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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Briefinterventions:
Attempt to increase awareness of the problems, consequences, and risks of alcohol
consumption
FiveAsmodel:
Askaboutuse Advicetoquitorreduce Assesswillingness Assisttoquitorreduce Arrangefollow-up.
Pharmacologicalmanagement
Treatmentofalcoholwithdrawalwithbenzodiazepinesshouldbeguidedbyobjectivescoring(e.g. ClinicalInstituteWithdrawalAssessmentforAlcohol(CIWA-Ar))(seeChapter35) All patientswithArLDshould begiventhiamine(see Chapter35); inpractice,parenteral high- dosethiamineisgiveninitiallyinpatientsadmittedwithArLD Suspected alcoholic hepatitis—discuss with hepatology for consideration of possible corticosteroidtherapy.
Surgicalmanagement
Livertransplantation:
Considerinpatientswith:
ArLDChild–PughC(poorestprognosis)OR ModelforEnd-StageLiverDisease(MELD)≥15OR
UKELDscoreof≥49 Liaisewithlocalhepatologyteam Sustainedabstinencefromalcoholisessentialpriortoconsiderationoftransplantation Onceonthetransplantwaitinglist,assessregularlyforongoingabstinencewithquestionnaireand laboratorytests(measurementofethylglucuronideinurineorhair).
Psychosocialconsiderations
ArLDshouldbeconsideredadualpathology—liverdiseaseandadiseaseofaddiction Thereisahighprevalenceofcomorbidpsychiatricordersanddevelopingotheraddictions.
Complications
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Alcoholwithdrawal(seeChapter35):
Occursinalcohol-dependentpatientswhosuddenlydecreaseorstopalcoholintake
Usuallydevelopswithin6–24hoursafterlastalcoholicdrink Alcoholichepatitis Decompensatedlivercirrhosis:
Ascites Complicationsofascitesincludingspontaneousbacterialperitonitis:
GIbleeding
Bacterialinfections
AKI Hyponatraemia Hepatorenalsyndrome:
Acute-on-chronicliverfailure Relativeadrenalfailure Cirrhoticcardiomyopathy Hepatopulmonarysyndrome Portopulmonaryhypertension:
Coagulopathy
HE
Monitoringandfollow-up
Clinical,biochemical,andultrasoundsurveillanceisindicatedforallpatientswithcirrhosis:
HCCscreeningshouldbeperformedinlivercirrhosisusingultrasoundevery6months
Biomarkers(i.e.AFP)arenotrecommendedforroutinesurveillanceofHCC.
Specialconsiderations
Most drugs commonly prescribed in ArLD, including benzodiazepines, will need dose adjustmentinaccordancewiththeseverityofliverimpairment(seeChapter35).
Furtherreading
1. EuropeanAssociation fortheStudy oftheLiver (2018). EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Available at: https://www.journal-of-
hepatology.eu/article/S0168-8278(18)31966-4/fulltext
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Chapter35
Alcoholusedisorders
Guidelines: NICE CG100 (Alcohol-use disorders: diagnosis and
management of physical complications):
https://www.nice.org.uk/guidance/cg100
NICECG115(Alcohol-usedisorders:diagnosis,assessmentandmanagement of harmful drinking (high-risk drinking) and alcohol dependence):
https://www.nice.org.uk/guidance/cg115
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Approximately25%ofadultsdrinkahazardousorharmfulvolumeofalcohol.Manyof these individuals are alcohol dependant and suffer from withdrawal symptoms if their level of intake falls. Stigma and discrimination are common, so the patient may try to downplay their level of dependence to avoid perceived judgement. Patients should thereforebereassuredthatthediscussionsareconfidential.
Diagnosis
Alwaysassess:
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Howmuchalcoholthepatienttypicallyconsumes(Box35.1) Whether the patient is misusing alcohol (using a tool such as the Alcohol Use Disorders IdentificationTest(AUDIT))—seeFig.35.1 Whetheralcoholintakeishazardousorharmful Theseverityofalcoholdependence Risktoself(includingunplannedwithdrawal,suicidality,andneglect)andrisktoothers(including violence) Extentofanyassociatedmentalorphysicalhealthandsocialproblems:
Thosewithharmfulalcoholintakeshouldberiskstratifiedforthepresenceoflivercirrhosis (seeChapter34).
Ifthereisuncertaintyregardingweeklyalcoholintake,consideraretrospectivedrinkingdiary andifpossible,takeacollateralhistory.
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Fig.35.1AlcoholUseDisordersIdentificationTest(AUDIT).
ReprintedfromBaborTetal(2001).‘AUDIT:theAlcoholUseDisordersIdentificationTest:guidelines foruseinprimaryhealthcare.’WHO:Geneva,withpermissionfromtheWorldHealthOrganization.
