Alcohol and GI bleeds

Question 1

What is the AUDIT questionnaire used for?

Answer 1

Assess the nature and severity of alcohol misuse.

Question 2

What should be done if AUDIT suggests alcohol dependence?

Answer 2

Consider using the SADQ or LDQ questionnaire to assess the severity of the dependence.

Question 3

What is the onset of alcohol withdrawal symptoms?

Answer 3

Typically start within 6-12 hours of the last drink and can last 3-7 days after cessation.

Question 4

What are some mild-moderate symptoms of alcohol withdrawal?

Answer 4

Anxiety
Nausea and vomiting
Autonomic dysfunction - tremor, tachycardia, sweating, palpitations
Insomnia

Question 5

What are some severe symptoms of alcohol withdrawal?

Answer 5

Delirium - medical emergency. Rapid onset and appears 48-72 hours after last drink. Can include confusion, hallucinatons, tremor, and features of clinical instability such as tachycardia, fever, ketoacidosis, and circulatory collapse. Can be treated with oral lorazepam, or parenteral lorazepam or haloperidol (both unlicensed) if necessary.

Seizures - occurs 12-24 hours after last drink. Generalised tonic-clinic seizures require urgent treatment.

Question 6

How should advice about lowering alcohol consumption be approached?

Answer 6

FRAMES:
F eedback - on the person’s alcohol problems.
R esponsibility - their responsibility to change.
A dvice - explain the harm caused by the person’s level of drinking and offer reasons for changing their behavior such as health, well-being, and finances.
M enu - what are the options for change?
E mpathy - use a warm, reflective, and understanding approach.
S elf efficacy - be optimistic about their ability to change their own behaviour.

Question 7

Give some examples of options for changing alcohol habits?

Answer 7

Identify and avoid high-risk situations for drinking.
Recognise personal cues for drinking such as stress and loneliness.
Try alternatives for managing these such as exercise, reading, meeting friends.
Alternate between alcoholic and non-alcoholic drinks.
Switch from higher to lower alcohol content drinks.
Keep a drinking diary.
Ask close contacts to hold you accountable.

Question 8

What pyschological methods can be used for alcoholics which fail to improve initially?

Answer 8

A brief intervention of motivational interviews, therapy and addressing issues.
If this fails, a psychological intervention focused on alcohol-related cognitions, behaviour, issues, and social networks can be done. Also, suggest AA and information for families and carers.

Question 9

What pharmacological therapy can be used for alcohol dependance?

Answer 9

Acomprosate calcium

Question 10

What is the mechanism of acamprosate?

Answer 10

Anti-craving medication which acts as a GABA mimetic to antagonise the same NMDA-receptor system affected by chronic alcohol use.

Question 11

How is acamprosate prescribed?

Answer 11

ASAP after assisted withdrawal and for up to 6 months, or longer if beneficial.

> 60kg: 666mgs tds (1998mg daily_
<60kg: 666mg od wth breakfast and 333mg at lunch and dinner (1332mg daily).

Question 12

What monitoring is required with acamprosate?

Answer 12

Patient should be supervised for 6 months.
LFTs not required but can be used to monitor recovery of liver function and may aid motivation.

Question 13

What are some side effects of acamprosate?

Answer 13

Abdominal pain and discomfort
Sexual dysfunction
Skin reactions

Question 14

What medicines can be given to alleviate symptoms during assisted alcohol withdrawal?

Answer 14

A long-acting benzodiazepine such as chlordiazepoxide hydrochloride.

Question 15

How is chlordiazepoxide dosed for alcohol withdrawal in primary care?

Answer 15

Fixed-dose regimen: Standard initial dose 10-50mg is determined by severity of alcohol dependance/ consumption and is weaned over 7-10 days.

Question 16

How is chlordiazepoxide dosed for alcohol withdrawal in inpatient facilities?

Answer 16

Symptom-triggered approach: drug regimen tailored to severity of withdrawal and any complications as and when.

Question 17

What are some side effects of chlordiazepxide hydrochloride?

Answer 17

Benzodiazepine:
Dizziness/hypotension
Drowsiness
Nausea
Respiratory depression

Question 18

What are some symptoms of chlordiazepoxide overdose?

Answer 18

Ataxia
Dysarthria (difficulty speaking)
Nystagmus (involuntary rhythmic eye movements)
Respiratory depression
Coma

Question 19

What can be given if a patient shows signs of chlordiazepoxide toxicity?

Answer 19

If awake and breathing well: oral activated charcoal within 1 hour.
If more severe: IV flumazenil

Question 20

What paradoxical symptoms can occur in some patients taking benzodiazepines?

Answer 20

Hostility and aggression. Can be attenuated by adjusting dose up or down.

Question 21

What is Wernicke’s encephalopathy?

Answer 21

A neurological condition caused by thiamine (B1) deficiency. It affects peripheral and central nervius system, resulting in opthalmoplegia (paralysis of eye muscles), ataxia (impaired balance and coordination), and confusion.

Question 22

Who is at risk of Wernicke’s disease?

Answer 22

People with alcohol dependence who are malnourished or have decompensated liver disease.

Question 23

What can be given to drinkers startring/in withdrawal at risk of Wernicke’s encephalopathy?

Answer 23

1 pair (15ml ampoule) of Pabrinex IM for 5 days into the gluteal muscle.
If possible, switch to oral prophylactic thiamine:
Mild deficiency: 25-100mg daily
Severe deficiency: 200-300mg daily
(usually 50mg tds)
For 6 weeks after successful withdrawal.

