Alcohol & Alcoholism Vol. 34, No. 3, pp.

330–336, 1999

DRINKING PATTERN AND ALCOHOL-RELATED MEDICAL DISORDERS

TILMAN WETTERLING*, CLEMENS VELTRUP, MARTIN DRIESSEN and ULRICH JOHN
Department of Psychiatry, University Medical School of Lübeck, Lübeck, Germany

(Received 27 July 1998; received and accepted in revised form 12 November 1998)

Abstract — Although heavy alcohol intake is known to be one of the most common causative factors of
liver disease, pancreatitis, upper gastrointestinal and neurological disorders, the influence of the drinking
pattern is largely unknown. The study investigated the relationship of alcohol-related medical disorders
in alcoholics and their drinking pattern. Two hundred and forty-one chronic alcoholics were referred con-
secutively for detoxification and their drinking pattern was sufficient for them to be included in this study.
History of alcohol abuse as well as drinking behaviour in the last 6 months were assessed by a semi-
structured interview. Findings included intensive clinical examination with abdominal ultrasound in most
subjects. Heavy drinking with frequent inebriation was most often found in our sample (44.4%), whereas
continuous heavy alcohol consumption without intoxication (33.6%), and an episodic drinking style
(22.0%) were less frequent. The heavy drinkers suffered more often from pancreatitis, oesophageal
varices, polyneuropathy or erectile dysfunction than episodic drinkers. They also showed more upper
gastrointestinal disorders, although the estimated life-time alcohol intake was comparable to continuous
drinkers. No difference relating to withdrawal delirium or seizures could be found between the groups
of alcoholics. Frequent heavy drinkers showed a trend to more alcohol-related medical disorders than
alcoholics with a different drinking pattern, although they were younger and their estimated life-time
alcohol intake was comparable to that of continuous drinkers. Thus, the drinking pattern, particularly
frequent inebriation, has an influence on the occurrence of alcohol-related disorders.

INTRODUCTION complications, such as delirium or seizures, than

Alcoholism, one of the most common chronic
disorders in the western world, causes or promotes
a plethora of diseases and injuries. The social
health care costs of harmful alcohol consumption
are enormous (Rice et al., 1986). Since ethanol is a
hydrophilic and lipophilic substance, it may harm
nearly every organ, but only some disorders are
thought to be related to heavy alcohol intake (so-
called alcohol-related disorders, such as liver
disease, pancreatitis, upper gastrointestinal, and
neurological disorders, e.g. polyneuropathy),
(Charness et al., 1989; Lieber 1998; Piette et al.,
1998). However, until recently, few studies were
available which focused on the influence of
drinking behaviour on the frequency of alcohol-
related disorders. For example, there is little
information on whether drinkers with frequent
intoxications suffer more often from withdrawal
*Author to whom correspondence should be addressed at:
Department of Psychiatry and Psychotherapy 1, Johann Wolf-
gang Goethe-University, Heinrich Hoffmann-Str. 10, 60528
Frankfurt/Main, Germany
330
continuous drinkers or vice versa. Furthermore, the
high amounts of alcohol drunk by frequently in-
toxicated alcoholics per day may injure the gastro-
intestinal tract directly and may also harm the liver
as a detoxifying organ. Therefore, this study was
aimed at evaluating the relationship between drink-
ing pattern and occurrence of medical complications
due to alcohol misuse.
METHODS AND SAMPLE
The sample was collected from 322 chronic
alcoholics referred consecutively for detoxification
to our department. History of alcohol misuse in-
cluding drinking pattern and physical illnesses, was
assessed by a semi-structured interview according
to the documentation standards of the German
Society for Addiction Research and Therapy
(Deutsche Gesellschaft für Suchtforschung und
Suchttherapie, 1991) containing 262 items providing
data on the socio-economic status, drinking history
and behaviour (frequency, amount, etc.), drug
abuse, history of somatic and psychiatric disorders,
etc. The drinking pattern was classified into three

