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Acute viding screening, assessment, education trolled trial (RCT) symptom-triggered and early specialist referral. administration of chlordiazepoxide sig- gastroenterology nificantly reduced the mean duration of Identifying the problem treatment (9 h v 68 h) and dose (100 mg v 425 mg) of chlordiazepoxide compared Symptoms that raise the possibility of with fixed dose regime, without increas- Vipul Jairath BSc MBChB MRCP, Specialist Registrar in Acute Medicine and alcohol abuse are outlined in Table 1. Co- ing complications or withdrawal symp- 2 Gastroenterology existing depression, cigarette smoking toms. Patients require experienced and other drug abuse are all common. nursing with close monitoring; those with Louise Langmead MD MRCP, Consultant Acute Physician and Gastroenterologist Four steps should be used to identify alcoholic need supportive alcohol-related problems: therapy, often in an intensive care unit. Division of Emergency Services, University College London Hospitals NHS Foundation • detailed personal and family history Trust of alcohol abuse Strategies for maintaining • quantity, type and frequency of abstinence Clin Med 2007;7:262–6 alcohol abuse Counselling. Many alcoholic patients fail screening questionnaires, and • to acknowledge a link between alcohol Acute gastroenterological problems are • search for complications of alcohol and their presenting problem. This can encountered frequently on the medical abuse. be addressed by screening and coun- assessment unit. This review focuses on Screening questionnaires are more selling. Even brief counselling interven- the management of alcoholism, acute effective than laboratory tests for tions can be effective. A randomised diarrhoea and upper gastrointestinal detecting problem drinking in unselected study involving over 900 patients across (GI) bleeding. populations. The best known is the CAGE 47 UK general practices demonstrated questionnaire (Table 2). Abnormal exam- that simple advice was associated with a The alcoholic patient ination findings include withdrawal (eg significant reduction in the number of tremor, tachycardia), signs of chronic liver drinks consumed per week by both men Alcohol-related admissions are increasing disease, peripheral neuropathy, malnour- and women compared with no advice.3 in the UK. Alcohol causes death from ishment and physical injuries. Signs of accidents, violence and poisoning, while (fever, hepatomegaly, Pharmacotherapy. Alcohol interacts with long-term use increases the incidence of ascites, jaundice, anorexia) indicate numerous neurotransmitter systems in and several cancers. One- potentially high mortality. the brain. Drugs can also be used to main- quarter of the UK adult population drink tain abstinence and reduce relapse in alcohol at levels which may cause harm Managing acute alcohol withdrawal patients with alcohol dependence, but and 2.9 million people show evidence of they should serve as adjuncts to psycho- alcohol dependence. The annual cost to Prompt identification of patients at risk is social therapies. Several treatments have the NHS is estimated at £1.4–1.7 billion.1 important. Benzodiazepines are the most Mortality from alcoholic cirrhosis has effective pharmacological management of increased 10-fold in the last 35 years. the symptoms of withdrawal which range Acute physicians play a major role in the from mild tremor to seizures, delirium Table 2. The CAGE questionnaire. care of patients with alcoholism by pro- tremens and death. In a randomised con- One positive response: need for closer evaluation suggested Table 1. Comorbid conditions and symptoms associated with excess alcohol use. Two positive responses: 60–95% sensitivity for identifying lifetime alcohol Comorbid condition Symptoms problems and 40–95% specificity from a wide range of studies Gastrointestinal Dyspepsia, , , oesophagitis, varices, Have you ever felt you should cut alcoholic , • down on your drinking? Cardiovascular Hypertension (especially resistant), cardiomyopathy Have people annoyed you by Respiratory Tuberculosis • criticising your drinking? Neurological Withdrawal seizures, delirium tremens Have you ever felt guilty about your Psychiatric Insomnia, depression, anxiety, hallucinosis, affective disorders • drinking? Withdrawal symptoms Tremor, anxiety, headache, palpitations, seizures Malignancy Increased risk of oral, pharyngeal, laryngeal, oesophageal, liver • Have you ever had an alcoholic drink and breast cancer on awakening (eye-opener)? Social/work problems Missed work due to hangovers CAGE = Cutdown, Annoyed by criticism, Guilty Other Decreased libido, impotence, injuries about drinking, Eye-opener drinkers.

