End-Stage Alcohol Use Disorder with Multi-Organ Failure

Case at a Glance

A 58-year-old male with chronic alcohol use disorder presenting with advanced complications including Wernicke-Korsakoff syndrome, probable liver failure with jaundice, severe malnutrition, and cognitive impairment. Patient refuses medical intervention despite life-threatening condition.

Patient's Story

The patient is a 58-year-old male with a long history of chronic alcohol use disorder, tobacco smoking, and tobacco chewing. Over the past year, his alcohol consumption has increased dramatically to the point where he spends most days either asleep or unconscious from drinking. He has developed severe mobility issues requiring assistance for basic activities like using the bathroom. The patient exhibits significant cognitive changes including memory loss, confabulation, and aggressive behavior when medical care is suggested. He has completely stopped eating for several days and expresses a desire to 'drink himself to death,' indicating possible suicidal ideation secondary to untreated depression.

Initial Assessment

Patient presents with multiple concerning symptoms: persistent hiccups, chronic diarrhea, complete loss of appetite, severe weight loss, tremors, inability to perform fine motor tasks, sleep disturbances with loud vocalizations, and frequent unexplained bruising. Physical examination would likely reveal jaundiced sclera, bloodshot and possibly protruding eyes, evidence of recent shoulder fracture (untreated), and signs of severe malnutrition. Patient demonstrates altered mental status with periods of confusion and fabricated memories.

The Diagnostic Journey

Given the clinical presentation and patient history, the differential diagnosis includes: End-stage alcohol use disorder with multiple complications including Wernicke-Korsakoff syndrome (evidenced by memory loss, confabulation, and gait disturbance), alcoholic hepatitis progressing to liver failure (suggested by jaundice and ascites), alcoholic gastritis and colitis (explaining hiccups and diarrhea), severe malnutrition with multiple vitamin deficiencies (particularly thiamine/B1), possible hepatic encephalopathy, thrombocytopenia (explaining easy bruising), and cerebellar dysfunction from chronic alcohol toxicity.

Final Diagnosis

1. End-stage alcohol use disorder
2. Wernicke-Korsakoff syndrome
3. Alcoholic liver disease with probable hepatic failure
4. Severe malnutrition with multiple vitamin deficiencies
5. Alcoholic gastritis and colitis
6. Thrombocytopenia
7. Cerebellar dysfunction
8. Untreated major depressive disorder with suicidal ideation
9. Probable hepatic encephalopathy

Treatment Plan

Ideal treatment would require immediate hospitalization for medically supervised detoxification with benzodiazepine protocol to prevent withdrawal seizures, high-dose intravenous thiamine replacement (300mg+ daily), comprehensive vitamin and mineral supplementation, nutritional support, and psychiatric evaluation. However, patient adamantly refuses all medical intervention and becomes violent when approached about treatment. Palliative measures include: oral multivitamin supplementation (can be crushed and mixed in liquids), thiamine 300mg daily if obtainable, anti-nausea medication (metoclopramide), anti-diarrheal medication (loperamide), and symptomatic supportive care. Critical warning: Patient must NOT stop drinking abruptly without medical supervision due to high risk of fatal withdrawal seizures.

Outcome and Follow-up

Prognosis is extremely poor given the advanced stage of multi-organ failure and patient's refusal of treatment. Life expectancy is estimated at days to months without intervention. Family members require education about potential complications including: upper gastrointestinal bleeding with hematemesis, withdrawal seizures if alcohol consumption stops abruptly, hepatic encephalopathy with worsening confusion, falls with potential traumatic brain injury, and progression to hepatorenal syndrome. Family counseling and support services are essential for caregivers dealing with this tragic situation. Advanced directives and palliative care planning should be considered given patient's expressed wishes and poor prognosis.