© 1999 Medical Council on Alcoholism

 DRINKING PATTERN AND MEDICAL DISORDERS
categories according to frequency of drinking (during
the previous 6 months) and amount of alcohol
intake: (1) continuous drinkers = (almost) daily
alcohol consumption without binges; (2) frequent
heavy drinkers = frequent alcohol consumption
(more than 3 days/week) with frequent intoxication
(more than one/week); (3) episodic drinkers = less
frequent, irregular alcohol consumption with
longer (> 5 days) sober periods, and some binges
(less than one/week).
It was possible to categorize the drinking pattern
in 241 patients (74.8%), as the remaining patients
showed irregular drinking behaviour. Thus, 64
females (mean age ± SD: 43.8 ± 8.8 years, mean
duration of harmful drinking: 10.4 ± 6.8 years) and
177 males (mean age: 41.0 ± 9.9 years, mean
duration of harmful drinking: 11.6 ± 8.7 years)
were included in this study. All subjects underwent
comprehensive clinical examination including
laboratory tests (at admission and 3 weeks after
admission) and tests for viral hepatitis A, B, and
C. Subjects with viral hepatitis were excluded.
Abdominal ultrasound was performed in 194
cases.
The life-time alcohol intake was estimated as the
product of the drinking frequency, the mean alcohol
intake/drinking day, duration of harmful alcohol
intake, and a ‘tolerance factor’. This ‘tolerance
factor’ was estimated as the reciprocal of the
ratio of reported increase of alcohol intake at
the onset of harmful drinking to the index drink-
ing period. Longer abstinence periods (> 3 months)
were taken into consideration when estimating the
duration of harmful drinking. Alcohol intake was
calculated in g/kg. All statistical calculations were
performed using the SPSS-PC program package
(version 7.5).
RESULTS
Heavy drinking with frequent intoxication was
found most often in our sample (44.4%), whereas
continuous alcohol consumption (33.6%) and an
episodic drinking style (22%) were less frequent.
The proportion of females was significantly lower
in the group of frequent heavy drinkers (15.0 vs
33.3% in continuous and 39.6% in episodic
drinkers, χ2 = 13.9, d.f. = 2, P = 0.0009). The
frequent heavy drinkers were significantly younger
(37.6 ± 9.4 years) than the continuous drinkers
331
(46.5 ± 8.5) and the episodic drinkers (42.8 ± 8.3
years) (Scheffé-test: P < 0.05).
Severity of alcohol dependence
The frequent heavy drinkers showed more severe
alcoholism according to ICD-10 criteria (World
Health Organization, 1992) for alcohol dependence
than the other groups. Nearly all of them (91.6%)
qualified for at least three of the six ICD criteria, so
that they were diagnosed as alcohol-dependent,
whereas only 75% of the continuous drinkers and
about 60% of the episodic drinkers fulfilled ICD-
10 criteria for alcohol dependence. Each ICD-10
criterion was fulfilled by frequent heavy drinkers
more often than by other groups, particularly an
impaired capacity to control drinking (66.4 vs
16% in continuous and 26.4% in episodic drinkers,
χ2 54.1, d.f. = 2, P < 0.0001), evidence of tolerance
(70.1 vs 34.6% and 26.4%, χ2 36.6, d.f. = 2,
P < 0.0001), and preoccupation with drinking
(74.8 vs 49.4% and 41.5%, χ2 20.8, d.f. = 2,
P < 0.0001) respectively.
Alcohol history
The alcohol history (Table 1) revealed that fre-
quent heavy drinkers tended to start drinking alcohol
earlier than episodic drinkers and experienced their
first inebriation earlier than the other groups. How-
ever, the mean duration of harmful alcohol drink-
ing was higher in the continuous drinkers. The
mean alcohol intake per drinking day in the last
6 months was much higher in the frequent heavy
drinking group (290 g) than the other two groups
(169 or 186 g of alcohol/drinking day).
Laboratory parameters
The measurement of laboratory parameters often
used as alcohol markers yielded elevated average
levels of γ-glutamyltransferase, alanine aminotrans-
ferase, aspartate aminotransferase, and carbohydrate-
deficient transferrin (only available in a few
subjects) in all groups. Continuous drinkers always
had the highest levels and frequent heavy drinkers
second highest (at both measures both at admission
and 3 weeks later). However, significant differences
were found only for mean corpuscular volume:
continuous drinkers 99.8 ± 7.0 fl, frequent heavy
drinkers: 95.4 ± 4.6 fl, and 94.8 ± 6.4 fl in episodic
drinkers (Scheffé-test P < 0.05).
332 T. WETTERLING et al.

