Ever wonder why you feel more tipsy disproportionate to the alcohol you drank? Or, can the alcohol level in urine be higher than blood?
Auto brewery syndrome (ABS) known by various names as Gut Fermentation Syndrome or Endogenous Alcohol Fermentation, and Ethanol Pseudotoxicity is a rare medical condition. Patients can get intoxicated without drinking alcohol. This topic has also been subject of daytime talk shows like DR. Phil. ABS may frequently be invoked as an underlying excuse in medical legal cases.
Historical perspective
Ladkin and Davies were the first to describe auto brewery syndrome in British medical Journal in 1948. The case involved an African child who suffered a rupture of the stomach due to extreme stomach distention as a result of fermentation producing gas. On autopsy, gastric as well as peritoneal fluid smelled of alcohol.
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How can a person get high alcohol levels without drinking? There is fermentation/breakdown of dietary carbohydrate by fungi or bacteria present in the gut resulting in production of alcohol. This alcohol is absorbed through the gut into the body. This causes an increase in blood/breath levels of alcohol, sometimes exceeding the legal limit of intoxication.
How common is auto brewery syndrome?
ABS may be an under-recognized or under-diagnosed condition because of ubiquitous use of alcohol in the society and lack of a standardized test. While rare, it’s true prevalence remains to be established. A recent systematic review of case reports by Bayoumy and colleagues found 20 patients diagnosed in the literature. Others have described the prevalence as less than 100 cases.
What causes auto brewery syndrome?
While most of the cases are caused by yeast of Candida and Saccharomyces cerevisiae variety, bacteria including Klebsiella pneumoniae, Pseudomonas aeruginosa have also been implicated.
Who is likely to suffer from auto-brewery syndrome?
Risk factors for development of auto brewery syndrome include antibiotic use, diabetes, liver cirrhosis, Crohn's or IBD, short bowel syndrome, small bowel/intestinal bacterial overgrowth, chronic intestinal pseudoobstruction etc. Patients with gastrointestinal surgery including weight loss or bariatric surgeries are predisposed to abnormal flora in gut and thus create ideal milieu for abnormally high fermentation of carbs producing increased alcohol.
There are ethnic differences as well. Japanese may be at particularly high risk. Genetic polymorphism in concentration of metabolic enzymes may underlie such variations.
Elevated levels of blood alcohol may be seen in patients with nonalcoholic steatohepatitis or NASH, and obese subjects. However, the elevation of alcohol levels is not significant.
While the use of acid blocking medications of H2-blockers like Cimetidine as well as proton pump inhibitor type (eg Prilosec, Prevacid, Nexium, Protonix, Nexium etc) can increase number of bacteria in stomach and small intestine (Small intestinal bacterial overgrowth) result in an increased fermentation of carbs to produce alcohol in the gut, its significance in causing auto brewery syndrome remains to be established.
Can the urinary bladder act as auto-brewery?
Known as urinary or bladder auto brewery syndrome, the offending bacteria or yeast in such cases may be present in the urinary tract resulting in production of alcohol in bladder or test tube holding urine same for testing. Subjects in such cases exhibit high alcohol levels in urine but not blood. In contrast to GI auto brewery syndrome, subjects with urinary auto brewery syndrome do not suffer from clinical effects of alcohol.
Why is ABS rare despite common risk factors?
Small amount of alcohol may be produced in gut in many subject. However, it may not manifest as high alcohol levels when tested in blood or breath. The reason is disparity between the amount of alcohol produced and body’s capacity to metabolize before it shows up in blood. Before alcohol can reach the bloodstream, the alcohol in the gut goes through what is known as a first-pass metabolism by enzyme alcohol dehydrogenase which is present in stomach and liver. Only the amount of alcohol that exceeds the metabolic capacity shows up in blood and breath.
As a practical matter, the amount produced within the gut is rarely large enough to overwhelm the body’s normal metabolism to show up as elevated alcohol levels in the blood or breath.
Clinical symptoms of auto brewery syndrome
Patient's presentation may be diverse and are typical of intoxication as sleepiness, nausea vomiting, confusion, loss of balance, fatigue, mental changes, memory and driving issues, slurred speech, alcohol breath, difficulty walking in straight line, nausea vomiting, passing out etc. Liver tests may be suggestive of alcoholic liver disease.
Can you distinguish it from high alcohol levels due to alcohol consumption?
Currently available testing cannot distinguish between elevated blood alcohol levels caused by production of alcohol in the body or ABS versus drinking of alcohol.
Can you use it as a DUI defense?
On rare occasions auto brewery syndrome has been used as successful driving under influence defense and the person can get acquitted.
How to test for Auto-brewery syndrome (ABS)
An upper endoscopy may be undertaken as a first to collect secretions to test for bacteria and fungi. The practical diagnostic value of endoscopy is dubious. Testing stool sample for these organisms may not be helpful either since fungi can be found normally in stool and usually not considered significant.
A glucose challenge test has been proposed. Person consumes a defined dose of glucose in a supervised setting. Supervision is important so as to prevent person surreptitiously drinking alcohol to give a false positive result. A variety of doses of glucose for consumption have been advocated.
Alcohol levels are measured for about 8 hours. A rise in blood alcohol level at any time is considered to be positive for ABS. If there is no increase in alcohol level for 8 hours, the alcohol testing may be extended for about 24 hours. While this test is widely mentioned in the literature, it has not been standardized or validated.
Treatment of ABS
While initial treatment of intoxicated person due to gut fermentation is similar to intoxicated patient due to excess alcohol consumption, treatment of underlying cause of gut fermentation is undertaken, usually empirically.
Common treatments include low carbohydrate diet plus use of antifungal medications like nystatin and fluconazole. Antibiotics are only used if a bacterial cause has been implicated. Probiotics like lactobacillus acidophilus have been successfully used.
Fecal transplantation as treatment
Since dysbiosis has been implicated as a causative factor, fecal transplantation has been successfully used for treatment as reported in reported in Annals of Internal Medicine. Commercial product of feces is now available for fecal microbiota transplant.
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People may falsely claim this disorder as a defense against DUI charge in court. On the other hand, innocent persons may be erroneously charged with drinking in excess and suffer penalties.
Auto brewery syndrome may be used as a potential successful defense against a charge of driving while intoxicated. The bar for burden proof is likely to be very high in front of skeptical judges and juries.
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