ease. Patients may also require laboratory or diagnostic studies, nutritional support, regular screening for liver cancer, and treat- ment of complications or coexisting infections. A number of com- plications can arise from alcoholic liver disease, including variceal bleeding, ascites, peritonitis, renal failure, and encephalopathy (Patel & Mueller, 2022). Pancreatitis Long-term alcohol use causes between 17 and 25 percent of cases of acute pancreatitis worldwide. This inflammatory condi - tion affecting the pancreas causes acute abdominal pain, nausea, vomiting, anorexia, and high lipase levels. Severe cases can pres- ent with sepsis, acute respiratory distress syndrome, or shock. Acute pancreatitis often requires hospitalization and management with IV fluids, electrolyte replacement, analgesics, and antiemet - ics (Klochkov et al., 2022). Between 40 to 70 percent of cases of chronic pancreatitis are caused by chronic alcohol use. Patients who experience recurrent Screening/assessment Alcohol use should be assessed in all patients routinely, especially those presenting with symptoms of alcohol abuse or any of the above comorbidities. When assessing a patient with suspected unhealthy alcohol use, ask about the following (Tetrault & O’Connor, 2021): ● 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 ○ Behavioral complications ○ Psychiatric complications ○ Use of other substances A physical examination should be conducted to assess for fea- tures of unhealthy alcohol use. Patients may come to appoint- ments smelling of alcohol or actively under the influence of al - cohol, as noted by slurred speech, incoordination, dehydration, flushing, confusion, aggression, nausea, or vomiting. Signs of alcohol withdrawal include tremor, agitation, or clouded senses. Patients with advanced liver disease may present with hepatic en- largement, splenic enlargement, or yellowing skin or eyes (Tet- rault & O’Connor, 2021). Laboratory evaluation can test for abnormalities related to heavy, repeated alcohol use or liver disease. Assessment of liver en- zymes, including aspartate aminotransferase (AST), alanine ami- notransferase (ALT), bilirubin, and albumin, can indicate liver dam- age. Hemoglobin and complete blood count can determine the Diagnosis The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) created a new diagnosis of AUD that replaced alcohol abuse and alcohol dependence, which were described in the DSM-IV. AUD is diagnosed when patients experience a problematic pattern of alcohol use that leads to clinically significant distress or impairment, including at least two of the following characteristics within a 12-month period (American Psychiatric Association, 2013): ● Patients experience a persistent desire or unsuccessful efforts to cut down or control use. ● Alcohol is taken in larger amounts or for longer durations than intended. ● A significant amount of time is spent on activities related to obtaining, using, or recovering from alcohol. ● Patients have cravings or strong urges to use alcohol. ● Recurrent alcohol use results in a failure to fulfill significant obligations at school, work, or home. ● There is continued use of alcohol despite recurrent or persis- tent interpersonal or social issues caused or exacerbated by the effects of alcohol.
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 sep- sis, pleural effusion, bacteremia, and shock (Klochkov et al., 2022). Self-Assessment Quiz Question #2 A number of complications can arise from alcoholic liver dis- ease, including all of the following EXCEPT: a. Variceal bleeding. b. Ascites. c. Heart failure. d. Encephalopathy. presence of anemia or blood dyscrasias associated with heavy alcohol use or liver disease (Tetrault & O’Connor, 2021). 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. The severity of alcohol withdrawal symptoms assessed include the following (American Society of Patients are scored based on symptom severity and classified as having mild withdrawal (fewer than 10 points), moderate with- drawal (10 to 18 points), and severe withdrawal (more than 19 points) (American Society of Addiction Medicine, 2020). ● Important recreational, social, or occupational activities are reduced or given up because of alcohol use. ● There is recurring alcohol use in physically hazardous situa- tions. ● There is continued alcohol use despite knowing of persistent physical or psychological problems caused or exacerbated by alcohol. ● Tolerance develops, as defined by either a need for signifi - cantly increased amounts of alcohol to achieve intoxication or desired effects, or a decreased effect with continued use of the same amount of alcohol. ● Withdrawal occurs, as manifested by either classic withdrawal symptoms or the need to use alcohol or other depressants to relieve or avoid withdrawal symptoms. Alcohol withdrawal can be life threatening and may require intensive or inpatient care. Diagnostic criteria for alcohol withdrawal include the following (American Psychiatric Association, 2013): ● Reduction in or cessation of alcohol use that was prolonged and heavy Addiction Medicine, 2020): ● Nausea and vomiting ● Headache ● Paroxysmal sweats ● Auditory disturbances ● Anxiety ● Visual disturbances ● Agitation ● Tactile disturbances ● Tremor ● Orientation and clouded senses
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