262 Clinical Medicine Vol 7 No 3 June 2007 CME Acute Medicine been developed aimed at maintaining Inflammatory bowel disease is a segmental limited to the abstinence including: splenic flexure or rectosigmoid area IBD includes (UC) and disulfiram (acetaldehyde where there is watershed between • Crohn’s disease. New cases of IBD, par- dehydrogenase inhibitor) intestinal blood flow derived from the ticularly UC, may present with bloody superior and inferior mesenteric arteries. • acamprosate (decreases glutamergic diarrhoea. neurotransmitters) Patients are usually elderly with high car- diovascular risk and . If naltrexone (opioid antagonist). Ulcerative colitis. 30% of patients with • UC will relapse each year and some will only mucosal blood flow is compro- All the above drugs reduce heavy have severe colitis requiring hospital mised, a segmental mucosal inflamma- drinking and increase abstinence rates in admission. The incidence is about 14 per tion develops which may be self limiting alcohol-dependent patients.4 100,000 per year. and can be managed expectantly. Otherwise, full thickness bowel Crohn’s disease. 25% of patients with Acute diarrhoeal illnesses ischaemia may ensue requiring urgent Crohn’s disease have colitis predomi- laparotomy and resection. Diarrhoea is a common cause of presenta- nantly which clinically behaves similarly tion to the medical assessment unit. to UC. The incidence is about eight new cases per 100,000 per year. Approach to the patient with acute Causes include infective , diarrhoea inflammatory bowel disease (IBD), ischaemic colitis, drug-induced (anti- Ischaemic colitis Patients typically present with a combi- biotics, non-steroidal anti-inflammatory nation of diarrhoea, vomiting, abdom- drugs (NSAIDs)) and overflow diarrhoea Ischaemic colitis usually presents as inal pain and sometimes fever. There are secondary to faecal impaction. sudden onset abdominal pain followed often pointers to diagnosis within these by bloody diarrhoea or rectal bleeding. It presenting syndromes (Table 4). Acute Infection Infection is the commonest cause of acute Table 3. Infective causes of acute gastroenteritis. gastroenteritis (Table 3). One in five Bacteria Shigella Traveller’s diarrhoea, food poisoning people are afflicted each year, accounting Salmonella for about 60,000 admissions to English Campylobacter jejuni NHS hospitals in 2005–06.5 Acute gas- Staphylococcus aureus Toxin-related food poisoning Bacillus cereus troenteritis is usually a mild, self-limiting Clostridium botulinum illness. Dehydration can occur in devel- Clostridium difficile Antibiotic-associated diarrhoea, oped countries, requiring hospital admis- pseudomembranous colitis sion. Death is uncommon, with the Enterohaemorrhagic Escherichia coli Haemorrhagic colitis, haemolytic elderly and babies at greatest risk. O157:H7 uraemic syndrome, thrombotic thrombocytopenic purpura Enterohaemorrhagic Escherichia coli Viruses Rotavirus Infants and young children O157:H7 has been responsible for serious Norwalk virus Sporadic outbreaks outbreaks of gastroenteritis in the UK, Enteric adenoviruses with high mortality. It can cause haemor- Astrovirus rhagic colitis, haemolytic uraemic syn- Caliciviruses drome and thrombotic thrombocytopenic Protozoa Entamoeba histolytica Occasionally fulminant colitis purpura. Rotavirus is the commonest Giardia intestinalis Usually chronic diarrhoea cause of acute diarrhoea in infants, Cryptosporidium parvum Cyclospora cayetanensis causing about one million deaths world- wide per year. Norwalk virus is spread by the faeco-oral route as well as direct person-to-person contact and is typically Table 4. Presenting syndromes in patients with acute diarrhoea. associated with sporadic outbreaks Symptom Suggested cause affecting large groups (eg cruise ships or hospitals). Antibacterial-associated Bloody diarrhoea Colonic inflammation (colitis; see below) diarrhoea has a high morbidity and places Non-bloody diarrhoea Viral infections, Escherichia coli, toxin-related diarrhoea heavy demands on healthcare resources. Vomiting More common in viral gastroenteritis and food poisoning Clostridium difficile is the most common Abdominal pain/cramps Common in all causes pathogen, causing a spectrum of disease Fever Suggestive of infective cause or severe colitis from mild self-limiting diarrhoea to a Very sudden onset Toxin-related food poisoning severe pseudomembranous colitis.

