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home - Liver - Alcohol - Alcoholism Written by Dr Sebastian Zeki
Knowledge


Recognises the rising incidence of acute and chronic liver disease in
the UK related alcohol abuse and in particular the increasing alcohol
consumption in adole nts young adults women and growth in
obesity

Recognises alcoholic hepatitis and understands the prognostic
scores determined by Maddrey’s discriminant function the Glasgow
alcoholic hepatitis score and their role in identifying which patients
may benefit from corticosteroids Can treat alcohol withdrawal

Aware of appropriate use of benzodiazepines in alcohol withdrawal
and can recognise the early signs of delirium tremens

Skills
Is able to take a relevant history and perform appropriate examination
Recognises those patients who would benefit from corticosteroids
instituting treatment and has awareness of indications for withdrawing
their use
Aware of the potential complications of alcoholic hepatitis chronic
liver disease and able to prevent or intervene where appropriate

Behaviours
Appreciates the role of other specialists nurse specialists
intensivists radiologists dieticians psychiatrists and addiction
specialist

Communicates effectively with patients their relatives in the context
of their disease its severity prognosis and substance abuse

Identifies the abstinent alcoholic who would benefit from
transplantation

Considers all therapeutic modalities and preparedness to refer to
specialist centre where diagnosis remains in doubt or appropriate
management cannot be performed as per national guidelines

Alcoholism

Nutrition —Undernutrition and Overnutrition is a risk factor for cirrhosis (BMI >25 kg/m2 for at least 10 years as an independent risk factor for steatosis, alcoholic hepatitis, and cirrhosis)Obesity —Independent predictors of fibrosis included the BMI, serum glucose levels, and the Perl's grade. Concurrent exposure to hepatotoxins —2 hepatotoxic agents will act synergistically and confer far greater risk to the development of liver disease than either one alone. AUDIT criteriaCAGE is better than AUDIT questions.AUDIT can identify patients before they become dependent.It is positive if the AUDIT score >8, or had one or more heavy drinking days per year.Sensitivity and specificity than shorter screening instruments (sensitivity 75 %; specificity 85 % ). Amount and duration of ethanol ingested —50 % will have cirrhosis or "precirrhotic" lesions if drink-ing >28 Units of EtOH/ day. Genetic factors —1. Female gender (increased risk for same given amount and duration and progresses more quickly)- - probably higher levels of EtOH/kg2. Ethnicity based polymorphisms in alcohol metabolism (eg asians protected due to ALDH2 isoenzyme deficiency)3. HLA phenotype4. Inherited susceptibility to alcoholism.5. Other: TNFalpha polypmorphisms esp position 238 Iron overload and C282Y muta-tion Coexisting hepatitis C and B virus infection HCV infection rates much higher than HBV infection (even if high risk behav-iours removed) Likelihood Of Developing Alcoholic Liver Disease Diagnostic Criteria for Alcoholism:CAGE.MAST -25 questions so not great for screening.AUDIT, (from WHO tool) with 10 ques-tions - cultural or ethnic bias. CAGE criteria:Do you need to Cut down drinking?.Are you annoyed by criticism of drinking?.Do you have Guilty feelings about drinking?.Do you need a morning Eye opener (a drink 1st thing in morning to steady nerves or for hangover?. Risk Factors And Social Aspects Abstinence — Abstinence can result in Improvement in fibrosis A reduction in or even normaliza-tion of the portal pressureResolution (or easier treatment) of ascites Factors dictating recidivism:Co-morbid substance abuse.Social function.Lack of social support. Disulfuram — ALDH inhibitor causing high plasma acetaldehyde levels.Causes facial flushing, tachycardia, hypotension, dyspnea, nausea, vomiting, headache, blurred vision, vertigo, and anxiety 30 mins after etoh.Lasts many hoursSyndrome lasts for hours ; inhibitory activity lasts for several days. Little evidence showing encour-ages abstinence. Naltrexone — Pure opioid antagonist- controls the craving for alcohol.Can cause hepatocellu-lar injury. Short-term naltrexone tx lowers the risk of relapse. Alcamprosate — GABA- mimetic reduces withdrawal symptoms (eg craving) in detoxified alcoholics in several placebo-controlled trials.No better than extra counsel-ling or naltrexone Baclofen — Baclofen better than placebo (71 versus 29 percent) in achieving abstinence in a placebo-controlled trial. Written by Dr Sebastian Zeki Se: 0.71. Sp: 0.90 for >2 responses.Only works if high pretest probability. Prevention

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