Table 1. Alcohol history

Continuous Frequent-heavy Episodic

Parameter drinkers drinkers drinkers Significance

Age at first alcohol 15.8 ± 2.5 15.2 ± 3.1 16.4 ± 4.4 n.s.
consumption (years)
Age at first binge (years) 19.1 ± 4.6 17.6 ± 4.3 19.7 ± 6.7 n.s.
Duration of harmful alcohol 13.0 ± 9.1 10.6 ± 7.9 9.9 ± 7.3 n.s.
consumption (years)
No. of prior in-patient 1.4 ± 2.3 2.5 ± 5.3 2.8 ± 8.4
detoxifications
Average alcohol intake in last 169 ± 103† 290 ± 175 186 ± 122†
6 months (g alcohol/drinking day)
No. of drinking days in last month 26.6 ± 5.8‡ 27.1 ± 4.9‡ 9.9 ± 4.8
Suicidal attempts
1 (%) 16.0 21.7 20.8 χ2 18 d.f.4,
>1 (%) 1.2 19.8 13.2 P = 0.0012

Values are in % or mean ± SD.

†Scheffé-test P < 0.05 vs binge drinkers; ‡vs episodic drinkers. n.s. Denotes not significant.

Alcohol-related medical disorders The estimated average life-time alcohol intake

The frequency of alcohol-related medical dis-
orders was similar in all groups (Table 2). The con-
tinuous and the frequent heavy drinkers showed
a history of pancreatitis and oesophageal varices
more often than episodic drinkers. Furthermore,
the frequent heavy drinkers’ group suffered from
chronic gastritis and gastrointestinal bleeding more
frequently. Polyneuropathy as well as erectile
dysfunction occurred more often in continuous and
frequent heavy drinkers. The rates of withdrawal
delirium or seizures were no different between the
groups. In summary, the frequent heavy drinkers
tended to show a higher number of alcohol-related
disorders than episodic drinkers, but no more than
continuous drinkers. In particular, more upper
gastrointestinal and neurological disorders were
detected in frequent heavy drinkers. Furthermore,
they required emergency treatment and had a his-
tory of severe brain trauma with unconsciousness
more often. They also attempted suicide more often
than continuous drinkers.
was similar in continuous drinkers (8.8 ± 13.1 kg
alcohol/kg body weight) and in frequent heavy
drinkers (8.5 ± 9.1 kg/kg), whereas that of episodic
drinkers was significantly lower (3.3 ± 7.1 kg/kg).
Female alcoholics drank significantly less alcohol
(4.4 ± 5.6 kg/kg body weight) than male alcoholics
(8.5 ± 11.6 kg/kg) (U-test, P = 0.0062).
The number of alcohol-related disorders was
strongly related to life-time alcohol intake (Table 3).
Alcoholics with none of these disorders had an
estimated life-time alcohol consumption of 4.9 ±
10.0 kg alcohol/kg body weight, those subjects
with one alcohol-related disorder had drunk
6.0 ± 6.9 kg/kg, those suffering from two disorders
6.8 ± 8.9 kg/kg, and the most affected alcoholics
(having three or more disorders) 12.9 ± 13.9 kg/kg
(Scheffé-test, P < 0.05). There was a strong
relationship between long-term alcohol intake and
chronic gastritis, gastrointestinal bleeding, pan-
creatitis, withdrawal seizures, delirium, polyneuro-
pathy, and severe brain injury.

Dose relationship Gender differences

In order to evaluate the impact of cumulative Although in our sample females drank
alcohol consumption on the occurrence of alcohol- significantly less alcohol than males, no clear
related disorders, the life-time alcohol intake was gender differences in the number of alcohol-
estimated (see the Methods and sample section). related disorders could be found (males 1.7 ± 1.6,
 DRINKING PATTERN AND MEDICAL DISORDERS 333

Table 2. History of alcohol-related medical disorders

Continuous Frequent-heavy Episodic

Disorder drinkers drinkers drinkers χ2

Liver disease
Fatty hepatitis* (%) 29.9 33.3 32.6 n.s.
Alcoholic hepatitis (%) 8.6 1.9 3.4 P = 0.0730
Liver cirrhosis* (%) 4.9 2.8 1.9 n.s.
Upper gastrointestinal disorder (%) 25.9 39.2 30.2 n.s.
Chronic gastritis (%) 16.0 32.7 22.6 P = 0.0298
Peptic ulcers (%) 7.4 12.1 13.2 n.s.
Gastrointestinal bleeding (%) — 10.3 5.7 P = 0.0116
Oesophageal varices (%) 6.2 3.7 — n.s.
Pancreatitis (%) 14.8 14.0 5.7 n.s.
Neurological disorder (%) 49.4 53.3 35.8 n.s.
Withdrawal seizures (%) 21.0 26.2 15.1 n.s.
Withdrawal delirium (%) 19.8 19.6 17.0 n.s.
Polyneuropathy (%) 29.6 29.9 11.3 P = 0.0250
Erectile dysfunction (%) 6.2 6.5 1.9 n.s.
No. of alcohol-related 1.6 ± 1.3 1.9 ± 1.7† 1.2 ± 1.4
medical disorders
0 (%) 24.7 24.3 39.6
1 (%) 23.5 24.3 18.9
2 (%) 32.1 23.4 30.2
> 3 (%) 19.8 28.0 11.3
Alcohol-related medical disorders 40.7 46.7 34.0
requiring current treatment (%)
Injury χ2 8.5,
Brain injury with 4.9 17.8 7.5 d.f. = 2,
unconsciousness (%) P = 0.0141