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bloody diarrhoea indicates an inflamma- colonoscopy to obtain mucosal biopsies, copan) may provoke acute colonic dilata- tory condition of the colon (acute infec- and computed tomography to rule out tion and should be avoided. NSAIDs can tive colitis, IBD). It can occur on a an intra-abdominal collection. worsen colonic inflammation. background of known IBD (eg ulcerative colitis or de novo IBD). Any acute colitis Specific treatment. Antibiotics may be Upper gastrointestinal has potential to progress to fulminant used in probable infective diarrhoea haemorrhage colitis, toxic and perforation, when symptoms are severe or there are therefore all patients need to be moni- signs of bacteraemia. Quinolones are rec- Upper GI bleeding is the commonest tored closely for signs of toxicity and ommended for traveller’s diarrhoea. gastroenterological emergency and car- deterioration. Ciprofloxacin is our preferred empiric ries high morbidity and cost. The annual treatment for infective diarrhoea. UK incidence is about 50–150 per 100,000 adults.7 Mortality has not Management Treatment for acute inflammatory bowel changed significantly in the last 50 years The essential principles of management disease. 70% of patients with acute UC (10–14%). It is highest in the elderly and of acute diarrhoea are: respond to high-dose intravenous (iv) in patients with significant comorbidity. resuscitation corticosteroids (hydrocortisone 100 mg Causes are shown in Table 5. • 6 hourly) within 5–7 days. Other rescue rehydration • treatments (which should be prescribed supportive care (including Approach to the patient with an • only by IBD specialists) include upper gastrointestinal bleed prophylactic anticoagulation with a ciclosporin and infliximab.6 Urgent low molecular weight heparin). subtotal colectomy and ileostomy, with a Upper GI bleeding usually presents with Patients should be isolated in case they view to interval reconstructive surgery, haematemesis and/or melaena. Several are infectious. Useful investigations in will be needed by 20–30% of patients facts must be elicited in the history, the first 24 hours include stool culture with severe colitis. Early referral to a including use of NSAIDs or aspirin, his- and abdominal X-ray to rule out toxic gastroenterologist is mandatory. tory of ulcers, alcohol intake, known liver dilatation. Further diagnostic tests Antidiarrhoeal drugs (loperamide, opi- disease or varices, weight loss, dysphagia include flexible sigmoidoscopy or oids) and smooth muscle relaxants (bus- and known abdominal aortic aneurysm. On examination, an abdominal mass may suggest an intra-abdominal malig- Key Points nancy. Signs of chronic liver disease may indicate variceal haemorrhage. Urgent The alcoholic patient investigations include full blood count, Identificaton of the problem coagulation screen, urea and electrolytes, and urgent blood cross-match. Use of a suitable screening questionnaire (eg CAGE) Be vigilant for systemic symptoms and comorbidities that may be attributable to alcohol misuse Management Manage acute withdrawal in the appropriate environment Resuscitation. Adequate fluid resuscita- Consider strategies for maintaining abstinence in willing patients, including tion takes priority over endoscopy. Two counselling and/or pharmacotherapy large-gauge iv cannulae should be sited. Patients with signs of haemodynamic Acute diarrhoea instability or active bleeding should Bloody diarrhoea indicates colonic inflammation which can progress to fulminant be monitored in a high dependency colitis whatever the underlying cause The elderly and babies are at greatest risk Table 5. Causes of upper Supportive treatment and fluid resuscitation are more important than specific gastrointestinal haemorrhage. treatments for infection or inflammatory bowel disease Patients should have prophylactic low molecular weight heparin (even if Cause % bleeding) Peptic ulcer 40–50 Acute upper gastrointestinal bleed Gastroduodenal erosions 10 Oesophagitis 5–10 Risk can be stratified using the Rockall score Mallory-Weiss tear 10 Fluid resuscitation is more important than endoscopy Varices 5–10 Vascular malformations 5 Endoscopy should be undertaken when the patient is stable Malignancy 4–5 Unidentified 20 KEY WORDS: alcoholism, diarrhoea, gastroenteritis, upper gastrointestinal bleeding

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Table 6. Rockall score proforma. Reproduced with permission from the BMJ Publishing Group.8

Initial Rockall score pre-endoscopy: total maximum 7 Full Rockall score postendoscopy: maximum 11: • score 2 predicts 0.1% mortality • score 8 associated with 41% mortality • initial score of 0 and final <2: potentially consider for early discharge Points 0 1 2 3 Score

1Age <60 60–80 >80

2 None P >100 SBP <100

3 Comorbidity None Cardiac failure Renal failure IHD Liver disease Major morbidity Malignancy

4 Endoscopic M-W tear or no All other Malignancy of diagnosis lesion and no diagnoses upper GI tract sign of bleeding

5 Major stigmata of None or dark Visible blood, adherent clot, recent haemorrhage spot only visible or spurting vessel

Rockall score

GI = gastrointestinal; IHD = ischaemic heart disease; M-W = Mallory-Weiss; P = pulse rate; SBP = systolic blood pressure.

environment. Blood transfusion should Table 7. Predicted mortality according to Rockall score (%). Reproduced with 8 be given to maintain haemoglobin above permission from the BMJ Publishing Group. 10 g/dl. Patients with bleeding and co- Rockall score 0 1 2 3 4 5 6 7 8 agulopathy (international normalised ratio >1.5) or thrombocytopenia (<50 × Pre-endoscopy 0.2 2.4 5.6 11 24.6 39.6 48.9 50 – 109/l) should be transfused fresh frozen Postendoscopy 0 0 0.2 2.9 5.3 10.8 17.3 27 41 plasma and platelets.