Box35.1Alcoholcontentofdifferentdrinks
1unitofalcohol=8gor10mLofpurealcohol 1unit=0.5pints(284mL)oflager/beer/cider(alcoholbyvolume(ABV)3.6%) 1unit=1smallshotmeasure(25mL)ofspirits(ABV40%)
1.5units=1smallglass(125mL)ofwine(ABV12%).
Hazardousalcoholintake
Level ofalcohol intake that putstheindividual at risk ofalcohol-related harm,typically14–35 units/weekforawomanand21–50units/weekforaman.
Harmfulalcoholintake
Levelofalcoholintakethatcausesharmtotheindividual,typically>35units/weekforawoman and>50units/weekforaman.
Alcoholdependence
Characterizedbycravingandhavingapreoccupationwithalcohol,andcontinuingtodrinkalcohol despitepotentiallycausingharm Severity ofdependence can be assessed using the Alcohol Dependence Questionnaire (SADQ) (Table35.1).
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Table35.1SADQscore
Section1:thinkofatypicalperiodofheavydrinkinginthelast6months. Addthescoresaccordingtofrequencyofeachoftheitems:almostnever=0,sometimes=1,often=2, nearlyalways=3
Physical
Wakeupfeelingsweaty Wakeupdrenchedinsweat Wakeupwithhandsshaking Wakeupwithbodyshaking
Affective
Dreadwakinginthemorning Dreadmeetingsomeonefirstthinginthemorning Wakingupfeelingdespairing Wakingupfeelingfrightened
Craving
Wantingtodrinkfirstthinginthemorning Drinkingfirstalcoholicdrinkasquicklyaspossible Strongcravingfordrinkonwaking
Dailyalcoholintake
Drinking>0.25bottleofspiritsOR1bottleofwineOR7beersinaday Drinking>0.5bottleofspiritsOR2bottlesofwineOR15beersinaday Drinking>1bottleofspiritsOR4bottlesofwineOR30beersinaday Drinking>2bottlesofspiritsOR8bottlesofwineOR60beersinaday
Dependence
Drinkingmorealcoholtoavoidshakes
Section2:imagineyouhavestoppeddrinkingcompletelyforafewweeks,andthenyoudrinkveryheavilyfor2 days.Howwouldyoufeelthenextmorning?
Addthescoresaccordingtofrequencyofeachoftheitems:notatall=0,slightly=1,moderately=2, quitealot=3
Iwouldbesweaty Myhandswouldshake Mybodywouldshake Iwouldbecravingadrink
InterpretationofSADQscore: 0–15=milddependence 16–30=moderatedependence 31–60=severedependence.
Referralcriteriaforspecialistassessment
Thosescoring>15ontheAUDIT.
Referralforhospitaladmission
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Peopleinacutealcoholwithdrawalorthoseassessedtobeathighriskofdevelopingseizuresor deliriumtremensmustbeofferedadmissiontohospital Havealowerthresholdforadmittingvulnerablepatients(e.g.frail,cognitivelyimpaired,lackof socialsupport,learningdifficulties,andhomeless) If admission is declined, or there is insufficient capacity, the patient must be advised not to suddenly reduce their alcohol intake and they should seek help from a local alcohol support service.
Investigations
Bedside
Performbedsidecognitivetestingtoscreenforpossiblealcohol-relatedcognitiveimpairment(see
Chapter10)includingWernicke’sencephalopathyandKorsakoff’ssyndrome(Box35.2)
UsetherevisedClinicalInstituteWithdrawalAssessmentofAlcoholScale(CIWA-Ar)(Fig.35.2) toassesstheseverityofwithdrawal.
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Fig.35.2ClinicalInstituteWithdrawalAssessmentofAlcoholScale,Revised(CIWA-Ar).
ReprintedfromSullivanJTetal(1989).Assessmentofalcoholwithdrawal:TherevisedClinical InstituteWithdrawalAssessmentforAlcoholscale(CIWA-Ar),BritishJournalofAddiction84:1353–
1357.
Box35.2Wernicke’sencephalopathyandKorsakoff’ssyndrome
Inharmfuldrinking,alcoholintakecanoccurattheexpenseofhealthynutrition.Malnourishment leadstodeficiencyofthiamine,whichisessentialforneuronalfunction Wernicke’s encephalopathyis characterizedbya triad of:(1) confusion,(2) ophthalmoplegia, and(3)ataxia.UrgenttreatmentwithIVthiamineisrequired
Korsakoff’s syndrome occurs in around 80% of patients with WE1 and is characterized by amnesia,confabulation,lackofinsight,andapathy.
Bloods
FBC(macrocyticanaemia) LFTandcoagulationprofilestudies(ArLD) Ca,Mg,phosphate(nutritionaldeficienciesduetoalcoholintake) Bloodsugarlevel(hypoglycaemia).
IfArLDissuspected,seeChapter34toguideinvestigations.
Management
Drinking >15 units alcohol/day OR score >20 on AUDIT AND no patient safety
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