Intractable Alcoholism in a Patient with a Levine Shunt

Abstract

Ellen S haw. M. D., Fellow in Hepatology: Mr. J is a fort y-six-year-old white male who was initially seen on th e medical service in July 1982. At that time he presented with hepatic encepha lopathy, jaundice, and ascites . A liver biopsy was per formed, confirming the clinica l diagnosis of a lcoholic hepati t is superimposed on cirrhosis. Following dischar ge it was difficult to mainta in Mr. J as an out patient. He did not follow dieta ry rest rictions or ta ke diur et ics as presc ribed . Addit iona lly he was unable to control his drinking. Fina lly about a yea r ago a Levine shunt was imp lanted in an effort to control his asci tes . Subsequently he did well for a period of several months. He was ab le to abstai n from alcohol with a resu lt ing decrease in his ascites and jaundice. Recent ly he has resu med drinking, with a retu rn of his sym ptoms. He has missed his last several appointments in the clinic. Co nt rol of his medical pro blem s rem ains problemat ic unless his alcohol abuse ca n be bett er controlled. Willis C. Maddrey , M.D., Maggey Prof essor and Chairman of the Department of Medicine: I a m grateful for th e opportunity to discuss thi s te rrible problem . I know this pat ient, as ma ny of you do. He is prototypical of a group of patients in whom cirrhosi s a nd a ll of its complicati ons induced by a lcohol has led to a complex situation that is a downw ard spira l. As Dr . Shaw relat ed , th is man developed cirrhosis, the major mani fest ati on of which was ascites. If he would trea t himself appropri at ely, that is to say, be a bsti nent and ta ke diuretics, in addit ion to his Levine shunt, then his life expecta ncy would be reasona ble, about ten yea rs. Once you get cirrhosis your life expecta ncy dr ops remarkabl y. But if Mr. J were to take care of himself he would probabl y be a ll right for about ten years . Our pro blem , therefore, is th is pa tient' s persist ent addiction to alcohol. As you know, when this patient dried out, he took a look a t his life and decid ed it was bett er to be an a lcoholic . T hat's our probl em . Wh at I would like to talk about is the pa rt I work with the most: the physica l consequences of a lcohol abuse . You are a ll aware of the stat ist ics, but they are wor th reviewing. A bout one in ten chronic a lcoholics will develop cir rhosis . A chronic alcoholic to a hepat ologist is someo ne who dr inks more than sixteen ounces of eighty-six proof whiskey or its equivalent a day. I'm not using a socia l definition . T here a re people who are imp aired a t less tha n that and ot her s who are not a t much more than tha t. In fact, I have a number of pa tients with minimal liver abnorm alit ies in whom I'm relat ively ce rtain tha t they're telling me the truth when the y tell me the y