Question 24

What can be given in a case of suspected/confirmed Wernicke’s encephalopathy?

Answer 24

2 pairs (2x15ml ampoules) of Pabrinex IM for 3 days into the gluteal muscle.
If possible, switch to oral prophylactic thiamine:
Mild deficiency: 25-100mg daily
Severe deficiency: 200-300mg daily
(usually 50mg tds)
For 6 weeks after successful withdrawal.

Question 25

What is Pabrinex?

Answer 25

Supplement injection containing:
B1 - thiamine
B2 - riboflavin
B6 - pyridoxine
B3 - nicotinamide
C - ascorbic acid

Question 26

How should Pabrinex be given?

Answer 26

IM, into the gluteal muscle.
Lower risk of anaphylaxis than IV.

Question 27

What are some key symptoms of a GI bleed?

Answer 27

Bright red blood in vomit
Black tarry stools
Abdominal cramps
Dizziness or fainting
Fatigue
Paleness

Question 28

What risk assessments should patients with an acute GI bleed undergo?

Answer 28

1. Glasgow-Blatchford bleeding score (GBS).
2. Enodscopy.
3. Full Rockall score

Question 29

What is the Glasgow-Blatchford bleeding score?

Answer 29

Considers haemoglobin, blood urea nitrogen, BP, symptoms, and medical history to assess risk of requiring intervention.
0: discharge
>0: high risk of GI bleed requiring intervention.
>6: >50% risk of requiring intervention.

Question 30

When should an endoscopy performed and why?

Answer 30

Unstable patients: immediately after resuscitation.
Stable patients: within 24 hours.
Long tube with light and camera on the end used to identify the site and cause of bleeding, as well as facilitate treatment.

Question 31

What is a Full Rockall score?

Answer 31

Assess risk of a rebleed and mortality of GI bleed patients, post-endoscopy. Considers age, shock (tachycardia, hypertension), comorbidities, endoscopy diasgnois, and symptoms.

Question 32

When should a GI bleed patient be offered a platelet transfusion?

Answer 32

If they are actively bleeding and have a platelet count of 50x10^9/L

Question 33

What should patients with massive GI bleeds be offered?

Answer 33

Transfusion of blood, platelets, and clotting factors.

Question 34

What is the difference between non-variceal and variceal bleeding?

Answer 34

Non-variceal: bleeding that develops in the oesophagus, stomach, or proximal duodenum from any etiology of UGIB other than varices. e.g., peptic ulcers.

Variceal: bleeding in the upper GIT caused by a burst or break in the oesophageal or gastric varices (abnormally dilated veins caused by portalhypertension due to cirrhosis in the liver).

Question 35

How can non-variceal bleeds be treated via endoscopy?

Answer 35

Mechanically (e.g., clips) with or without adrenaline.
Thermal coagulation with adrenaline.
Fibrin or thrombin with adrenaline.

Question 36

Following endoscopic treatment of a non-variceal bleed, what should be done?

Answer 36

Assess risk of rebleed with Rockall score. If high risk, give IV high-dose PPI and assess for rebleed.
If rebleed occurs, repeat enodscopy, interventional radiology, or surgery can be given.

Question 37

Who is at higher risk of variceal bleeds?

Answer 37

History of cirrhosis with/without varices
Stigmata of chronic liver disease
Blood results
Radiological findings

Question 38

How is a variceal UGIB be treated?

Answer 38

Terlipressin
Prophylactic antibiotic therapy

If oesophageal, band ligation or transjugular intrahepatic portsystemic shunts

If gastric, endoscopic injection of N-butyl-2-cyanoacrylate or transjugular intrahepatic portsystemic shunts

Question 39

What is terlipressin?

Answer 39

An IV synthetic vasopressin analogue with specificity for the splanchnic circulation which causes vasoconstriction in the dilated vessels to reduce portal pressure.

Question 40

What is N-butyl-2-cyanoacrylate?

Answer 40

Tissue adhesive solution which hardens over surgical wounds to form a strong bond around the wound edges.

Question 41

How do transjugular intrahepatic portsystemic shunts treat variceal UGIB?

Answer 41

Stent is put in to connect portal vein to hepatic vein to relieve pressure in portal vein and reduce UGIB

Question 42

What is hepatic encephalopathy?

Answer 42

A reversible syndrome observed in patients with advanced liver dysfunction characterised by neuropscyhiatric abnormalities resulting from the body’s inability to remove ammonia from the blood and accumulation of toxins in the brain. Symptoms include personality changes, intellectual impairment, and reduced consciousness.

Question 43

How is hepatic encephalopathy graded?

Answer 43

Conn score Grade 0 (no symptoms) to 4 (coma)

Question 44

How is hepatic encephalopathy treated?

Answer 44

Lactulose 30-50ml tds

Rifaximin 550mg bd

Question 45

How does rifaximin treat hepatic encephalopathy?

Answer 45

Semi-synthetic derivative of antibiotic rifamycin which inhibits ribonucleic acid. Decreases intestinal production and absoprtion of ammonia. Also reduces reccurrence.

Question 46

How does lactulose treat hepatic encephalopathy?

Answer 46

Contains acidophilic bacteria (Lactobacillus) which uses ammonia for bacteria protein synthesis. This in turn lowers colon pH to suppress proteolytic bacteria involved in ammonia production. Decreases blood ammonia by 25-50%.