Risk stratification. Risk stratification is Non-variceal bleeding particularly those with ulcers on the used to triage patients to outpatient lesser curve of the stomach and posterior management at one end of the spectrum Medical therapy. A meta-analysis of 21 wall of the duodenal cap due to ulcer or urgent endoscopy and high depen- RCTs (most of which used omeprazole) proximity to large underlying arteries. dency care at the other. The Rockall score of the benefit of proton-pump inhibitor When bleeding persists despite thera- uses independent clinical, laboratory and therapy for bleeding peptic ulcers found peutic endoscopy a surgical procedure is endoscopic risk factors which accurately no significant reduction in either risk of necessary, usually oversewing of the predict mortality (Tables 6 and 7).8 The rebleeding or need for surgery.9,10 artery or partial gastrectomy. Child-Pugh score of severity of cirrhosis can be used to predict mortality in the Endoscopic therapy. Several endoscopic first 30 days post-variceal haemorrhage. modalities are available to achieve Table 8. Endoscopic therapies for haemostasis for bleeding ulcers (Table 8). non–variceal bleeding. Endoscopy. Upper GI endoscopy is a safe Combination therapy of adrenaline Thermal Heater probe/argon procedure with low mortality and com- injection with mechanical methods of therapy plasma coagulation plication rate. It allows diagnosis, risk haemostasis improve the risk of Injection Adrenaline 1/10,000 stratification and mechanical therapy to rebleeding compared with a single treat- therapy Alcohol Fibrin sealants achieve haemostasis. Procedural risks 11,12 ment. Saline (local tamponade) (cardiorespiratory effects of sedation, Mechanical Endoclips aspiration, bacteraemia, bleeding, perfo- Surgery. Most bleeding ulcers can be con- Combination eg Adrenaline + endoclips ration) are greater in therapeutic trolled endoscopically. However, some treatments endoscopy (eg variceal band ligation). patients may have refractory bleeding,

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Variceal bleeding 6 Carter MJ, Lobo AJ, Travis SP; IBD Section, British Society of Gastroenterology. Variceal bleeding carries a poor prog- Guidelines for the management of nosis. Mortality at one year from sub- inflammatory bowel disease in adults. Gut sequent variceal bleeding is 5%, 25% and 2004;53(Suppl 5):V1–16. 7 Rockall TA, Logan RF, Devlin HB, 50% in Child’s class A, B and C patients, Northfield TC. Incidence of and mortality respectively. from acute upper gastrointestinal haemorrhage in the United Kingdom. Medical therapy. Terlipressin, a synthetic Steering Committee and members of the analogue of vasopressin, is effective at National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ 1995; achieving initial haemostasis and reduc- 311:222–6. tion in all-cause mortality compared with 8 Rockall TA, Logan RF, Devlin HB, placebo. Prophylactic antibiotics reduce Northfield TC. Risk assessment after acute mortality in cirrhotic patients hospi- upper gastrointestinal haemorrhage. Gut talised for acute bleeding. Propranolol 1996;38:316–21. 9 Leontiadis GI, Sharma VK, Howden CW. used as secondary prophylaxis reduces Systematic review and meta-analysis of rebleeding. proton pump inhibitor therapy in peptic ulcer bleeding. Review. BMJ 2005;330:568. Endoscopic therapy. Variceal band liga- 10 Khuroo MS, Yattoo GN, Javid G et al. A tion is the modality of choice in control- comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med 1997; ling active bleeding. It should be carried 336:1054–8. out with anaesthetic support and often 11 Chung S, Lau J, Sung J et al. Randomised endotracheal intubation, because of the comparison between adrenaline alone and high risk of aspiration. adrenaline injection plus heater probe treatment for actively bleeding ulcers. BMJ 1997;314:1307. Balloon tamponade. If bleeding continues 12 Park CH, Joo YE, Kim HS et al. despite terlipressin and endoscopic A prospective, randomized trial comparing therapy, balloon tamponade should be mechanical methods of hemostasis plus used. This controls active bleeding in 90% epinephrine injection to epinephrine of patients, although rebleeding occurs in injection alone for bleeding peptic ulcer. Gastrointest Endosc 2004;60:173–9. 50% when the balloon is deflated. Serious complications include aspiration and oesophageal perforation. Transfer to a specialist centre should be sought for con- sideration of transjugular intrahepatic portosystemic shunt insertion or surgery.

References

1 Prime Minister’s Strategy Unit. Alcohol harm reduction strategy for England. London: Cabinet Office, 2004. 2 Saitz R, Mayo-Smith MF, Roberts MS et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994;272:519–23. 3 Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988;297: 663–8. 4 Anton RF, O’Malley SS, Ciraulo DA et al; COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA 2006; 295:2003–17. 5 Hospital Episode Statistics, 2007. www.hesonline.nhs.uk

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