CHRONIC ALCOHOLISM
Approach to the patient
History
Many long case patients may have chronic alcoholism as a significant factor contributing to the overall morbidity. Some important facts to remember in dealing with the problem of alcoholism are as follows:
1. There is a genetic predisposition to alcoholism, so the family history is important.
2. Twenty per cent of alcoholics can stop their habit without help.
3. Mortality in the alcoholic is commonly caused by heart failure (cardiomyopathy), ischaemic heart disease, stroke, cancer, accident or suicide.
In taking a history from patients who abuse alcohol, remember to obtain all relevant details of their habit. Pay particular attention to the amount and type of alcohol consumed each day, the duration of the habit, whether the patient has any drinking partners, how the patient finances their habit, how the family is coping and whether the patient has ever attempted to give up alcohol. Most alcoholics consume 8–10 standard drinks per day; however, this threshold may vary depending on the ethnicity and body habitus of the individual. Most patients may abuse multiple substances. Therefore it is important to ask about other recreational drug use and tobacco smoking. Remember: the patient may withhold the truth due to denial or confabulation. Ask about depression, suicidal ideation, sexual problems, family/marital issues and occupational problems.
The C A G E questionnaire is considered the standardised assessment of the severity of alcohol addiction. Ask the following questions of all suspected alcoholic patients:
Examination
Signs of chronic alcoholism in the physical examination (Fig 11.1) are poor personal hygiene, obesity or malnutrition, multiple ecchymoses due to easy bruising, bilateral parotid gland swelling and Dupuytren’s contracture. Look for atrial fibrillation and evidence of congestive cardiac failure due to alcoholic dilated cardiomyopathy. Perform a detailed neurological examination, looking for midline cerebellar ataxia, peripheral neuropathy and stroke. Examine the respiratory system, looking for evidence of pneumonia and tuberculosis. Gastrointestinal examination may reveal signs of alcoholic liver disease, alcoholic hepatitis and pancreatitis. Remember that chronic alcohol consumption is a risk factor for carcinoma of the head and neck and the oesophagus. Perform a cognitive assessment, looking for signs of alcoholic brain damage, Wernicke’s encephalopathy and Korsakoff’s psychosis.
Investigations
Do not be surprised to encounter denial of alcoholism, even in the most likely of patients. The following are some investigations that can be done to confirm chronic alcoholism:
Management
1. Acute management of the alcoholic patient includes the administration of oral vitamin B complex (with folic acid) and thiamine 100 mg daily. Alcohol withdrawal (see box) should be managed with diazepam orally, given in decremental doses over 3–5 days as guided by a standard alcohol withdrawal scale.
2. Rehabilitation and abstinence. Some useful steps that can be employed are:
3. Some patients may complain of persistent insomnia. This problem is better managed with behavioural methods, meditation and exercise than with medications.
4. Always offer the patient the option of group support in the form of Alcoholics Anonymous or institutions run by organisations such as the Salvation Army.
5. Discuss with the patient the options of pharmacological anti-craving agents, such as acamprosate and naltrexone. Cognitive behavioural therapy has also shown promise as a means of maintaining abstinence.
Symptoms and signs of alcohol withdrawal
These features start appearing 5–10 hours after the last drink. They usually peak within the first 2–3 days and gradually improve through day 5. Alcoholic seizures occur within the first 48 hours and delirium tremens also occurs during this period. Delirium tremens is characterised by visual, auditory and tactile hallucinations. Some patients experience protracted abstinence syndrome and alcoholic hallucinosis, which can last as long as 6 months.
ALCOHOLIC/CHRONIC LIVER DISEASE
Case vignette
A 35-year-old man has been admitted with severe ascites and haematemesis in the background of chronic alcohol abuse and hepatitis C infection. Upper gastrointestinal endoscopy has revealed bleeding oesophageal varices, which was treated with banding. He has been experiencing increasing daytime somnolence. On examination he has finger clubbing and Dupuytren’s contractures. He demonstrates asterixis and scleral icterus. His abdomen is tender and positive for shifting dullness. He has tense ascites and splenomegaly. His temperature chart demonstrates spiking fevers.
1. What investigations would you request to further work up this man?
2. What is your overall detailed assessment of this man’s clinical status?
3. What immediate management plan would you consider?
4. What is his long-term prognosis?
5. What definitive management options are available to improve this man’s outcome?
Approach to the patient
History
Ask about anorexia, abdominal pain and bloating. Obtain a detailed history on alcohol intake and also enquire into other risk factors for infective hepatitis. Intravenous drug abuse or previous tattoos may suggest hepatitic C infection, and unprotected sexual intercourse with multiple partners may suggest hepatitis B. Ask whether the patient has been tested for or diagnosed with viral hepatitis in the past. Obtain a detailed social history. Ask about the effects of hypogonadism in the male patient (lack of libido and impotence). Check whether the patient has had haemetemesis or melaena, which may be due to erosive gastritis, or oesophageal varicies due to portal hypertension. Perform a cognitive assessment to exclude hepatic encephalopathy.
