ALCOHOL INTOXICATION WITHOUT CONSUMING ALCOHOLIC BEVERAGES: NOT A RARE AILMENT
ANY. MORE
J C MEEROFF, MD, PhD and S. MEEROFF
South Florida Institute of Integrative Medicine, USA
“Drunkenness is nothing but voluntary madness” Seneca
the Young
"I have taken more out of alcohol than alcohol has taken out of
me." Winston Churchill
First you take a drink, then the drink
takes a drink, then the drink takes you. ”F. Scott Fitzgerald
“Is life worth living? It all depends on
the liver” William James
"Alcohol is the anesthesia by which
we endure the operation of life." ~ George Bernard Shaw
INTRODUCTION
Ethyl alcohol
(ETOH) abuse also known as alcohol use disorder or alcoholism resulting from excessive
drinking ETOH beverages is the second most common form of substance abuse in
the world, after tobacco smoking. Some people are more severely affected than
others which is probably related to genetic factors. In the US an estimated 10%
of adult men and 5% of adult women suffer from alcoholism. Excessive drinking
habits produce health problems and/or social difficulties at home, at work, at
school, or with the law. Addicts lost control of their drinking habits and are
unable to stop or cut down despite serious negative health consequences and the
loss of valued activities and/or relationships.
ETOH in
alcoholic beverages is rapidly absorbed from the upper GI tract into the
circulation. From there, ETOH enters most tissues of the body except for bone
and fat. In an adult male, ETOH can penetrate to approximately 70% of body
tissues. Body composition is important, because if the percentage of adipose
tissue is high and ETOH can only be distributed throughout the remaining lean
tissue, then in obese people there is a higher concentration of ETOH in those
areas. Once in different organs ETOH produce damage according to the
tissue it affects. ETOH is a strong toxin that must be neutralized or
eliminated from the body as soon as possible. Ten percent of ETOH is eliminated
through the skin, the lungs and the kidneys,. The other 90 percent is
metabolized by the liver and other organs. ETOH is catabolized in the liver in
three steps:
1. ETOH to acetaldehyde by the enzyme
alcohol dehydrogenase or ADH
2. Acetaldehyde to acetic acid by the enzyme
acetaldehyde dehydrogenase or ALDH
3. Acetic acid to carbon dioxide
(CO2) and water.
Acetaldehyde is the main
responsible for ETOH drunkenness causing symptoms such as
slurred
speech, incoordination, mood and behavior changes, headaches, fatigue, nausea,
muscle pain, facial flush and palpitations.
The mechanisms involved in ETOH
tissue damage are complex and interactive. They can be separated into chemical
and immune injuries. In the liver, the organ that gets the most damage by ETOH,
the biochemical mechanisms involve chemicals that are detoxified via the
cytochrome P-450 system and/or conjugation processes. When there is an excess
of ETOH and acetaldehyde in the liver the detoxification mechanisms are not sufficient
to clean the organ and damage may occur. Toxic metabolites alter plasma
membrane, mitochondria, intracellular ion homeostasis, or degradative enzyme
activity. Immune mechanisms involve cell cooperation, and are mediated by
cytokines, nitric oxide, and complement.
Distilled ETOH beverages do not stimulate
the secretion of gastrin, leading to hypersecretion of gastric acid, but not
distilled alcoholic beverages contain impurities that certainly do it.
Figure 1 Catabolism of ETOH (from Duke
University
https://sites.duke.edu/apep/module-1-gender-matters/content/content-how-is-alcohol-eliminated-from-the-body/)
On the other hand, the colonic microbiota
plays an important role in human digestive physiology making a significant
contribution to health. The human gut alone contains on average 40,000 different
bacterial species, 9 million unique bacterial genes and 100 trillion microbial cells. The principal metabolic activities of colonic microorganisms are
associated with CHO and protein digestion. CHO fermentation is a
beneficial process in the colon, because it disintegrates complex plant and
animal polysaccharides into simple monosaccharides, which can be absorbed by
the host. This process extracts energy from indigestible carbohydrates and
produce beneficial short-chain fatty acids while also provides energy to the symbiotic
micro-organisms living in the gut.
