barcelona . spain - European Association for the Study of the Liver

BARCELONA . SPAIN
92 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 93
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
THE ACUTELY ILL PATIENT: ALCOHOL WITHDRAWAL
Table 1 At admission Day 2 Day 7
WBC (109/l) 12.2
11.3
Hemoglobin (gr/dl) 11.7 10.8 11
Platelets (109/l)
100
13.1
99 105
Bilirubin (mg/dl) 24 21.4 25.1
AST (UI/l) 289 243 169
ALT (UI/l) 124 101 90
GGT 653
Creatinine (mg/dl) 0.8 1.5 1.8
Albumin (gr/dl) 2.7 3.1
PT /control PT
(seg)
45/15 40/15 38/15
INR 3.7 3.2 3.0
Na (mEq/l) 134 130 128
CRP (mg/L) 46 65
HBsAg
Anti-HCV Abs
Negative
Negative
Blood cultures Negative + (P. Aeruginosa)
Urine cultures Negative Negative
Ewan Forrest
Glasgow, UK
E-mail: Ewan.Forrest@ggc.scot.nhs.uk
KEY POINTS
• Alcohol misuse and dependency is common amongst general hospital admissions.
• Patients with Alcoholic Liver Disease will often, but not always, be alcohol dependent.
• At risk patients can be recognized with screening tools such as FAST and CAGE.
• Benzodiazepines are the mainstay of treatment, but lorazepam is preferred for the treatment of
patients with liver disease.
• Symptom Triggered Treatment is effective for many patients but patients at high risk of severe
withdrawal may require Fixed Dose Treatment.
INTRODUCTION
Alcohol withdrawal syndrome (AWS) arises in alcohol-dependent patients typically within 24-72 hours of
having their last alcoholic drink. Features of AWS include two or more of the following: tremor, insomnia,
nausea, anxiety, transient hallucinations, agitation and autonomic hyperactivity (sweating, tachycardia).
In its most severe manifestations it may be complicated by withdrawal seizures or delirium tremens. This
latter condition is characterized by disorientation, impaired consciousness, attention deficit, hallucinations
and marked adrenergic activity. In these severe forms it is described as having a mortality of up to 20%,
although with recognition and appropriate treatment this can be reduced to 1%. The management of AWS
relies upon the recognition of at risk patients and the use of appropriate treatment in the most effective way.
This can be especially problematic in patients who have co-existent liver disease.
IDENTIFICATION OF PATIENTS AT RISK OF AWS
Before effective treatment of AWS can be initiated it is vital to recognize those patients at risk. AWS is a
feature of alcohol dependency and so tools designed to look for this can be used to identify such patients.
Screening tools include the CAGE (cut down, annoyed, guilty and eye-opener), Short Alcohol Dependence
Data (SADD/Q) and the Michigan Alcohol Screening Test (MAST) questionnaires can be used for this
purpose. However recognition of hazardous/harmful alcohol consumption is also important as these
patients may benefit from brief intervention and still may experience some symptoms of AWS. The Alcohol
Use Disorders Identification Test (AUDIT) is a screening tool for hazardous drinking. Higher AUDIT scores
have been associated with greater risk of AWS. However whilst AUDIT is effective, it is a relatively long
test for use amongst general hospital admissions comprising ten separate questions. To cope with this the
Fast Alcohol Screening Test (FAST) was developed. This is derived from AUDIT but is much shorter and
easier to use. We have found that higher FAST values correlate well with positive CAGE questionnaires and
subsequent benzodiazepine requirement. As a result we use the FAST to stratify hazardous and dependent
drinking patterns in all patients admitted to general hospitals who are drinking more than the recommended
limits. This allows for at risk patients to be targeted for AWS management.
PREVALENCE OF ALCOHOL MISUSE
The prevalence of alcohol dependency in general medical hospital admissions can be as high as 18.6% (up
to 24.8% amongst male admissions). However it is incorrect to assume that all patients with alcoholic liver
disease (ALD) will have alcohol dependency. In one study only 26% of patients were severely dependent
drinkers on the basis of SADD assessment, with 40% having relatively low scores. In another study which
excluded patients admitted primarily for complications of liver disease, patients with a history of heavy
alcohol use had liver biopsies. Those with severe AWS were more likely to be binge drinkers and have
evidence of alcoholic hepatitis on histology. Relatively few patients who had cirrhosis without super-added
hepatitis experienced severe AWS.