*Diagnosed by abdominal ultrasound (n = 194).

†Scheffé-test P < 0.05 vs episodic drinkers. n.s. Denotes not significant.

females: 1.4 ± 1.2; U-test, not significant). Never-
theless, male alcoholics showed a trend towards a
higher rate for most alcohol-related disorders than
did female alcoholics, probably due to their higher
alcohol intake (males: 3.4 ± 2.2 g/kg vs females:
2.4 ± 1.3 g/kg body weight/drinking day; U-test,
P = 0.0015) and a higher drinking frequency (males:
about 24 vs females: 21 days/month; U-test,
P = 0.0615). Females showed a tendency towards a
lower rate of pancreatitis (males 14.1%, females
7.8%), gastrointestinal bleeding (males 7.3%,
females 1.6%), and seizures (males 25.4%, females
12.5%; χ2 3.9, d.f. 1, P < 0.05), whereas liver
cirrhosis and oesophageal varices were diagnosed
more frequently in female alcoholics (males 1.7%,
females 7.8% and males 2.8%, females 6.3%
respectively).
Contributing factors
In order to evaluate the influence of contributing
factors, such as age, duration of harmful alcohol
consumption, gender and drinking pattern as well as
estimated life-time alcohol intake, on the occurrence
of alcohol-related disorders, a stepwise logistic
334 T. WETTERLING et al.

Table 3. Alcohol-related disorders in relation to estimated life-time alcohol intake

Intake
(kg of alcohol/kg body weight)
Significance
Disorder Not present Present (U-test P)

Liver disease
Fatty hepatitis 7.7 ± 11.5 7.6 ± 9.4 n.s.
Alcoholic hepatitis 7.5 ± 10.6 5.6 ± 5.9 n.s.
Liver cirrhosis 7.3 ± 10.0 12.0 ± 20.0 n.s.
Upper gastrointestinal disorder
Chronic gastritis 6.4 ± 9.8 10.5 ± 11.8 0.0017
Peptic ulceration 7.2 ± 10.3 8.9 ± 12.2 n.s.
Gastrointestinal bleeding 6.9 ± 10.0 15.3 ± 14.7 0.0105
Oesophageal varices 7.2 ± 10.0 12.3 ± 18.3 n.s.
Pancreatitis 6.7 ± 9.2 12.7 ± 16.1 0.0401
Neurological disorder
Withdrawal seizures 6.3 ± 9.5 11.3 ± 12.7 0.0000
Withdrawal delirium 6.5 ± 9.3 11.3 ± 14.0 0.0197
Polyneuropathy 6.6 ± 10.2 9.8 ± 10.9 0.0104
Erectile dysfunction 7.4 ± 10.7 8.2 ± 6.3 n.s.
Injury
Brain injury with unconsciousness 6.9 ± 9.7 11.4 ± 14.7 0.0151

Values are means ± SD. n.s. Denotes not significant.

