Snapshot A 56-year-old man is brought to the ED after he had a severe episode of hematemesis. On exam, you note spider angiomas, and abdominal ascites. His hand is show at right. Introduction Definition is clinical CAGE questions (need 2 positive) Cut - Do you ever feel you should cut back on drinking? Annoyed - Do you ever feel annoyed when other question your drinking? Guilty - Do you ever feel guilty for your drinking? Eye-opener - Do you never need an eye-opener in the morning? Presentation Symptoms due to liver failure altered mental status/encephalopathy due to reduced excretion of ammonia worse in alkalemic states NH3 favored over NH4+ lactulose acidifies gut contents and leads to increased NH4+ loss in the stool bleeding due to reduced synthesis of coagulation factors Physical exam neurological findings cerebellar dysfunction (gait instability, truncal ataxia, dysdiadochokinesia, intention tremor and hypotonia) findings from liver failure asterixis jaundice reduced excretion of billirubin pitting ankle edema reduced synthesis of albumin findings from hyperestrinism palmar erythema gynecomastia spider angiomas female hair distribution findings from portal hypertension hepatosplenomegaly caput medusae ascites Evaluation CAGE test tried to Cut down, been Annoyed, felt Guilty, and had an Eye-opener 2 or more yes answers is considered positive test Serology transaminitis AST:ALT > 2:1 serum γ-glutamyltransferase (GGT) is most specific for recent use MCV will be elevated in chronic users Treatment Pharmacologic disulfiram aversive conditioning: blocks acetaldehyde dehydrongenase leading to build up of unpleasant intermediate metabolite when ETOH is consumed acamprosate (low/medium evidence) relapse prevention by blocking glutamate receptor naltrexone reduces cravings (opioid antagonist) gabapentin topiramate Psychotherapy Alcoholics Anonymous (AA) and other peer support groups - seem to be the most effective by some sources motivational interviewing to encourage entrance into AA rehabilitation Prognosis, Prevention, Complications Complications alcoholic hepatitis/cirrhosis esophageal varices pancreatitis chronic pancreatitis will present with weight loss, vitamin ADEK deficiency, low/normal amylase and lipase peripheral neuropathy testicular atrophy increased cancer risk oral, laryngeal, pharyngeal, esophageal, lung, and liver squamous cell carcinoma is classically associated ED Management Inpatient Management Chronic Management Prevent further ethanol intake Prevent individual from harming self or others Sedate patient if agitated or aggressive Order urine toxicity screen Stabilize vitals if necessary Administer (in order) thiamine and Mg2+ multivitamin B12/folate IV fluids + dextrose Begin CIWA and benzodiazepine taper if signs of withdrawal Do not administer medications that lower seizure threshhold (bupropion, haloperidol) Begin psychotherapy (must occur with medications) individual group (AAA) Begin medication immediately disulfiram naltrexone acamprosate gabapentin topiramate