Microbial protein fermentation is a
complex and still poorly understood process that alters the gut microbiota and generates
a diverse range of bioactive molecules which can exert a wide range of
metabolic effects in the host.
When there is an increased supply of carbohydrates
(CHO) from ingesting to many monosaccharides, disaccharides and even
polysaccharides, combined with an overpopulation of bacteria and yeasts in the
intestine, anaerobic ETOH fermentation takes place at an increase rate and
velocity converting glucose and other simple CHO into ethyl alcohol and carbon
dioxide = C6H12O6 → 2C2H5OH + 2CO2. Then significant
amount of ETOH is absorbed. Clinically, this situation mimics drunkenness
causing severe psychosocial trauma to those individuals affected since they are
not alcoholics but act like alcoholics.
DIGESTIVE PHYSIOLOGY IN A
CAPSULE
In normal conditions, the stomach, the
duodenum and the small intestine should be relatively free from bacteria, yeast
and/or parasites. Normally the low pH of the gastric secretion digests protein
efficiently and kills the acid sensitive microbes that may be there; then the high
pH of the duodenum kills alkali sensitive microbes with bicarbonate and continue
the process of digesting foods; finally bile salts, which are toxic to many microbes,
and pancreatic enzymes further digest protein, fats and carbohydrates eliminating
germs that may have bypassed the gastroduodenal barrier. In the small bowel most
of the digestion and absorption of nutrients take place.
Contrarily to what occurs in the upper GI
tract, anaerobic bacteria, largely bacteroides, thrive in the lower GI track,
where foods that were not completely digested before are then fermented to
produce substances highly beneficial to the body but also generate increased
amounts of alcohols such as ethyl alcohol, isopropyl alcohol, butyl alcohol and
methyl alcohol. These alcohols are metabolized to acetaldehyde, propyl aldehyde,
and possibly formaldehyde. The catabolic products are partially eliminated via the
stools, but some are absorbed into the circulation producing damage to many
tissues and organs.
Alcoholic fermentation is an intricate
biochemical process during which yeasts convert sugars into ETOH,
CO2, and other metabolic byproducts that contribute to the chemical composition
and odor of the fermented foodstuffs.
Circulating alcohols and acetaldehydes produce
symptoms and signs such as foggy brain ("toxic
brain", feeling poisoned), red or flushed skin, dizziness, disorientation,
headaches, pain, nausea, vomiting, dehydration, dry mouth, burping or belching,
fatigue, memory and/or concentration problems and mood changes
Endogenous absorbed alcohols also decrease
the concentration of glucose in plasma. This makes the sufferer crave for sweet
products, the nutrients microorganisms need for their own survival. This is an
evolutionary symbiotic strategy by microbes to remain alive.
Every normal individual produces small
amounts of endogenous alcohol that are rapidly removed from the body through
enzymatic activity via ADH and ALDH.
Genetically predisposed individuals due
to faulty ADH and/or ALDH enzymes get more ETOH intoxicated than others. If those individuals ingest too many CHO a surplus of ETOH is produced and
absorbed into the circulation creating complications to the brain, the liver,
the stomach, the pancreas, and other organs.
AUTO BREWERY SYNDROME
Auto-brewery syndrome (ABS), also
known as gut fermentation syndrome, endogenous ethanol
fermentation or drunkenness disease, is a condition where an
overgrowth of yeast and/or bacteria residing in the gastrointestinal
tract converts dietary CHO into ETOH leading to drunkenness without consuming any alcoholic beverages.
In ABS, the absorption by interstitial
diffusion of the ETOH endogenously produced causes the same physical and
psychological manifestations as someone who has been drinking ETOH beverages in
excess and creates a serious social problem to the sufferer.
