Too much alcohol could cause black diarrhea

Introduction: Alcoholic people have a significantly increased risk of acute upper gastrointestinal bleeding. The time it takes until the emergency endoscopy is performed depends primarily on the patient's own assessment.
Method: 417 patients from Leipzig (n = 277) and Munich (n = 140) with an average alcohol consumption of 660 g / week were asked about their theoretical behavior in the event of symptoms of acute upper gastrointestinal bleeding.
Results: If they vomit blood or black fluid, 71% and 51%, respectively, would call the emergency doctor. If deep black stools suddenly appeared, 32% would alert the emergency doctor. Only 25% of the respondents considered immediate medical help necessary in each of the 3 situations. Patients with frequent doctor contacts and women assessed the symptoms as more of an emergency. There were no differences with regard to age, vocational training, marital status and the amount of alcohol consumed.
Discussion: Respondents had poor understanding of the meaning of gastrointestinal bleeding symptoms. In particular, alcoholic patients with infrequent doctor contacts should be made aware of the warning symptoms melena and hematemesis, because any delay has a significant impact on the prognosis and the consumption of resources.
Dtsch Arztebl 2008; 105 (5): 73-7
DOI: 10.3238 / arztebl.2008.0073
Keywords: upper gastrointestinal bleeding, hematemesis, melena, self-assessment, alcoholism
Alcohol can damage the upper gastrointestinal tract in a number of ways and in different areas. Alcohol, for example, lowers the tone of the lower esophageal sphincter. The result is decreased gastroesophageal clearance and increased gastroesophageal reflux. Depending on the concentration, alcohol also damages the mucosal barrier of the esophageal mucosa. Recirculating gastric acid can penetrate into the regeneration layer of the epithelial cells and destroy it (1). In the stomach, alcohol causes an inverted, concentration-dependent increase in gastric acid production (2). Through complex mechanisms, damage to the mucous membrane up to hemorrhagic gastritis is induced. While the incidence of duodenal ulcer is increased in alcoholic patients, several studies found no effect on the incidence of gastric ulcer (3).

In addition to these phenomena, which can be explained purely chemically, alcohol is an important carcinogen for carcinomas of the oral cavity, pharynx, hypopharynx and esophagus. Most devastating is the effect on the throat: a daily alcohol intake of 100 g increases the risk of throat cancer by 125 times. Alcohol users who smoke tobacco actually increase their risk 210 times that of the normal population (3).

Another alcohol-related risk due to damage to the upper gastrointestinal tract are secondary diseases of liver cirrhosis, such as portal hypertension (portal hypertensive gastropathy, esophageal and fundic variceal bleeding) or disorders of plasmatic coagulation or platelet count and function.

Upper gastrointestinal bleeding occurs with an incidence of about 150/100,000 per year; the mortality rate is between 8 and 14% (4–6). Alcohol-consuming patients are particularly at risk of upper gastrointestinal bleeding and death from it (7). A study of more than 220,000 natural deaths in Sweden found that alcohol-related illnesses account for 17% of all mortality. However, patients who died from variceal bleeding or non-varicose upper gastrointestinal bleeding were alcoholic patients in 29% and 47% of cases, respectively (8).

The standard treatment for upper gastrointestinal bleeding is immediate therapeutic esophagogastroduodenoscopy, although the guidelines assess the optimal time frame for this examination differently (9). A meta-analysis of 23 studies on non-varicose upper gastrointestinal bleeding showed that timely endoscopy has a positive effect on transfusion requirements and length of stay in hospital, but not on complications and mortality (10). Another study also showed a significant reduction in the cost of emergency endoscopy compared to elective endoscopy (11).

Due to the widespread use of modern hemostatic techniques, mortality from upper gastrointestinal bleeding - especially in patients with liver cirrhosis - has been reduced in recent decades: In a French long-term study, for example, the wider use of endoscopic rubber band ligation resulted in a reduction in mortality within 4 years in acute upper gastrointestinal bleeding from 11.7 to 7.2% (p = 0.03) (5). There is therefore a consensus in Germany that endoscopy should be performed immediately after hospital admission and any necessary circulatory stabilization. This approach is also reflected in a clearly formulated recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) (12).

