HDAD. CAMPOO DE SUSO

History

A 54-year-old man presents with abdominal pain for several days. The pain is a constant dull ache which is central and radiates to the right. He has had some associated vomiting but the vomit is usually bile as he has not been eating well. He has on a few occasions vomited some blood (haematemesis) but says that this was after particularly heavy consumption of alcohol. He is not aware how many units he drinks in a week but reluctantly admits he drinks every day. His breakfast often consists of a drink as he feels very shaky otherwise. Once he has had a drink he feels better able to manage the day ahead. He lives alone in a bed sit and eats poorly.

He says he was sacked for taking time off work for physical complaints. He has been separated from his wife for six months and no longer has regular contact with his children who he says have turned against him. The marriage had been difficult for some years because he was unable to hold down a regular job. He held a middle manager’s post until he turned 50. Since then he has had a series of short-term junior posts. He believes that this is as a result of changes in local government and not related to his drinking.

Physical examination

He has a ruddy complexion, several spider naevi on his face and red palms. He has a body mass index of 32. He is slightly tender in the right hypochondrium and lumbar regions and in the epigastric region of his abdomen.

Mental state examination

He smells of alcohol. He is reasonably well-dressed. He looks unwell and is clearly uncomfortable. He has good eye contact. His speech is normal. He admits he has felt low as his life has deteriorated over the last few months but says he is not ‘depressed’. He can still enjoy himself and is reactive at interview. He does not have any self-harm ideation. He has little hope for the future. There is no evidence of psychosis.

He is orientated in time, place and person. His short-term memory is poor but there are no long-term memory problems.

Normal Haemoglobin 12.4 g/dL 13.3–17.7g/dL Mean corpuscular volume (MCV) 109 fL 80–99 fL

Normal Alkaline phosphatase 351 IU/L 30–300 IU/L Alanine aminotransferase 276 IU/L 5–35 IU/L Gamma-glutamyl transpeptidase 865 IU/L 11–51 IU/L

Bilirubin 24 μmol/L 3–17 μmol/L

INVESTIGATIONS

ANSWER 19

His liver function tests are likely to show:

• Elevation of alanine aminotransferase (ALT) also known as alanine transaminase. • Elevation of aspartate aminotransferase (AST) also known as aspartate transaminase

(2 to 4 fold).

• ALT usually greater than AST (ratio of greater than 2 suggests alcoholic liver disease).

• A switch to AST greater than ALT may indicate cirrhosis.

• Likely to be elevations of gamma-glutamyl transpeptidase (GGT), alkaline phosphatase and ferritin.

LFTS in this man’s case were:

The threshold for the CAGE suggesting potential problems is 2 out of 4. It is clear in this case that this man has a significant problem. The following signs and symptoms strongly suggest alcohol dependence syndrome:

1 Strong desire to take alcohol with a narrowed repertoire of drinking.

2 Dominance of drinking over other responsibilities.

3 Tolerance to alcohol, that is needing more and more alcohol to produce the same effects.

4 Physiological withdrawal state if alcohol is reduced or ceased.

5 Use of alcohol to prevent withdrawal.

6 Preoccupation with alcohol use and compulsion to drink.

7 Return to drinking even after periods of abstinence.

8 Persistence of alcohol use despite the harmful effects (may be physical, social or emotional).

There is often co-morbidity with other mental illnesses such as depression, social anxiety, anxiety, obsessive-compulsive disorder, other substance misuse and personality disorders. The physical complications of alcohol misuse include liver disease such as fatty liver, alcoholic hepatitis or alcoholic cirrhosis. High blood pressure and other cardiac problems

This asks the following key questions:

1. Have you ever felt you should cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

The CAGE questionnaire

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can occur especially if drinking is compounded by poor diet, low exercise and obesity. There is increased likelihood of cancer of the liver, stomach, colon, rectum, lung, pancreas, larynx and oesophagus. Pancreatitis, epileptic seizures and sexual dysfunction are also common. Abrupt abstinence in someone with alcohol dependence syndrome can lead to delirium tremens, which includes shaking, sweating, diarrhoea and seizures as well as hallucinations and an acute confusional state (see Case 25). This requires urgent medical attention as it can be life threatening.

Other physical signs in acute intoxication are slurred speech, dizziness, clumsiness, unsteadiness, blackouts, collapse and somnolence. Weight loss can occur with poor nutrition, or in end-stage disease. Peptic ulceration and pancreatitis can lead to abdominal pain. The skin can often give tell-tale signs including redness in the face or cheeks, rhinophyma, palmar erythema, hand ‘liver flap’ and numbness or tingling of the fingers. Malnutrition and pseudo-Cushings can also create distinctive changes.

It is common for social problems and family dysfunction to go hand in hand with alcohol dependence. This is clearly the case with this man.

• Alcohol misuse has a range of physical, social and psychiatric complications.

• Listen carefully to how the CAGE questions are answered as many may be less than forthcoming.

• A significant number of acute medical admissions are directly or indirectly related to alcohol (including in the elderly).