In this chapter Case studies levels 1–3 explore the management of a patient with alcoholic liver disease. The patient has alcoholic liver cirrhosis and first presents with alcohol withdrawal (Case study level 1), then the patient’s risk of bleeding and treatment for the maintenance of alcohol abstinence are considered (Case study level 2). The patient then goes on to develop encephalopathy (Case study level 3). Case studies levels Ma and Mb consider two patients: one presents with TB and the other liver failure.
Case study level 1 – Alcoholic cirrhosis; alcohol withdrawal
Learning outcomes
Level 1 case study: You will be able to:
- describe the risk factors
- describe the disease
- describe the pharmacology of the drug
- outline the formulation, including drug molecule, excipients, etc. for the medicines
- summarise basic social pharmacy issues (e.g. opening containers, large labels).
Scenario
Mrs MW, 59 years old, is divorced and unemployed. She was admitted to an acute medical ward at the hospital presenting with general malaise, a grossly distended abdomen, swollen ankles, and jaundice. It was also noted that she smelt of alcohol and was showing signs of alcohol withdrawal.
Questions
1. What is cirrhosis of the liver?
2. List possible causes of cirrhosis.
3. What other clinical signs and symptoms may Mrs MW present with?
4. What drug treatment, including dose, would you recommend for Mrs MW’s alcohol withdrawal? What recommendations would you make if the patient was unable to take the medication orally?
Answers
1 What is cirrhosis of the liver?
Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury. It is an advanced stage of liver fibrosis that is accompanied by distortion of the hepatic vasculature.
2 What are the risk factors for developing primary dysmenorrhoea?
Causes of cirrhosis can usually be identified by the patient’s history combined with serological and histological investigation. Alcoholic liver disease and hepatitis C and B are the most common causes of cirrhosis.
The association of excessive alcohol consumption with liver disease has been recognized for centuries. After the identification of the hepatitis C virus and of non-alcoholic steatohepatitis in obese patients with diabetes, the diagnosis of cirrhosis without an apparent cause (cryptogenic cirrhosis) is rarely made. Genetic causes of cirrhosis include hemochromatosis and Wilson’s disease.
Epidemiological studies have identified a number of factors that contribute to the risk of developing cirrhosis. Regular (moderate) alcohol consumption, age older than 50 years, and male gender are examples that increase cirrhosis risk in chronic hepatitis C infection, and older age, obesity, insulin resistance or type 2 diabetes, hypertension and hyperlipidemia in non-alcoholic steatohepatitis.
3 What other clinical signs and symptoms may Mrs MW present with?
Cirrhosis is often asymptomatic until complications of liver disease are present. Mrs MW may present with itching, jaundice, dark urine, pale fatty stools, abdominal pain, nausea, fatigue, bleeding – such as nosebleeds, hepatic encephalopathy, hepatomegaly, ascites, distended abdominal veins, spider angiomata, palmar erythema and asterixis. She may also present with the signs and symptoms of alcohol withdrawal, which include irritability, anxiety, tachycardia, tremor, sweating, confusion, and hallucinations.
4 What drug treatment, including dose, would you recommend for Mrs MW’s alcohol withdrawal? What recommendations would you make if the patient was unable to take the medication orally?
Long-acting benzodiazepines (e.g. diazepam and chlordiazepoxide) are used to attenuate alcohol withdrawal symptoms but they also have a dependence potential. To minimize the risk of dependence, administration should be for a limited period only (e.g. chlordiazepoxide 20 mg 4 times daily, gradually reducing to zero over 7–14 days). Mild alcohol withdrawal symptoms may be treated with a lower starting dose, such as 15 mg four times a day. In all cases, the patient should be counseled about the proposed length of the treatment course. Benzodiazepines should not be prescribed if the patient is likely to continue drinking alcohol.
In patients unable to take medication by the oral route, diazepam may be administered by intramuscular or slow intravenous injection (into a large vein, at a rate of not more than 5 mg/min), at a dose of 10 mg, repeated if necessary after not less than 4 hours. Alternatively, diazepam may be administered via the rectal route as a rectal solution or suppository. The intramuscular route should only be used when both the oral and intravenous routes are not possible.
General references
- Schuppan D and Afdhal NH (2008) Liver cirrhosis. Lancet 371: 838–851.
- Heidelbaugh JJ and Sherbondy M (2006) Cirrhosis and chronic liver failure: Part II. Complications and treatment. American Family Physician 74: 767–776.
- Joint Formulary Committee (2008) British National Formulary 55. London: British Medical Association and Royal Pharmaceutical Society of Great Britain, March.
- Vincent WR, Smith KM, Winstead PS and Lewis DA (2007) Review of alcohol withdrawal in the hospitalized patient: management. Orthopedics 30: 446–449.
Author: Caron Weeks [BPharm (Hons), MRPharmS, DipPharmPrac. Lead pharmacist – Medicine, Southampton University Hospitals NHS Trust] and Mark Tomlin [BPharm, MSc, MRPharmS (IPresc) Consultant Pharmacist, Critical Care, Southampton General Hospital]