The most common symptoms of upper gastrointestinal bleeding are vomiting (hematinized) blood and the appearance of black stools (tarry stools). Although there is a lack of systematic studies, experience has shown that patients with high alcohol consumption often only present themselves to the emergency room with a considerable delay when they experience these symptoms, or call the emergency doctor late. This leads to increased blood loss and often the need for intensive care monitoring and an increased need for transfusions.

The aim of the study by the authors was to determine the knowledge of alcoholic patients about symptoms of gastrointestinal bleeding and to identify groups with particular deficits.

method
Between June 2006 and March 2007, the authors asked patients with high alcohol consumption about their theoretical behavior in the event of symptoms of acute upper gastrointestinal bleeding. The subjects were interviewed orally, if necessary only after any clinically detectable symptoms of alcohol withdrawal had subsided. The patient's answers were recorded on a standardized questionnaire. Regardless of the reason for hospital admission, the authors questioned all alcoholic patients who were admitted to a normal ward during the period mentioned.

An alcoholic illness was assumed if the patient currently or had a history of consuming more than 140 g (women) or 420 g (men) of alcohol per week. Weekly alcohol consumption was determined through detailed surveys. For this purpose, the volumes of all alcoholic beverages that test subjects had consumed per week in the last 3 months were recorded and multiplied by the average concentration in% by volume (beer 5% by volume, wine 12% by volume, spirits 40% by volume). The calculated number of milliliters was multiplied by the specific gravity (0.7913 g / mL) of the ethanol to obtain the amount in grams. Exclusion criteria were clinically detectable symptoms of alcohol withdrawal, the inability to communicate, or the patient's refusal to answer the questionnaire.

The questions were, “What would you do if you suddenly found this evening:
- black vomiting
- bloody vomiting
- deep black stool? "
Immediately after the survey, the respondents should choose the answer that they consider to be correct: “wait”, “tomorrow family doctor” or “today emergency doctor”. The immediate alerting of the emergency doctor was rated as the correct answer.

In addition, data on age, gender, exact weekly alcohol consumption, the number of doctor contacts within the last year and marital status were requested. The authors also asked whether vocational training had been completed.

The study is of a purely exploratory nature. The univariate chi-square test and the Mann-Whitney U-test were used to assess the influence of the various predictors on the patient's reaction. The multivariate evaluation of the predictors was carried out using a logistic regression analysis. The patient's reaction (emergency doctor yes or no) was assumed to be the dependent variable. Independent variables were city, age, gender, marital status, level of education and the amount of alcohol consumed. Statistical significance was found in p < 0,05="">

Results
The authors questioned 417 patients with high alcohol consumption (98 women, 319 men; median age 51, range: 18 to 82 years) from Leipzig (n = 276, 51 women, 225 men) and Munich (n = 140, 47 women, 93 men ) with an average alcohol consumption of 660 g / week (interquartile range 276 g to 1 023 g). The first quartile also included 30 patients with high alcohol consumption (7%) who were abstinent at the time of the survey. 109 respondents (26%) had participated in an alcohol withdrawal program at least once. 12 other patients refused to take part in the survey (3%). On the basis of the alcohol quantities given in the anamnesis, the authors assume that the respondents were predominantly alcoholic patients; however, an exact diagnosis based on the symptoms in ICD10 or DSM4 was not carried out. The main hospital diagnosis was also not recorded. When the anamnesis was taken, however, 219 (52.5%) and 104 (24.9%) patients indicated that they had been previously diagnosed with cirrhosis of the liver or chronic pancreatitis. According to their own information, 10 patients (2.4%) had both diseases. 15 patients (3.6%) had an epileptic seizure before. In 43 patients (10.3%) there was no history of alcohol-related illness. The remaining 26 patients (6.2%) could only insufficiently remember their personal history.

Bloody vomiting was seen as the most worrying symptom: 71% of those surveyed would call the emergency doctor immediately if they had this symptom (graphic). In both the univariate and the multivariate analysis, gender (women answered correctly more often), place of residence and the number of doctor visits were significant influencing factors (table, eTable). The awareness of dangers with black vomiting and tarry stools was much worse; here only half or a third of the respondents would need immediate medical help (graphic). A significant influencing factor in the multivariate analyzes was the number of doctor contacts per year for both target criteria. Only 106 patients (25%) answered all 3 questions correctly.

