 .