Case 3 - alcohol use - clinical perspective Flashcards
how many deaths a year worldwide
3 million
it is the ….. leading cause of death
7th
when is the peak incidence
35-54
what percentage receive treatment in the UK
only 18%
what is the prevalence of alcohol dependence in the uk
1.3% prevalence
alcohol use disorder is categoried by which model
DSM-5
alcohol dependence is categorised by
ICD-10 and DSM-IV
what is dipsomania
alcoholism, specifically in a form characterized by intermittent bouts of craving for alcohol
what is potomania
It is described as the excessive intake of alcohol, particularly beer, together with poor dietary solute intake that leads to fatigue, dizziness, and muscular weakness.
what is potomania a unique syndrome of
hyponatremia
diagnosis criteria using ICD-11 for alcohol dependence
disorder of regulation of alcohol use
Repeated or continuous use of alcohol
Strong internal drive to use alcohol
Present for 12 months or 1 month if continuous
internal drive, compulsion, desire, urge or craving to use alcohol
Impaired control
Prioritisation of alcohol over other activities
Persistent use despite harms
what are two examples of neuroadaption in alcohol dependence
tolerance
withdrawal of symptoms and use of alcohol to alleviate withdrawal
what is the CAGE questionnaire
C: have you ever felt that you needed to cut down on your drinking
A: have people annoyed you by criticising your drinking
G: have you ever felt guilty about drinking
E: have you ever felt that you need a drink first thing I the morning to steady your nerves or get rid of a hangover
what is the gold standard screening tool for alcohol
AUDIT screening tool: FAST version
what is FAST
it is an alcohol assessment harm tool. it consists of a subset of questions from the full alcohol use disorders, identification test AUDIT
what was FAST developed for
developed for use in emergency departments, but it can be used in a variety of settings
what is the first question of the FAST questionnaire
how often have you had 6 or more units if female and 8 or more if male in a single occasion in the last year?
what happens if the answer is monthly or weekly
if monthly, answer the following questions, if weekly stop here
what are the UK guidelines for safe drinking
14 units per weeks
spread use over three days if drinking 14 units a week
what does one unit of alcohol equal
10ml or 8g of pure alcohol
what is binge drinking for men
over eight units
what is binge drinking for women
over six units
what is frequent binge drinking between age 18-25 associated with
with 2-3 times increased risk of alcohol dependence between the ages of 25-45
how many calories are in a gram of pure alcohol
7.1
what are the effects of alcohol on the oesophagus
carcinoma of oesophagus, especially squamous carcinoma
Oesophageal varices, associated with chronic liver disease - watch out for Hb drops, raised urea, coffee ground vomit
what are the effects of alcohol on the stomach
acute gastritis
Acute ulceration
Chronic peptic ulceration
Portal gastropathy
what is the indirect effect of alcohol related liver disease
indirect metabolite effect e.g acetaldehyde
what is there activation of in alcohol related liver disease
activation of free radicals
what systems are induced in alcohol related liver disease
induction of enzyme systems especially cytochrome p450
what is the usual vitamin deficient in alcohol related liver disease
B group
what are the symptoms of acute pancreatitis
severe abdominal pain
Radiating to the back
Nausea and vomiting
what is there elevation of in acute pancreatitis
serum amylase
what are symptoms of chronic pancreatiits
intermittent severe upper abdominal and back pain
Weight loss
what is exocrine tissue replaced by in chronic pancreatitis
fibrosis
what does this lea to
pancreatic malabsoption - steatorrhoea and reduced vitamins
what vitamins are reduced
A,D,E,K
what percentage of heavy drinkers go on to progress to alcoholic hepatitis or cirrhosis
10-20%
what does obesity do to the risk of alcoholic liver disease
doubles the risk
are each of these reversible or irreversible symptoms of alcoholic liver disease:
acute fatty change
hepatic fibrosis
cirrhosis
hepatic decompression
acute alcoholic hepatitis
acute fatty change - reversible
Hepatic fibrosis - reversible
Cirrhosis - irreversible
Hepatic decompression - fatal
Acute alcoholic hepatitis - reversible
what are the effects of alcohol on the cardiac system
atrial fibrillation
Myocardial infarction
Congestive heart failure
Cardiomyopathy
what is Delirium Tremens
delirium with hallucinations and autonomic disturbances in alcohol withdrawal
what is Wernicke’s encephalopathy
acute - delirium, ataxia and ophthalmoplegia - glutamatergic overdrive
what is Korsakoff’s psychosis
chronic - triad of short term memory loss, confabulation and ataxia
what are both these conditions secondary to
to effects of alcohol and B1(thiamine) deficiency
what kind of polyneuropathy in particular is seen in alcohol dependence
stocking fashion
what is polyneuropathy usually secondary to
Secondary to thiamine and other b vitamin deficiency e.g B12 (cobalamin)
when are seizures present
in early withdrawal
when are DT’s present
later on
what is altered brain function attributed to
imbalance of excitatory and inhibition neurotransmission
what does decrease GABAa receptor function lead to
increased seizure susceptibility, increased anxiety and altered sensitivity to alcohol cues
what does increased NMDA receptor function lead to
increased seizure susceptibility, increased neurotoxicity and altered senstivity to alcohol cues
what does increased voltage operated Ca2+ channel function lead to
increased seizure susceptibility, increased neurotoxicity
what do you give if there is a decrease in GABAa function
you give benzodiazepines
what do you give if there is an increase in NMDA function
thiamine or pabrinex
what do you give if there is an increase in Ca2+ channel activity
you give acamprosate
where does myopathy typically affect
proximal muscles in the pelvic girdle
what is the major blood disorder usually found in alcohol abuse
thrombocytopenia and bleeding;
usually present with low platelets
what is the relationship between alcohol and bone marrow
alcohol is toxic to bone marrow, leads to reduced normal cell levels
what does the effect on the liver lead to
folate deficiency and other effects on RBCs
what can all of this leaf to
pancytopenia
list step by step, alcohol metabolism
ethanol is metabolised by alcohol dehydrogenase to acetaldehyde
then acetaldehyde is metabolised by aldehyde dehydrogenase to acetate
why do we prescribe disulfiram
it stops the action of aldehyde dehydrogenase from metabolising acetaldehyde into acetate
what should one do to reduce harm reduction in alcohol dependence
drink diary
Look at trigger points - consider changes to behaviour
Swap to lower strength alcohol
Low strength wine is available
if dependent people present and cannot under an inpatient or community detox then they should continue drinking - aim to drink at a level that prevents withdrawal symptoms
Unsupervised detox has a mortality of >10%
refer/signpost to drug and alcohol services
what is the RADAR pathway in greater manchester
rapid access detox for alcohol dependent people requesting a detox in any A&E in manchester
how long is the medically supervised detox in the RADAR pathway
5-7 days
list the safe alcohol advice
alway have at least 4 consecutive days alcohol free
Try to avoid/minimise heavy sessions back to back
Try to avoid/minimise long drinking sessions
Eat a heavy meal before potential session at least 1-2 hours before - most alcohol is absorbed through the small intestine
Stay well hydrated and have more food early in the night when out
Substitute in non-alcoholic or lower alcohol options
Memory loss is a bad sign - avoid
Sometimes some people shouldn’t drink
Think about content and where you are at mentally and physically
Self care