The table shows further significant differences from subgroup analyzes: women would be more inclined to call the emergency doctor than men with both black and bloody vomiting (p < 0,05).="" der="" vorteil="" der="" leipziger="" patienten="" in="" ihrer="" richtigen="" reaktion="" auf="" blutiges="" erbrechen="" wurde="" durch="" ihre="" unterbewertung="" des="" symptoms="" „teerstuhl“="" aufgehoben;="" insgesamt="" scheinen="" damit="" keine="" wesentlichen="" unterschiede="" zwischen="" ost-="" und="" westdeutschen="" alkoholkranken="" patienten="" zu="" bestehen.="" am="" deutlichsten="" waren="" die="" wissensunterschiede,="" wenn="" man="" sie="" mit="" den="" erfolgten="" arztkontakten="" innerhalb="" des="" letzten="" jahres="" in="" zusammenhang="" brachte:="" insbesondere="" bei="" den="" weniger="" augenfälligen="" blutungssymptomen="" meläna="" und="" erbrechen="" von="" hämatin="" bestanden="" deutliche="" unterschiede="" in="" den="" antworten="" zugunsten="" von="" patienten="" mit="" häufigen="" arztkontakten.="" die="" faktoren="" alter,="" familienstand,="" wöchentlicher="" alkoholkonsum="" und="" abgeschlossene="" berufsausbildung="" wirkten="" sich="" nicht="" unterschiedlich="" aus="" (kasten,="" egrafiken="">

discussion
The study suggests that alcoholic patients have insufficient knowledge of the significance of possible symptoms of upper gastrointestinal bleeding. This applies to both obvious symptoms, such as vomiting blood, and less obvious symptoms, such as vomiting from hematin or tarry stools. Only a quarter of the respondents derived an acute need for action from all 3 symptoms. As expected, the bloody vomiting was given the highest priority.

Knowledge about the significance of melena as a serious symptom of gastrointestinal bleeding was particularly poor: Even in the best-informed group of patients with at least 12 doctor contacts in the last year, only every second respondent would call the emergency doctor immediately. This association could indicate that close doctor-patient relationships may involve repeated education about warning symptoms. It was not examined whether the patients in this group had suffered gastrointestinal bleeding more frequently than patients with infrequent medical contacts due to their assumed increased morbidity. Such a difference could have an impact on the more frequent correct assessment of bleeding symptoms in this group.

The method cannot prove whether the data collected is more positive in the practical confrontation with the theoretically sketched emergency. The disadvantage of the study - its theoretical character - must be pointed out here. The scenario was designed in an open manner and is ultimately not entirely specific for life-threatening gastrointestinal bleeding. Symptoms such as vomiting from previously drunk coffee or the often deep black stool after drinking blueberries are also included in the description. However, more precise details in the description would have simplified the answer too much. Likewise, no age- and gender-identical comparison group of people without alcohol consumption was surveyed; knowledge may not be better in the general population. Due to the patient selection, the collected data are not to be regarded as representative: Only patients hospitalized in normal wards with high alcohol consumption were examined in 2 German cities.

While the self-assessment of short-term alcohol consumption - for example directly before a traffic accident - correlates well with the measured blood alcohol levels (13), the results of numerous population-related surveys on chronic alcohol consumption are significantly below the alcohol quantities sold in the same region. In one of the largest studies on this subject - the “Finnish Drinking Habit Survey” from 1992 - residents of a region underestimated their actual alcohol consumption by 43% (14–15). Women seem to be more prone to understatement than men, and the consumption of spirits is much more clearly underestimated than that of beer and wine (16). Although the authors adhered to internationally recommended standards when structuring the interview (17), the alcohol quantities given by those affected can only be viewed as an indication of the individual level of alcohol consumption. Interestingly, however, there were no differences between the respondents with the lowest and those with the highest weekly alcohol consumption in terms of their response to clinical signs of upper gastrointestinal bleeding.

Conclusion
Patients with high alcohol consumption represent a risk collective for upper gastrointestinal bleeding. However, there is very poor knowledge of the correct response to hematemesis and melena. Women and patients with more than 12 doctor contacts in the last year were among the best informed. In particular, patients with high alcohol consumption and infrequent doctor contacts should be advised of the warning symptoms melena and hematemesis by their general practitioner, the gastroenterologist who is also treating them, but also by colleagues involved in the therapy from the psychosocial area. Every time delay caused by the patient has a significant influence on the prognosis and the consumption of resources.

