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c v t u c d n o n o o o o m e l l a n i e i f d g n h e y e e e e y c s s s t r r - f f f f l , . SUBSTANCE MISUSE FACT SHEETS CATEGORY I – CLINICAL PRESENTATIONS: GASTROENTEROLOGY

l Oesophageal and gastric varicies appropriate advice regarding safe injecting techniques, l Malnutrition due to altered small bowel function vaccination for blood borne viruses (hepatitis B) and provision of clean injecting equipment. All patients who have used or l Acute and chronic pancreatitis continue to use illicit drugs must be tested for viral hepatitis (Barclay et al, 2008) (hepatitis B and hepatitis C) and appropriate therapy offered. 3.1 Special/distinctive features Confirmed chronic HBV cases should be referred for specialist l Poor diet and nutrition from the lifestyle can be assessment and management. predisposing factors to gastroenterological and hepatic Diagnosis will include endoscopic and histopathological testing, problems x-rays and scans in addition to routine blood tests. Consideration l Poor immunity should be given to an alcohol detoxification and support in the l Damage to the digestive system as a result of the small community. For further reading see fact sheet on Alcohol packages of drugs being hidden in orifices such as vagina Withdrawal. or rectum, or ingested as part of smuggling (“drug mules”) For example, in the case of Eric diagnosis of alcohol related l Patients may present with a history of self- medication with ishaemic colitis is based on the presence of rectal bleeding, over the counter drugs to treat heartburn or acid abdominal pain, a history of substance use, substituted by indigestion endoscopic and histopathologic findings, and the absence l Gastrointestinal bleeding, including Mallory-Weiss tear of other aetiologic mechanisms of ischaemic colitis. 3.2 Barriers Following tests and investigations, he is seen by his doctor who can then provide him advice about his drinking, assist l Patients may not consider the effect that their substance use has on their system him in calculating his units and help him consider ways to reduce his drinking to the recommended limit for harmful l Fear of symptoms being life threatening drinking. The hospital doctor can also refer him to an l Lack of detection or recognition by doctors in screening assessment for suitability to attend a stop drinking for substance use in patients presenting with programme run by the local alcohol service. gastrointestinal disorders 4.0 Assessment Hepatitis A Alcohol misuse is ubiquitous and causes abdominal pain, Intravenous drug users (IDUs) are at higher risk of hepatitis A nausea, vomiting and haematemesis. Abdominal symptoms, infection due to poor living conditions with spread probably such as non-specific abdominal pains, diarrhoea and occurring through faecal contamination of drugs or injecting constipation are common with many drugs (both licit and illicit). paraphernalia. Blood to blood spread through needle sharing Liver failure is a rare condition characterised by deepening during viraemia is also possible. When considering whether to jaundice, increasing confusion, coma, ascites, sepsis and give a single dose vaccine or combined e vaccine, consider the eventually death. Many drugs can cause liver failure but drugs likelihood of a drug user returning for a subsequent dose. One of misuse, particularly ecstasy and herbal remedies, are often dose of hepatitis A vaccine confers greater protection against implicated. hepatitis A than one dose of the combined vaccine because the Nausea and vomiting is typically caused by disorders of the combined vaccine only has half the amount of hepatitis A digestive tract or the brain, or ingested substances. Many drugs, antigen than the single component vaccine. including alcohol and opioid analgesics, can cause nausea and l Vaccinate all injecting drug users against hepatitis A. vomiting. Severe alcoholism can induce Mallory-Weiss tears (also l Single component hepatitis A vaccine is preferable to known as gastro-esophageal laceration syndrome). This involves combined hepatitis A and B vaccine. bleeding from tears in the mucosa at the junction of the stomach and oesophagus, and is caused by retching, coughing, l Hepatitis A vaccine is available as a single component or vomiting. For young adults or middle aged patients with a vaccine or combined with hepatitis B vaccine. For a single history of drug use and presenting with ischaemic colitis, vaccine, give 2 doses with the second dose after 6–12 consider cocaine-induced intestinal thrombosis. months; the second dose may be delayed for up to 3 years. 5.0 Treatment Hepatitis B A careful history with details of current and past drug intake is l Vaccinate all drug users against hepatitis B (non-injectors essential. Details of actual alcohol intake are mandatory – vague may become injectors). statements such as ‘social drinker’ are meaningless. l Use accelerated 0, 7 and 21 day schedule to aim to Management focuses on harm reduction – patients should be complete the course as quickly as possible, and although encouraged to reduce their intake of harmful drugs and incomplete vaccination schedules offer some protection, substitute medication (such as methadone for injecting drug completing the course is recommended. users) should be made available. If reduction is declined every l Offer hepatitis B vaccination to partners and children. effort should be made to reduce harmful practices and 2 SUBSTANCE MISUSE FACT SHEETS CATEGORY I – CLINICAL PRESENTATIONS: GASTROENTEROLOGY

