Alcohol Dependence

Question 1

What is the progression of alcohol-related liver disease?

Answer 1

1. Alcoholic fatty liver (hepatic steatosis)
2. Alcoholic hepatitis - reversible with permanent abstinence
3. Cirrhosis - irreversible, stopping drinking can prevent further damage, continuing has a poor prognosis.

Question 2

What are the signs suggestive of excessive alcohol consumption?

Answer 2

• Smelling of alcohol
• Slurred speech
• Bloodshot eyes
• Dilated capillaries on the face (telangiectasia)
• Tremor

Question 3

What blood results suggest alcohol-related liver disease?

Answer 3

• Raised MCV
• Raised ALT and AST, AST:ALT ratio above 1.5 in particular
• Raised GGT
• Raised ALP later in disease
• Raised bilirubin in cirrhosis
• Low albumin due to reduced synthetic function of liver
• Increased prothrombin time (reduced clotting factors)
• Deranged U&Es in hepatorenal syndrome

Question 4

What would liver USS show in suspected alcohol-related liver disease?

Answer 4

• Liver USS -fatty changes with increased echogenicity, later shows cirrhotic changes

Question 5

What are the stages of alcohol withdrawal?

Answer 5

6-12hrs: tremor, sweating, headache, craving and anxiety
12-24hrs: hallucinations
24-48hrs: seizures
24-72hrs: delirium tremens

Question 6

How does delirium tremens present?

Answer 6

• Acute confusion
• Severe agitation
• Delusions and hallucinations
• Tremor
• Tachycardia
• Hypertension
• Hyperthermia
• Ataxia (difficulties with coordinated movements)
• Arrhythmias

Question 7

What medications are used to manage alcohol withdrawal?

Answer 7

• Chlordiazepoxide (librium) - combats effects, given orally as a reducing regime over 5-7 days
• Diazepam is a less common alternative
• High dose B vitamins (Pabrinex) given IM or IV, with long term oral thiamine - to prevent Wernicke-Korsakoff syndrome

Question 8

What are the features of Wernicke’s encephalopathy?

Answer 8

• Confusion
• Oculomotor disturbances (disturbances of eye movements)
• Ataxia (difficulties with coordinated movements)
• Medical emergency with high mortality rate

Question 9

What are the features of Korsakoff syndrome?

Answer 9

• Memory impairment (retrograde and anterograde)
• Behavioural changes
• Reversible and results in full-time institution care

Question 10

What is the management for mild alcohol dependence?

Answer 10

• Psychological intervention e.g., CBT
• Acamprosate calcium or oral naltrexone hydrochloride

Question 11

What is included in a liver screen?

Answer 11

• FBCs - anaemia due to GI bleed, low coagulation
• LFTs, U&Es
• Coagulation screen
• Immunoglobulins
• HepB, HepC and HIV
• Viral screen - EBV, CMV
• Liver USS
• Ferritin and total iron binding capacity
• Alpha 1 antitrypsin
• Alpha fetoprotein (AFP) - tumour marker
• Autoantibody screen
• Serum copper