The authors thank Dr. med. Andreas von Aretin, chief physician of
Department of Internal Medicine II of the St. Elisabeth Hospital in Leipzig, for their kind support.

Conflict of interest
The authors declare that there is no conflict of interest within the meaning of the guidelines of the International Committee of Medical Journal Editors.

Manuscript dates
submitted: April 10, 2007, revised version accepted: November 6, 2007

Address for the authors
PD Dr. med. Niels pond
University of Leipzig
Medical Clinic and Polyclinic II
- Gastroenterology and Hepatology -
Philipp-Rosenthal-Strasse 27
04103 Leipzig
Email: [email protected]

Summary
Self Assessment of Warning Symptoms in Upper
Gastrointestinal bleeding
Introduction: Alcohol addicted patients are at increased risk of upper
gastrointestinal bleeding. Delay to endoscopy is mainly determined by patients' self assessment. Methods: The authors asked 417 patients with high alcohol consumption from Leipzig (n = 277) and Munich
(n = 140) with an average alcohol consumption of 660 g / week about their behavior when faced with symptoms of acute upper gastrointestinal bleeding. Results: 71% or 51% said they would call the emergency physician if they were to vomit blood or black liquid. Only 32% would call emergentcy medical aid if they were to pass black stools, and only 25% of those surveyed thought urgent medical attention necessary in any of the 3 scenarios. Patients with regular contact with health care providers, and women, were more likely to consider these 3 scenarios as medical emergencies. The authors found no
differences by age, educational level, marital status and alcohol consumption. Discussion: Knowledge concerning the impact of symptoms of gastrointestinal bleeding was poor, in our study. Patients with high alcohol consumption and infrequent contact with health care providers, in particular, should be informed about symptoms such
as melena and hematemesis, as delayed presentation significantly
affects prognosis and resource consumption.
Dtsch Arztebl 2008; 105 (5): 73-7
DOI: 10.3238 / arztebl.2008.0073
Key words: upper gastrointestinal tract hemorrhage, hematemesis, melena, self assessment, alcoholic disease