S G U S R S E D L” IC C A T S N R R O G S A S TE U N U N ST G T P R E U N A Y D G B R U N H T O SU D CO “ E N N E R E & L S V A I L E H L O D I L C I N T A H I T U LU AT G B O IO A M L L SI ER R LC P D I A O E V E A O SE ST H V D O H Vomiting √√ √√ √ Abdominal pain √√ √ √ Constipation √√ Diarrhoea √√√√√√ Haematemesis √ Acute liver failure √√√√ Chronic liver failure √√√ Viral hepatitis √√ Exacerbation of pre-existing liver disease √√√ Pancreatitis √ Gastritis √√(cocaine)

Hepatitis C 7.0 References and useful resources l Screening and diagnosis of infection enable patients to Appleby, VJ; Darnbrough,E; Forrester,K; Simpson,R; Clarke,C; & Moreea S. (2015) understand how they can implement life changes to slow PTU-118 An audit of the prevalence of chronic hepatitis C and treatment outcomes in drug users attending substance misuse centres in Bradford – the rate of HCV progression. planning for future service provision Gut ;64:A114 doi:10.1136/gutjnl-2015- l No vaccine available. 309861.233 Badrakalimuthu, V.R, Rumball, D & Chawla, A (2011) Hepaitis C: a patient’s journey l Consider antiviral treatment in chronic hepatitis C. from a psychiatrists’ perspective. Advances in Psychiatric Treatment 17 340-349 6.0 Referral/networks/services Barclay, G.A, Stewart, J.B, Day, C.P and Gilvarry, E (2008) Adverse physical effects It is helpful for patients like Eric to be referred to a specialist of alcohol misuse. Advances in Psychiatric Treatment. (14), 139-151 service, for example an alcohol liaison service (if it exists) or the EASL Hepatitis C Guidelines 2016: http//www.easl.eu/research/our- contributions/clinical-practice-guidelines/detail/easl-recommendations-on- local alcohol or substance misuse team, for further assessment treatment-of-hepatitis-c-2016 and advice. Eric has not shown any signs of withdrawal, and he Kumar P and Clark M (2009) Clinical Medicine. 7th edn. London: Elsevier does not drink until the evenings. This would indicate that he NICE (2004) Hepatitis C - pegylated interferons, ribavirin and alfa interferon (NICE does not require a detoxification, but he may benefit from some technology appraisal,TA75) http://guidance.nice.org.uk/TA75 individual or group sessions to assist in his motivation to reduce This guidance replaces Hepatitis C - alpha interferon and ribavirin (TA14). This his alcohol intake. This may also be available from his GP if the guidance is extended by Hepatitis C - peginterferon alfa and ribavirin (TA106). http://guidance.nice.org.uk/TA75 GP, or any other practice staff, is skilled and trained in substance NICE (2006) Hepatitis B (chronic) - adefovir dipivoxil and pegylated interferon alpha- misuse. Eric like other patients will require monitoring of the 2a (NICE technology appraisal,TA96) http://guidance.nice.org.uk/TA96 gastrointestinal problems and will need advice on what signs This guidance has been partially updated by CG165 Hepatitis B (chronic) and symptoms to look out for and how he should respond. NICE (2013) Hepatitis B (chronic): Diagnosis and management of chronic hepatitis B in children, young people and adults http://www.nice.org.uk/guidance/cg165 Public Health England. Health Protection Report II (26) July 28 2017. Hepatitis C in the UK Annuals Report https//www.gov.uk/government/publications/health- protection-report-volumeII-2017/hpr-volume II-issue-26-news-28-July

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