The Alcoholic

Hospitals and ER's always have frequent flyers. These are patients who come to the ER or get admitted to the hospital repeatedly for the same reason. They are usually drunkards who need a bed for the night or stubborn elderly patients who refuse to take their medicine and have no family or friends to take care of them. The hospital where I did my internship had many such patients because we were located in one of the poorer neighborhoods.

One of these patients in particular was known to practically every physician, nurse, and security guard in the hospital. I can't give his name, but whenever anybody heard he was coming around, they rolled their eyes because they knew they were in for a frustrating and busy admission. We'll call him D.G.

D.G. is a 35 year old African American man who appeared like he was at least 50. He had gray hair, was constantly in pain, could not walk straight, and had blood shot eyes. To say that he was an alcoholic would be an understatement. He drank roughly 2 liters of vodka daily and a six pack of beer. He was incredibly frustrating to work with. He refused to take all medications, was rude to everyone, including the nicest, kindest nurses, and he always threatened to leave AMA (against medical advice) if he didn't get what he wanted. D.G. was usually able to make it a 2-3 weeks in between admissions.

Alcohol was killing him. I would be surprised if he made it past the next year if he continues to drink (and he will). Even if he miraculously decided to stop drinking, he would probably eventually succomb. His problems stemmed mainly from his liver, which had become so heavily scarred from constantly detoxifying the body of alcohol. This is cirrhosis of the liver.

Most people know about the circulatory system and how the heart pumps blood around blood vessels to feed various organs. This is the systemic circulatory system. But there is another circulatory system called the portal system. This system is still "powered" by the heart, but it involves a different set of blood vessels. These blood vessels start at the intestine, where they pick up nutrients absorbed by the GI tract and transports these nutrients (via blood) to the liver. The liver then does a whole host of metabolic functions including detoxification of the blood. The blood then moves on and eventually joins up with the systemic circulatory system. So the liver is the middle man between the portal and systemic circulatory system.

When the liver gets scarred, blood cannot travel through it as easily as it should. So pressure backs up into the portal system. This is called portal hypertension. Normal portal pressure is about 8mmHg, which is a very low pressure when you consider that normal arterial blood pressure is around 100mmHg. So when portal pressures increase, you get a whole host of physiologic changes. There are veins in the esophagus, stomach, and rectum which are involved in the portal system. When portal hypertension occurs, these veins get engourged. They become varicose veins, just like the ones on your legs but in different locations. Because they are located just beneath a thin layer of mucosa, these varicose veins can bleed very easily. Esophageal varices can be especially dramatic because patients can start vomitting blood, and it just poors out of them. Definitely a medical emergency. D.G. has been admitted multiple times for esophageal varices. I admitted him once in the ICU and he had lost more than half of his total blood volume. Ultimately we stopped the bleeding, but he left AMA when we refused to give him a turkey sub.

Another problem with portal hypertension is that fluid starts leaking out of the circulation and into the abdominal cavity. The portal system is not equipped to handling pressures that high, so the normal equilibrium which holds fluid in the blood vessels is disturbed. The result is what is called ascites, which is just fluid in the abdomen. The liver is also responsible for making albumin, a protein found in abundance in the blood. This protein also helps keep fluid within blood vessels. So when people have damaged livers, they stop making albumin and this further encourages fluid to accumulate in the abdomen.

D.G. probably had about 10 liters of fluid in his abdomen. That's 5 large coke bottles of fluid (and that may be underestimated). The first time you see him, it is really quite striking. His abdomen is larger than a pregnant woman's (although he does walk like one). The skin on his belly has a orangey-brown color and is spread so tightly that it looks like it will rip. The underlying abdominal muscles have also been spread thin and abdominal contents have bulged out of his abdomen and form a 5 centimeter lump on the side of his belly button. His belly button also has another lump. When you palpate his abdomen, it is rock hard. Push on your own belly and feel how soft it is. Now push on a piece of concrete and imagine that is what your stomach feels like.

D.G. walks around with this protuberant abdomen. The rest of his body is skinny, wasted, and cachectic because his only source of nutrition is alcohol. He looks like a starving child from Africa. These children also have protuberant abdomens from ascites because they do not eat enough protein. In turn, the liver cannot make albumin, which needs protein as a building block.

Every 3-4 weeks, D.G. has to come back to the hospital to have the fluid in his abdomen drained. Otherwise, I suppose he would ultimately pop. This procedures is called a paracentesis. This is a procedure that residents can perform. While it is not the most difficult procedure to perform, a procedure is always met with caution because of the potential complications. Paracentesis usually involves finding a pocket of ascites (fluid) and sticking a needle through the abdominal wall and into that pocket of fluid. Occasionally an ultrasound will be used to locate that pocket of fluid because you don't want to stick a needle into any of the abdominal organs. Interns are always very nervous and shaky the first time they do it because it seems like it could have potentially devastating consequences.

With D.G., it is a different story. His abdomen is so filled with fluid that you would be hard pressed to puncture an organ before you drain a significant amount of fluid. Performing a paracentesis on D.G. is like sticking a straw into a juice box. You just aim and shoot. Nothing to be worried about. This is one procedure that D.G. is actually cooperative with because it makes him much more comfortable after the fluid is removed. We usually are able to drain 6 liters of fluid at a time. This does not make his abdomen look any smaller, but it does make it a little softer to push on. D.G. came in so often for paracenteses and they were so easy to perform that the program director at our residency thought about setting up a formal rotation so that every resident could practice the procedure.

The sad thing about D.G. is that ascites and portal hypertension are just the beginning of his problems. He has many family issues, psychological issues, and a whole host of medical problems to deal with. It is easy for physicians to just blaim patients for their bad habits and chalk it up to stubbornness, but the fact is that D.G. had a lot to be sad about. There may be an underlying reason for his addiction.

Ultimately, though there is only so much that we can do in the medical profession. We can only treat what we know how to treat. Without cooperation from the patient and his social network, we are helpless.