Alcohol

Question 1

when diagnosing Alcohol use what are the 3 categories used?

Answer 1

Acute intoxication, Harmful use (pattern of use causing damage to physical or mental health. Use >1month), Dependence

Question 2

what categories make up Dependence? (if 3 or more of these then pt is dependent)

Answer 2

Cravings, control difficulty, Primacy, Increased tolerance, withdrawl state, persistent use despite harmful consequences

Question 3

what is a withdrawl state?

Answer 3

Group of symptoms of variable clustering and severity on complete/relative withdrawal of a psychoactive substance, after persistent use of that substance

Question 4

what sy comprise a withdrawl state? What is the worst?

Answer 4

Tremor, weakness, nausea, vomiting, anxiety, seizures, confusion, agitation even death. Delerium tremens = Profound confusion, tremor, agitation, hallucinations, delusions, sleeplessness, autonomic over-activity, Mortality in DTs = 5%, Death: cardiovascular collapse, infection, hyperthermia, seizures or self injury. Usually 48-72 hours after alcohol stopped.

Question 5

Physical Health impacts of alcohol?

Answer 5

Wernicke’s Encephalopathy, Korsakoff’s psychosis, loss of memory, fits, confusional state, poor control of DM, cirrhosis, hep, muscle loss, cardiomegaly, hypertension, ulcers, gastritis, pancreatitis, impotence, infertility, sti’s, hiv/aids, violence, accidental injury, cancers.

Question 6

define Wernicke’s Encephalopathy and Korsakoff’s Psychosis

Answer 6

Wernicke’s Encephalopathy = Confusion, ataxia, opthalmoplegia, nystagmus
Korsakoff’s Psychosis = Prominent impairment of recent and remote memory, preservation of immediate recall, no general cognitive impairment, retrograde and anterograde memory, impaired learning and disorientation, may exhibit nystagmus and ataxia.

Question 7

what causes this?

Answer 7

Thiamine deficiency (poor intak eand absorption, poor hepatic function, increaed requirement for alcohol metabolism), (lack of Vitamin B12)

Question 8

Mental Health impacts of alcohol?

Answer 8

Anxiety, Depression, Sleep disruption, Morbid Jealousy, Alcoholic hallucinosis, Deliberate self-injury, Suicidal thoughts/acts. Impacts on relationships and employment, financial and legal impacts too.

Question 9

Screening tools…

Answer 9

CAGE = cut down, annoyed at critisism, guilty, eye-opener. (over 2 indicates a likely problem), AUDIT, FAST, PAT (used in u and e’s), also ask about personal and forensic hx.

Question 10

Mx non. Medication based?

Answer 10

Practical advice, education, harm reduction, Holistic/bio-psycho-social approach = Support for patient and family, Psychological help (e.g. CBT, group therapy), Social work input (benefits, housing, child protection), Skills training, Community Support (eg AA, ADA), Inpatient or residential treatment.

Question 11

Mx Medication based?

Answer 11

Prevention of Wernicke-Korsakoff Syndrome = Thiamine
Management of alcohol withdrawal = Benzodiazepines , commonly Chlordiazepoxide
Aversion/deterrent medication = Disulfiram (Antabuse)
Anti-craving medication = Acamprosate (Campral), Naltrexone, Nalmefene, (Baclofen)

Question 12

Alcohol and the liver - What is the function of the liver?

Answer 12

Carbohydrate metabolism = Excess glucose – glycogenesis (storage), Low blood glucose – glycogenolysis to provide more
Fat metabolism = Lipid metabolism predominantly within the liver, Breaks down fats to produce phospholipids and cholesterol
Protein metabolism = Deamination (break down) and Transamination (make up) of amino acids, Byproduct is Ammonia – liver synthesises urea to remove, Albumin synthesis (main protein of blood plasma) almost exclusive to the liver, Storage for when you need it = Glucose, Iron, Copper, Vitamins
Synthesis = Fibrinogen (to Fibrin for clotting), Thrombopeitin (platelet production in bone marrow)
Kupffer cells – rubbish collectors (bacteria, old cells etc)
Production of bile – allows fat breakdown in small intestine
Metabolism of drugs and alcohol

Question 13

how does the liver metabolise alcohol?

Answer 13

Blood arrives at liver, Alcohol – Acetylaldehyde – Acetate, Enzymes: ADH and ALDH, Acetate converted to fatty acids, C20 and H20
Healthy liver processes 1 unit of alcohol per hour, Acetaldehyde is a carcinogen!

Question 14

what causes a fatty liver?

Answer 14

Deposition of triglycerides in liver = fatty liver, ‘Inappropriate’ activation of kupffer and stellate cells. Alcohol – acetaldehyde – acetate – fatty acids, because Alcohol is calorie rich, Fat deposited around central veins then parenchyma, Abstain from alcohol – liver returns to normal - it is reversible.

Question 15

outline the progression of alcohol related liver disease…

Answer 15

normal - fatty liver (steatosis) - steatohepatitis - fibrosis - liver Cirrhosis.

Question 16

on Ix what indicates chronic alcohol use?

Answer 16

Elevated gamma GT liver enzyme), Macrocytosis (large red blood cells), Low platelets, Elevated ferritin, Enlarged smooth edged liver on AUSS and a thorough hx.

Question 17

what does alcoholic hepatitis result in?

Answer 17

Fatty change within the liver And Infiltration with leucocytes, Hepatic necrosis, Results in = Hepatomegaly, Jaundice, Abdominal Pain, Fever, Hepatic decompensation

Question 18

what is the GAHS?

Answer 18

Glasgow Alcoholic Hepatitis Score (28 day survival), Age, markers of inflammation and liver function

Question 19

how is alcoholic hepatitis tx?

Answer 19

Steroids, management of infection and nutrition, Renal impairment and coagulopathy, Abstinence (abstience always improves the prognosis)

Question 20

what occurs during fibrosis?

Answer 20

chronic inflammaiton, activaiton of stellate cells, collagen production, localised fibrosis around the vein, collagen bridging between veins/tracts, loss of lobule structure.

Question 21

complications of cirrhosis…

Answer 21

variceal haemorrhage, encephalopathy ascites.