and hepatology

Published on 24/06/2015 by admin

Filed under Internal Medicine

Last modified 24/06/2015

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CHRONIC ALCOHOLISM

Approach to the patient

History

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 Michigan Alcohol Screening Test (MAST) can be used for a more formal assessment of the severity of alcoholism.

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.

Management

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.

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.