regression was performed. The statistical analysis
revealed no significant contributory factor for oeso-
phageal bleeding, gastric ulcer or fatty hepatitis.
Life-time alcohol intake had the highest influence
on the rate of withdrawal delirium, gastrointestinal
bleeding, and pancreatitis, the duration of harmful
alcohol consumption on brain injuries and with-
drawal seizures, and age on gastrointestinal bleed-
ing, chronic gastritis, alcoholic hepatitis, and liver
cirrhosis. The drinking pattern only contributed to
the rate of polyneuropathy and to a tendency to a
higher number of brain injuries.
DISCUSSION
Heavy alcohol intake is known to be a common
cause of medical disorders. Much empirical data
indicate that a relationship exists between alcohol-
related disorders and the amount of alcohol drunk
(Anderson, 1995; Lemmens, 1995). The frequency
of alcohol-related disorders, however, shows dif-
ferent relations to daily alcohol intake (Lemmens,
1995). There is a paucity of literature concerning
the relationship between drinking patterns and the
occurrence of alcohol-related disorders, perhaps due
to difficulties in assessing drinking habits adequately.
Thus, definitions of drinking patterns vary widely
between most studies. Moreover, alcohol consump-
tion may be unstable over longer periods (Skog
and Duckert, 1993; Schuckit et al., 1997). Using
6-month pretreatment drinking data, we developed
definitions of frequent heavy, continuous, and epi-
sodic drinking patterns. We avoided the term ‘binge
drinking’, since the definitions applied in the lit-
erature are rather different (Epstein et al., 1995).
Probably due to the drinking habits in northern
Germany, which has a very high average per capita
level of alcohol consumption (12 l/year), frequent
heavy drinking was the most common pattern in
our sample.
Since ethanol is almost entirely detoxified in
the liver (Lieber, 1998), hepatic disorders are very
common in alcoholics. In about one-third of our
sample, a liver disease, most often fatty hepatitis,
was diagnosed. As in most other studies, the few
 DRINKING PATTERN AND MEDICAL DISORDERS
subjects in our sample with liver cirrhosis tended
to have a higher alcohol consumption than those
without. Our findings of fatty hepatitis, however,
revealed no relationship with the estimated life-
time alcohol intake. In contrast to a similar study
(Connors et al., 1986), we did not find that frequent
heavy drinkers have more liver problems than con-
tinuous drinkers, probably due to the very similar
estimated life-time alcohol intake of both groups in
our sample.
The alcoholics suffering from chronic gastritis,
gastrointestinal bleeding, pancreatitis, and poly-
neuropathy had a significantly higher life-time
alcohol intake than those without. Chronic gastritis
and gastrointestinal bleeding occurred more often
in frequent heavy drinkers than in the other groups,
probably due to the damage caused by the high
amounts of alcohol drunk per day. Polyneuropathy
was diagnosed in about 30% of the frequent
heavy and continuous drinkers. Furthermore, com-
plications during alcohol withdrawal, particularly
delirium and seizures, occurred more frequently in
alcoholics with high alcohol consumption.
Our data revealed no clear gender differences
in the rate of alcohol-related disorders. Thus, our
results do not agree with studies suggesting a
higher vulnerability to alcohol in females (Morgan
and Sherlock, 1977; Loft et al., 1987; Mezey et al.,
1988). This discrepancy may be due to the fact that
our estimations, in contrast to most other investiga-
tions, considered the relative alcohol consumption
per kg body weight.
The high rate of brain trauma in ‘binge drinkers’
may indicate a higher risk of severe injuries in
this group, but in another study drinking measures
were not found to be significantly related to injury
(Treno et al., 1997). Apart from unintentional
injuries, alcoholics often display violent behaviour
(Romelsjö, 1995). In view of the high suicide rate
in alcoholics (Romelsjö, 1995), the finding that the
frequent heavy drinkers more frequently attempted
suicide than the other groups becomes relevant in
planning therapeutic intervention.
The estimated life-time alcohol intake is a rough
measure, because alcohol consumption is unstable
over longer periods (Skog and Duckert, 1993;
Schuckit et al., 1997). Nevertheless, our data
showed internal consistency, as the subjects with a
higher number of alcohol-related medical disorders
had drunk significantly more than those suffering
from none of these disorders. Furthermore, those
335
subjects who suffered brain trauma with uncon-
sciousness also reported higher alcohol consump-
tion than those with no such history.
CONCLUSION
In conclusion, our data showed that frequent
heavy drinkers were alcohol-dependent according
to the ICD-10 criteria more often than subjects with
different drinking patterns. Furthermore, although
being significantly younger, they had a higher num-
ber of alcohol-related medical disorders than epi-
sodic drinkers. Compared with continuous drinkers,
frequent heavy drinkers were younger, but their
estimated life-time alcohol intake was comparably
high, and they had more upper gastrointestinal dis-
orders and severe brain injuries. Furthermore, they
required emergency treatment more often. Thus, a
test such as the AUDIT (Bohn et al., 1995) pro-
viding data on the drinking pattern should be used
for screening for alcoholism (Sharkey et al., 1996),
as laboratory parameters do not help in distinguish-
ing frequent heavy drinkers.
Acknowledgement — This study was supported by grants
from the German Ministry of Research and Technology (BMFT
No. 07EB9421, 07FDA01), Bonn, Germany.
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