Alcohol Withdrawal

Question 1

Definition

Answer 1

The symptoms that may occur when a person has been drinking too much alcohol on a regular basis and suddenly stops drinking

Question 2

Aetiology/Risk Factors

Answer 2

· Chronic alcohol consumption suppresses the activity of glutamate (an excitatory neurotransmitter), so the body compensates by increasing sensitivity to glutamate

· So, when alcohol consumption stops, you get increased glutamate activity leading to excitatory symptoms

Question 3

Epidemiology

Answer 3

· If untreated, 6% of alcohol-dependent patients develop clinically relevant symptoms of withdrawal

· Up to 10% of them will delirium tremens

Question 4

Presenting Symptoms

Answer 4

History of high alcohol intake

Mild symptoms:
Insomnia and fatigue
Tremor
Mild anxiety/nervousness
Mild restlessness/agitation
Nausea and vomiting
Headache
Sweating
Palpitations
Anorexia
Depression
Craving alcohol

Severe symptoms:
Hallucinations
Severe memory disturbances
Disoriented to time, place and person
Withdrawal seizures (generalised tonic-clonic)
Delirium tremens

Question 5

Delirium Tremens

Answer 5

An acute confusional sate often seen as withdrawal syndrome in chronic alcoholics and caused by sudden cessation of drinking alcohol. It can be precipitated by a head injury or an acute infection causing abstinence from alcohol

Features:
Anxiety
Tremor
Sweating
Vivid and terrifying visual and sensory hallucinations 
Can be fatal

Question 6

Investigations

Answer 6

NONE for alcohol withdrawal itself

• Urea & Cr – check dehydration (can lead to impaired renal function)
• LFTs – check liver damage
• Ethanol: positive
• Electrolytes & lactate – high lactate suggests seizures, ketoacidosis, alcohol ingestion
• FBC – check infection, may show macrocytic anaemia
• CT head – check intracranial causes
• CXR – exclude cardiopulmonary causes

Question 7

Management Plan

Answer 7

· Chlordiazepoxide - reduces symptoms of alcohol withdrawal (or lorazepam, diazepam)

· Barbiturates may be used if refractory to benzodiazepines (eg phenobarbitol)

· Thiamine (Pabrinex) - prevents progression to Wernicke-Korsakoff syndrome

Question 8

Possible Complications

Answer 8

Over-sedation

Delirium tremens (1-5 days)

Alcohol withdrawal seizures –> status epilepticus

Possible death if left untreated

Question 9

Prognosis

Answer 9

Persistent insomnia and autonomic symptoms for around 6 months after acute withdrawal phase

Half of patients remain abstinent for 1 year

Prevent relapse with counselling/pharmacology

· Delirium tremens has a mortality of 35% if untreated

· Mortality is < 2% with early detection and treatment