● Past and current use of alcohol and any prior treatment. ● Family history of issues related to alcohol and treatment. ● Details on the quantity and frequency of use. ● Symptoms and behaviors associated with the following: ° Alcohol use disorder criteria. ° Medical comorbidities. examination should be conducted to assess for features of unhealthy alcohol use. Patients may come to appointments smelling of alcohol or actively under the influence of alcohol, as noted by slurred speech, incoordination, dehydration, flushing, confusion, aggression, nausea, or vomiting. Signs of alcohol withdrawal include tremor, agitation, hypertension, diaphoresis, or clouded senses. Patients with advanced liver disease may present with hepatic enlargement, splenic enlargement, ascites, or yellowing skin or eyes: 211 Laboratory evaluation can test for abnormalities related to heavy, repeated alcohol use or liver disease. Liver enzymes, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin and albumin, can assess for liver damage. Hemoglobin and complete blood count can determine the presence of anemia or blood dyscrasias associated with heavy alcohol use or liver disease. 211 Patients with suspected alcohol withdrawal should have a similar assessment, with a focus on assessing recent or current withdrawal symptoms, history of prior withdrawal, and urine drug testing to rule out other substance use. The Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-AR), developed in the 1980s, is a standardized evaluation tool that can be used to assess the severity of withdrawal symptoms. It can help clinicians determine the need for medically supervised withdrawal and is commonly used to guide the treatment of alcohol withdrawal symptoms. It measures the severity of alcohol withdrawal symptoms, ° Behavioral complications. ° Psychiatric complications. ° Use of other substances.A physical
Accidents such as falls, burns, and firearm injuries are more common among heavy drinkers, as is unsafe sex, intimate partner violence, homicide, and suicide. 208 Alcoholic liver disease Alcoholic liver disease covers a spectrum of liver disorders, beginning with steatosis, or fat accumulation in the liver, progressing to hepatitis, or inflammation of the liver cells, and ending with cirrhosis, or irreversible damage to the liver. 209 Signs and symptoms of liver disease can include: 171 ● Edema ● Jaundice ● Dark colored urine ● Itchy skin ● Pale, bloody, or tar-colored stool ● Chronic fatigue ● Confusion ● Nausea or vomiting Heavy alcohol users can present with alcoholic liver disease between 40 and 50 years of age. Liver disease can be progressive; between 10 to 20% of patients with alcoholic hepatitis progress to cirrhosis each year. The management of alcoholic liver disease can vary depending on the extent of disease. Alcohol cessation is highly recommended, and patients may also require laboratory or diagnostic studies, nutritional support, regular screening for liver cancer, and treatment of complications or co-existing infections. A number of complications can arise from alcoholic liver disease, including variceal bleeding, ascites, peritonitis, renal failure, and encephalopathy. 209 Pancreatitis Long term alcohol use causes between 17 and 25% of cases of acute pancreatitis worldwide. This inflammatory condition affecting the pancreas causes acute abdominal pain, nausea, vomiting, anorexia, and high lipase levels. Severe cases can present with acute respiratory distress syndrome or shock. Acute pancreatitis often requires hospitalization and management with IV fluids, electrolyte replacement, analgesics and antiemetics. 210 Between 40 to 70% of cases of chronic pancreatitis are caused by chronic alcohol use. Patients who experience recurrent cases of acute pancreatitis are significantly more likely to progress to chronic pancreatitis, in which the inflammation of the pancreas worsens over time, leads to permanent damage, and increases the patient’s risk of pancreatic cancer. Chronic pancreatitis can cause the pancreas to work less efficiently, leading to poor fat absorption, steatorrhea, and diabetes. Complications of chronic pancreatitis can be local effects on the pancreas, such as necrosis and pseudocysts, as well as systemic complications such as sepsis, pleural effusion, bacteremia and shock. 210 Screening/Assessment Alcohol use should be assessed in patients presenting with any of the above comorbidities. When assessing a patient with suspected unhealthy alcohol use, patients should be asked about the following: 211
including the following: 171 ● Nausea and vomiting. ● Headache. ● Paroxysmal sweats. ● Auditory disturbances. ● Anxiety. ● Visual disturbances. ● Agitation. ● Tactile disturbances. ● Tremor. ● Orientation and clouded senses.
Patients are scored based on symptom severity and classified as having mild withdrawal (less than 10 points), moderate withdrawal (10 to 18 points), and severe withdrawal (more than 19 points). 171
Book Code: CA23CME
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