The yeast that might be responsible for ABS
includes the following:
ü Candida albicans
ü Candida glabrata
ü Candida tropicalis
ü Torulopsis glabrata
ü Candida parapsilosis
ü Candida krusei
ü
Candida kefyr
ü
Saccharomyces cerevisiae (brewer’s yeast)
ü
Saccharomyces boulardii
Bacteria causing ABS include:
ü
Klebsiella
pneumoniae and
Until recently ABS was considered a rare
medical condition but in reality it is more frequent than anticipated before especially
among individuals consuming fermented products mixed with high CHO containing foods. Both,
foods prepared with garlic and/or honey may contain yeast and other
microorganisms that can play a role in ABS. In the favorable conditions of the
gut, these organisms use lactic
acid fermentation or mixed acid fermentation pathways
to produce ETOH that is then easily absorbed from the small intestine, causing
an increase in blood alcohol concentrations leading to drunkenness without the
consumption of alcoholic beverages.
Interestingly enough ABS was
popularized and became the center of much recent medical attention after the
Inga Lindstrom German TV series episode from October 2019 named “Ausgerechnet Söderholm” where “Dr Alma Ekberg” (actress Susan Hoecke) diagnosed patient
“Lasse Viklund” (actor Stephan Baumecker) with ABS and helped him resolve all
the psychosocial difficulties he encounter for being treated as an alcoholic
when he was not.
In an initial retrospective review of
our metabolic associated fatty liver disease (MAFLD) patient’s records we
recognized most of the symptoms and signs of ABS. We also noticed that a
significant proportion of those patients consumed considerable amounts of white
(fresh) and/or black garlic (aged) mixed with honey and/or other sources of CHO.
To eliminate the yeast and bacteria responsible for the ETOH formation,
ABS is treated with anti-fungal oral medication such as clotrimazole, fluconazole, ketoconazole, terbinafine,
nystatin and/or the novel combination of paramomycyn bound to chrome. There are
also anecdotal reports claiming that several herbs and nutrients may be
effective against yeast. They include: Clove, Wormwood, Turmeric-Curcumin, Henna,
Whitania somnifera, apple cider, coconut oil and niacin
A diet low in CHOs is necessary in order to decrease the supply of
sugars.
The use of Metronidazole (Flagyl) is not recommended since it may
increase rather than eliminate the yeasts responsible for the syndrome.
GARLIC INTOXICATION
Garlic (Allium sativum) is a nutrient difficult to classify. It is a
vegetable but it can also be consider an herb, a spice or simply a flavoring
agent. Garlic has some alleged medicinal properties. Garlic, known as the “stinking
rose” contains several organosulfur compounds being allicin (allyl
thiosulfinate) the most important one. Allicin, a thioester of sulfenic
acid, is an oily, slightly yellow liquid that gives garlic its unique odor. Its
biological activity can be attributed to both its antioxidant activity and its
reaction with thiol-containing proteins. Allicin is unstable and can be reduced
in garlic products that are aged to lessen odor. Odorless garlic contain little
or no allicin. The lower the amount of allicin, the less effective a garlic
product might be for medicinal purposes.
Garlic is ingested everywhere in the world as fresh natural cloves,
powder garlic salt and/or encapsulated garlic extract. More recently ingestion
of black or caramelized garlic has also become popular.
So popular and universal is garlic consumption that in the USA there is
a National Garlic Day occurring on April 19th of each year.