The German version of this article is available online:
www.aerzteblatt-international.de
eGraphics and eTable:
www.aerzteblatt.de/artikel08m73
Teyssen S, Singer MV: Alcohol and the esophagus. In: Singer MV, Teyssen S (Ed.): Alcohol and alcohol-related diseases.Basics - Diagnostics - Therapy. Berlin, Heidelberg, New York: Springer-Verlag 1999; 158-67.
Singer MV, Leffmann C, Eysselein VE, Calden H, Goebell H: Action of ethanol and some alcoholic beverages on gastric acid secretion and release of gastrin in humans. Gastroenterology 1987; 93: 1247-54. MEDLINE
Singer MV, Teyssen S: Alcohol-associated organ damage. Dtsch Arztebl 2001; 98 (33): A 2109. FULL TEXT
Rockall TA, Logan RF, Devlin HB, Northfield TC: Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering committee and members of the national audit of acute upper gastrointestinal haemorrhage. BMJ 1995; 311: 222-6. MEDLINE
Di Fiore F, Lecleire S, Merle V et al .: Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol 2005; 17: 641-7. MEDLINE
Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J: Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ 1997; 315: 510-4. MEDLINE
Kelly JP, Kaufman DW, Koff RS, Laszlo A, Wiholm BE, Shapiro S: Alcohol consumption and the risk of major upper gastrointestinal bleeding. Am J Gastroenterol. 1995; 90: 1058-64. MEDLINE
Sjögren H, Eriksson A, Broström G, Ahlm K: Quantification of alcohol-related mortality in Sweden. Alcohol Alcohol. 2000; 35: 601-11. MEDLINE
ASGE Standard of Practice Committee: The role of endoscopy in the management of non-variceal acute upper gastrointestinal bleeding. Guidelines for clinical application. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1992; 38: 760-4. MEDLINE
Spiegel BM, Vakil NB, Ofman JJ: Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med 2001; 161: 1393-404. MEDLINE
Lee JG, Turnipseed S, Romano PS et al .: Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999; 50: 755-61. MEDLINE
Cherpitel CJ, Ye Y, Bond J et al .: Validity of self-reported drinking before injury compared with a physiological measure: cross-national analysis of emergency-department data from 16 countries. J Stud Alcohol Drugs 2007; 68: 296-302. MEDLINE
Edwards G, Anderson P, Babor TF et al .: Alcohol policy and the public good: a good public debate. Addiction. 1996; 91: 477-81. MEDLINE
Mustonen H, Metso L, Paakkanen P, Simpura J, Kaivonurmi M: Finnish Drinking Habits in 1968, 1976, 1984, 1992 and 1996. Tables and Publications Based on Finnish Drinking Habit Surveys. Themes 7/1999. National Research and Development Center for Welfare and Health, Helsinki, Finland.
Lemmens PH: The alcohol content of self-report and "standard" drinks. Addiction 1994; 89: 1703-6. MEDLINE
Dawson DA: Methodological issues in measuring alcohol use. Alcohol Res Health 2003; 27: 18-29. MEDLINE
Clinic for Gastroenterology, Hepatology and Gastroenterological Oncology, Städtisches Klinikum München GmbH, Klinikum Bogenhausen: Dr. med. Gundling, Prof. Dr. med. Schepp
Department of Gastroenterology and Hepatology, Medical Clinic and Polyclinic II, University of Leipzig: Harms, Prof. Dr. med. Schiefke, Prof. Dr. med. Mössner, PD Dr. med. pond
1. Teyssen S, Singer MV: Alcohol and the esophagus. In: Singer MV, Teyssen S (Ed.): Alcohol and alcohol-related diseases. Basics - Diagnostics - Therapy. Berlin, Heidelberg, New York: Springer-Verlag 1999; 158-67.
2. Singer MV, Leffmann C, Eysselein VE, Calden H, Goebell H: Action of ethanol and some alcoholic beverages on gastric acid secretion and release of gastrin in humans. Gastroenterology 1987; 93: 1247-54. MEDLINE
3. Singer MV, Teyssen S: Alcohol-associated organ damage. Dtsch Arztebl 2001; 98 (33): A 2109. FULL TEXT
4. Rockall TA, Logan RF, Devlin HB, Northfield TC: Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering committee and members of the national audit of acute upper gastrointestinal haemorrhage. BMJ 1995; 311: 222-6. MEDLINE
5. Di Fiore F, Lecleire S, Merle V et al .: Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol 2005; 17: 641-7. MEDLINE
6. Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J: Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ 1997; 315: 510-4. MEDLINE
7. Kelly JP, Kaufman DW, Koff RS, Laszlo A, Wiholm BE, Shapiro S: Alcohol consumption and the risk of major upper gastrointestinal bleeding. Am J Gastroenterol. 1995; 90: 1058-64. MEDLINE
8. Sjögren H, Eriksson A, Broström G, Ahlm K: Quantification of alcohol-related mortality in Sweden. Alcohol Alcohol. 2000; 35: 601-11. MEDLINE
9. ASGE Standard of Practice Committee: The role of endoscopy in the management of non-variceal acute upper gastrointestinal bleeding. Guidelines for clinical application. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1992; 38: 760-4. MEDLINE
10. Spiegel BM, Vakil NB, Ofman JJ: Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med 2001; 161: 1393-404. MEDLINE
11. Lee JG, Turnipseed S, Romano PS et al .: Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999; 50: 755-61. MEDLINE
12. Schepke M, Sauerbruch T: Use of endoscopy in patients with esophageal varices: http://www.dgvs.de/media/2.3.Oesophagusvarizen.pdf
13. Cherpitel CJ, Ye Y, Bond J et al .: Validity of self-reported drinking before injury compared with a physiological measure: cross-national analysis of emergency-department data from 16 countries. J Stud Alcohol Drugs 2007; 68: 296-302. MEDLINE
14. Edwards G, Anderson P, Babor TF et al .: Alcohol policy and the public good: a good public debate. Addiction. 1996; 91: 477-81. MEDLINE
15. Mustonen H, Metso L, Paakkanen P, Simpura J, Kaivonurmi M: Finnish Drinking Habits in 1968, 1976, 1984, 1992 and 1996. Tables and Publications Based on Finnish Drinking Habit Surveys. Themes 7/1999. National Research and Development Center for Welfare and Health, Helsinki, Finland.
16. Lemmens PH: The alcohol content of self-report and "standard" drinks. Addiction 1994; 89: 1703-6. MEDLINE
17. Dawson DA: Methodological issues in measuring alcohol use. Alcohol Res Health 2003; 27: 18-29. MEDLINE