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Acute Gastroenterology CME Acute Medicine 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 hepatitis 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 alcoholic hepatitis (fever, hepatomegaly, Pharmacotherapy. Alcohol interacts with long-term use increases the incidence of ascites, jaundice, anorexia) indicate numerous neurotransmitter systems in cirrhosis 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, peptic ulcer disease, gastritis, oesophagitis, varices, Have you ever felt you should cut alcoholic liver disease, pancreatitis • 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 colitis limited to the abstinence including: splenic flexure or rectosigmoid area IBD includes ulcerative colitis (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 vascular disease. 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 gastroenteritis, 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. Clinical Medicine Vol 7 No 3 June 2007 263 CME Acute Medicine 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.
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