Pure garlic, not containing symbiotic bacteria and/or yeast attached, manufacture
a special alcoholic molecules named allyl alcohol (AA). Acute toxicity studies have
shown that AA causes kidney and liver damage as well as skin and eye irritation
AA is produced from garlic in two ways: firstly by a self-condensation
reaction of allicin and secondly by a reaction between alliin, the precursor of
allicin, and water. AA is released after ingestion of garlic and is present in
exhaled air after its consumption, the highest concentration being after
ingestion of freeze-dried garlic tablets. Mechanisms, first proposed by Block for the formation of
AA in aqueous environments such as those found in vivo result from
the transformation of the thiosulphinates such as diallyl trisulphide and
diallyl disulphide with up to one-third of the ‘lost’ allyl groups during the
transformation producing AA. Recent investigations in rats reported that
similar degradative metabolites are formed in vivo too.
Scientific evidence demonstrated that allicin has some inhibitory
effects against Helicobacter pylori, Escherichia
coli and Lactobacillus casei. Allicin has also demonstrated some
efficacy against Entamoeba histolytica and Giardia lamblia. Contrarily,
the evidence that Allicin may be an effective anti-candida product is very
weak. Anecdotal evidence indicates that allicin may be potentially beneficial in reducing high blood pressure, decreasing hypercholesterolemia,
preventing coronary artery disease, improving circulatory deficiencies of the distal extremities,
preventing the common cold, reducing benign prostatic enlargement, reducing the
incidence of GI tumors and preventing tick bites. Garlic applied to the skin
may also be effective in treating fungal skin infections such as ringworm, jock itch, and athlete's foot.
Caramelized garlic is made from fresh garlic
that has been aged and heated. The caramelization process (Maillard reaction) is
a chemical reaction between amino acids and reducing sugars that gives the
treated substance a distinctive color and flavor. Caramelized garlic is a dark
brown product with a sweet jelly-like texture that resembles of balsamic vinegar or tamarind taste. Caramelized
garlic was first used as a food ingredient in Asian cuisine. Currently black garlic's popularity has spread around the world as it
has become a desirable ingredient used in both home-cooking and high-end
cuisine.[
When garlic cloves fresh or aged are
added to honey, or other high CHO containing foods, the water in garlic help sugars
to ferment converting sugars such as glucose, fructose, and sucrose into cellular
energy and at the same
time producing ETOH and CO2 as by-products. This type
of fermentation also takes place in some species of fish such as goldfish and carp to provide energy when oxygen is scarce.
Clinically garlic intoxication is
characterized by “foggy brain”, flatulence and “garlic odor” in the exhaled
air.
In summary garlic, a vegetable with some
beneficial medical actions, may be dangerous to the liver by at least two mechanisms:
1.
Producing too much endogenous ETOH and
2.
Generating too much allyl alcohol.
Therefore it is necessary to have caution
when using garlic products in the diet.
provisional CLASSIFICATION
OF Alcoholic intoxication leading to chronic liver damage without drinking
alcoholic beverages
In a preliminary attempt to classify the disorders caused by elevated
alcohol in the blood causing drunkenness and potentially leading to chronic
liver damage without consuming ethyl alcohol beverages, we recognize three
types of syndromes. We are confident that further research will expand this
list.
1. Auto
brewery syndrome (ABS)
INTOXICATION
WITH ENDOGENOUS ETHANOL
Eating excessive quantities of CHOs when the intestine has an
overpopulation of fermentative bacteria and/or yeast
2. GARLIC INTOXICATION
INTOXICATION
WITH ALLYL ALCOHOL
Eating too much black garlic mixed with fermented CHOs
3. DRINKING TOXIC ALCOHOLS
INEBRIATION
WITH TOXIC ALCOHOLS
Drinking purposely or by accident alcohols, other than ETOH, that are
not intended for recreational consumption such as methanol, ethylene alcohol, isopropyl
alcohol, benzyl alcohol, propylene glycol, etc
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Copyright 2021 © JCMeeroff, MD, PhD. All rights reserved.
MEEROFF JC & MEEROFF S (2021). Alcoholic intoxication without consuming alcoholic beverages: not a rare ailment any more. https://www.meeroffmedicine.com/articles/ Auto brewery Syndrome
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