3. Alcohol Withdrawal + Wernicke's-Korsakoff Syndrome

Question 1

What is 1 unit of alcohol?

Answer 1

10ml or 8g of pure alcohol

Question 2

How long does it take an average person to process 1 unit of alcohol so that there is no alcohol in the bloodstream?

Answer 2

1 hour

Question 3

What would 13 ABV mean?

Answer 3

13% pure alcohol

ABV means ‘alcohol by volume’

Question 4

What is the government recommended limit on weekly alcohol intake

Answer 4

14 units max per week spread out over 3+ days and not more than 5 units per day.

Question 5

What are some of the complications of alcohol?

Answer 5

• Alcoholic Liver Disease
• Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma
• Alcohol Dependence and Withdrawal
• Wernicke-Korsakoff Syndrome (WKS)
• Pancreatitis
• Alcoholic Cardiomyopathy

Question 6

What symptoms are expected in someone undergoing alcohol withdrawal?

Answer 6

6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens

Question 7

How can you minimise the symptoms of alcohol withdrawal?

Answer 7

individuals should gradually drop their alcohol intake levels over a period of time, instead of going teetotal to begin with.

Question 8

In a new ward patient (<3 days) with acute confusion, what should you instantly be thinking of?

Answer 8

Whether they are undergoing alcohol withdrawal

Question 9

What percentage of those undergoing treatment for alcohol withdrawal will relapse?

Answer 9

50%

Question 10

What questionnaires can you use to assess whether someone is suffering from alcohol dependence syndrome?

Answer 10

• CAGE

- AUDIT

Question 11

What is the CAGE questionnaire?

Answer 11

C – CUT DOWN? Ever thought you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Ever feel guilty about drinking?
E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?

Question 12

What is the AUDIT questionnaire?

Answer 12

This involves 10 scored multiple choice questions, with a score of 8 or more giving an indication of harmful use.

Question 13

What are delirium tremens?

Answer 13

Delirium tremens is a medical emergency associated with alcohol withdrawal with a mortality of 35% if left untreated. They present as;

• Acute confusion
• Severe agitation
• Delusions and hallucinations
• Tremor
• Tachycardia
• Hypertension
• Hyperthermia
• Ataxia (difficulties with coordinated movements)
• Arrhythmias

Question 14

What is the pathophysiology behind delirium tremens?

Answer 14

Alcohol stimulates GABA receptors in the brain. GABA receptors have a “relaxing” effect on the rest of the brain. Alcohol also inhibits glutamate receptors (also known as NMDA receptors) having a further inhibitory effect on the electrical activity of the brain.

Chronic alcohol use results in the GABA system becoming up-regulated and the glutamate system being down-regulated to balance the effects of alcohol. When alcohol is removed from the system, GABA under-functions and glutamate over-functions causing an extreme excitability of the brain with excess adrenergic activity.

Question 15

How are the symptoms of alcohol withdrawal managed?

Answer 15

• CIWA-Ar tool used to score patient on their withdrawal symptoms and guides treatment plan
• Chlordiazepoxide (“Librium”) is a benzodiazepine used to combat the effects of alcohol withdrawal. Diazepam is a less commonly used alternative. The dose is determined by local hospital formulary, but is normally given orally for 5-7 days
• Intravenous high-dose B vitamins (pabrinex). This should be followed by regular lower dose oral thiamine.

Question 16

What is Wernicke-Korsakoff Syndrome?

Who does it occur in and why?

Answer 16

It is essentially thiamine (vitamin B1) deficiency.

This occurs in alcoholics because as well as them having a poor diet (so lack of B1 to begin with), alcohol causes a poor absoption of B1 in the body.

Question 17

What is Wernickes encephalopathy in Wernicke-Korsakoff Syndrome?

Answer 17

This is the first symptom causing stage of a thiamine deficiency.

The features of presentation include;

• Confusion
• Oculomotor disturbances (disturbances of eye movements)
• Ataxia (difficulties with coordinated movements)

It is a medical emergency and has a high mortality rate if untreated.

Question 18

What is Korsakoff’s Syndrome in Wernicke-Korsakoff Syndrome?

Answer 18

This is what follows Wernickes encephalopathy if it goes untreated.

The features of presentation include;
- Memory impairment (retrograde and anterograde)
Behavioural changes

Korsakoff’s syndrome is often irreversible and results in patients requiring full time institutional care

Question 19

How can Wernicke-Korsakoff Syndrome be treated and prevented?

Answer 19

• Thiamine supplementation

- Abstaining from alcohol

Question 20

What is pabrinex?

Answer 20

It is IV high dose vitamin-Bs given to those undergoing the symptoms of alcohol withdrawal