Patient Case Study

Pennine Acute NHS Trust, North Manchester

Dr Alex Adelakun MBBS; MRCP(UK)

Prescribing information is available either at the meeting where these slides are presented or available online in the link below this presentation

Presentation commissioned and funded by Kyowa KirinKKI/UKIRE/PAB/0227 September 2020

Patient Profile• Mr MW, 55years old; • Unemployed; Unkempt and lives with a friend, also an alcoholic• Lives in a deprived part of Manchester• Background history of alcohol dependence and smoker• Previous alcohol withdrawal seizures and confusional state; poor

compliance with thiamine and other medications. Recurrent admissions• Previous radiological and clinical evidence of alcohol liver disease• Poor engagement with community alcohol services

Patient HistoryAdmitted to ED via ambulance services with:• Diarrhoea and vomiting• Lethargy and poor appetite; dehydrated; smells heavily of alcohol and tobacco• Central abdominal pain and swelling• Evidence of excessive alcohol consumption and withdrawal shakes (no clear

documentation of encephalopathy score or malnutrition score) • Appeared pleasantly confused, possible weight loss as muscle wasting noted.• No medication card available but records showed on Thiamine and Vitamin Bco

strong.• Patient smokes about 20-30 per day

Patient Situation• Had been previously discharged 2 weeks before re-admission• Abdominal distention and pain, dark stools, reduced urine output• Tremors in both hands• Mild confusion; mildly jaundiced; spider naevi; palmar erythema; moderate bilateral leg

swelling( features of chronic liver disease) • Deranged liver functions and renal functions; low haemoglobin; low platelets; raised

lactate• Raised inflammatory markers: CRP and white cells• Hepatosplenomegaly with generalised tenderness on examination, with ascites

(abdominal fluid)• Rectal examination: loose motions with fresh red blood• No evidence of previous smoking cessation advice or referral to the smoking cessation

services

Actions and OutcomeDiagnosis: Decompensated alcohol liver disease: cirrhosis with portal hypertensive gastropathy; alcohol withdrawal; probable GI bleed secondary to haemorrhoids; Probable colitis.

He was admitted and promptly started on Pabrinex (vitamins B & C) High Potency concentrate for solution for infusion; PRN chlordiazepoxide; Antibiotics( co-amoxiclav and metronidazole)

• Faecal calprotectin; stool culture; slow IV Fluids 12 hourly; CT scan of his abdomen and pelvis• Gastro-enterology team review for flexible sigmoidoscopy.• Dietician review also planned in view of obvious malnutrition• Alcohol Liaison referral sent• Social assessment requested• Nicotine replacement therapy offered and administered

Actions and Outcomes….ctd• CT revealed (as described above): pancolitis (widespread bowel

inflammation) and liver cirrhosis and bowel oedema.• Antibiotics and Pabrinex continued as patient became more confused.• Gastro team reviewed: advised for conservative management as stool

culture excluded infection; and calprotectin corroborated colitis.• Alcohol liaison officer review to take place as out-patient as currently no

in-patient review due to COVID-19 regulations• Patient remained acutely unwell for a few days but slowly recovered from

alcohol withdrawal confusion and tremors. Diarrhoea also settled• Started to improve clinically after 4 days as his liver functions and

inflammatory markers improved. Dietician reviewed and put dietary plan in place. He was eventually discharged to intermediate care after 7 days.

CT abdomen showing widespread colitis, cirrhosis and bowel oedema

Key Learnings• Patients with alcoholic liver disease can present in many ways. Some of their presenting symptoms may

be subtle but potentially life threatening.• Alcohol liver disease often progresses to multiple organ dysfunction so must be treated as an urgent

case. • It is crucial to consider holistic approach to management as presentation may be complicated: History

and clinical examination are important. Multi-disciplinary team approach crucial.• Early treatment of suspected hepatic encephalopathy/ malnutrition is essential to prevent progression to

Wernicke's encephalopathy. Malnutrition can lead to irreversible brain damage( Korsakoff’s psychosis), if not tackled promptly.

• High index of suspicion required to exclude intra-abdominal and/or systemic pathology as cirrhosis promotes bacterial translocation within the bowels and patient can become septic quickly.

• Community follow up is absolutely crucial as rate of relapse is high and this inevitably leads to undesirable outcomes.

• Alcoholics may have other substance abuse/dependence issues and this must be explored and addressed at the earliest opportunity, in this case, smoking cessation must be addressed promptly.

What could be done better• The amount of alcohol consumed daily was not established• The malnutrition score/ risk was also not appropriately documented at admission• Initial assessment of capacity and encephalopathy has to be carried out and

documented using the tools available. • There was no documented collateral history• The lessons from this have incorporated into the junior doctors learning modules to

highlight the importance of assessment for malnutrition, encephalopathy; mental capacity assessment, collateral history and holistic assessment of decompensated alcohol liver disease.

• The review of in-patient guideline for alcohol liver disease and acute withdrawal has been proposed to facilitate learning and improvement of service delivery.

• Importance of resumption of in-patient alcohol liaison assessment is being reviewed as COVID-19 cases subside in hospital setting.