Transcript GASTROENTEROLOGY - addiction

GASTROENTEROLOGY
September 2015
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Recognition of the multiple symptoms associated with alcohol
misuse
Appreciation of the importance of a comprehensive drug and
alcohol history in all patients with gastroenterological and
hepatic symptoms
Explanation of the association between illicit drug use and
viral hepatitis
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Substances cause a range of physical problems eg vascular
and carcinomatous complications of the stomach
Injecting drug users are at high risk of hepatitis B due to
sharing injecting equipment and sexual contact
Viral hepatitis (especially hepatitis C) is common in injecting
drug users and in people who snort cocaine
Synthetic drugs eg ecstasy lead to digestive and hepatic
damage, vascular complications of the stomach
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Alcohol causes hepatitis, fibrosis and cirrhosis of the liver;
colon and rectal cancer
Nutritional deficiencies eg vitamin B, vitamin C and iron can
lead to stomatitis and glossitis
Cocaine leads to gastric ulcerations, retroperitoneal fibrosis,
visceral infarction, intestinal ischemia, gastrointestinal tract
perforation
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Stomatitis
Glossitis
Reduced saliva production
Enlarged adiposeglands
Leukoplakia, erythroplakia, submucous fibrosis of
oropharyngeal mucosa
Oral lichen planus
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Disrupted oesophageal function
Oesophagitis , gastritis, doudenitis
Oesophageal and gastric varices
Malnutrition due to altered small bowel function
Acute and chronic pancreatitis
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Poor diet and nutrition
Poor immunity
Damage to the digestive system as a result of packages of
drugs being hidden in orifices eg rectum, vagina or ingested
Self medication in order to treat heartburn and acid
indigestion
Gastro intestinal bleeding including Mallory Weiss tear
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Patients may not consider the effect that their substance use
has on their system
Fear of symptoms which may be life threatening
Lack of detection of recognition by doctors in screening for
substance use in patients presenting with gastro intestinal
disorders
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A careful history with details of current and past substance
misuse is essential
Details of alcohol use are mandatory
Nausea and vomiting is caused by disorders of digestive tract
and the brain
Alcohol use causes pain, nausea, vomiting and hematemesis
from Mallor Weiss tears
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Opioid analgesics can cause nausea and vomiting
Abdominal pain, diarrhoea and constipation are common with
licit and illicit drugs
Acute liver failure presents with deepening jaundice,
confusion, coma and death is caused by many drugs
particularly ecstasy
Cocaine can present with ischemic colitis from intestinal
thrombosis
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Since 1988 injecting drug users have been targeted for
vaccination
Availability of vaccination and uptake remains poor so needs
to be proactive
A harm reduction approach is the focus of management
Diagnosis includes endoscopy, histopathological testing, xrays, scans, routine blood tests
Alcohol detoxification should be considered
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Reduction of harmful drugs and substitute medication eg
methadone should be prescribed
If reduction is declines, reduction of harmful practices should
be encouraged
Safe injecting practices, vaccination for BBV, and provision of
clean injecting equipment
All patients must be tested for hepatitis and appropriate
therapy offered
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Vaccinate all drug users against Hepatitis A as they at risk due to
poor living conditions and fecal contamination of drugs and
injecting equipment
Hepatitis A is available as a single component vaccine and
combined with hepatitis B
Single component hepatitis A vaccine is preferable to combined
hepatitis A and B vaccine
For single vaccine give 2 doses and second dose after 6-12
months
The second dose may be delayed for up to 3 years
When deciding on the optimal regime consider if the patient will
return for subsequent doses
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About 21% of injecting drug users have past or current
hepatitis infection
Vaccinate all drug users against hepatitis B
Use accelerated 0, 7and 21 days schedule to complete the
course as quickly as possible
Partners and children should be offered vaccination
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Screening and diagnosis of infection enables patients to
understand how they can implement life changes to slow the
rate of progression
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There is no vaccine available
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Consider anti viral treatment in chronic hepatitis C
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Referral to specialist addiction services for further
assessment, advice and treatment
This may include motivational interviewing, group, individual
or family behavioural treatments to reduce substance use
Primary care teams can advise and monitor gastrointestinal
symptoms and may have the skills to manage substance
problems
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Appleby, VJ; Darnbrough,E; Forrester,K; Simpson,R; Clarke,C; Moreea S. (2015) PTU-118 An audit of the prevalence of chronic hepatitis c and treatment
outcomes in drug users attending substance misuse centres in Bradford – planning for future service provision Gut ;64:A114 doi:10.1136/gutjnl-2015309861.233 http://gut.bmj.com/content/64/Suppl_1/A114.1.abstract?eaf
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Badrakalimuthu, V.R, Rumball, D & Chawla, A (2011) Hepatitis C: a patient’s journey from a psychiatrists’ perspective. Advances in psychiatric treatment.
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Barclay, G.A, Stewart, J.B, Day, C.P and Gilvarry, E (2008) Adverse physical effects of alcohol misuse. Advances in psychiatric treatment. Vol.14, 139-151
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Kumar P and Clark M (2009) Clinical Medicine. 7th edn. London: Elsevier
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NICE (2004) Hepatitis C - pegylated interferons, ribavirin and alfa interferon (NICE technology appraisal,TA75) http://guidance.nice.org.uk/TA75
This guidance replaces Hepatitis C - alpha interferon and ribavirin (TA14).
This guidance is extended by Hepatitis C - peginterferon alfa and ribavirin (TA106). http://guidance.nice.org.uk/TA75
NICE (2006) Hepatitis B (chronic) - adefovir dipivoxil and pegylated interferon alpha-2a (NICE technology appraisal,TA96)
http://guidance.nice.org.uk/TA96
This guidance has been partially updated by CG165 Hepatitis B (chronic)
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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
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NICE (2010) Hepatitis C - peginterferon alfa and ribavirin (NICE technology appraisal,TA200) http://guidance.nice.org.uk/TA200