Alcohol Withdrawal

Question 1

A 64 year old legal secretary who lives alone is admitted to hospital with a urinary infection. You are asked to see her because of confusion and hallucinations. She states that she consumes 0.5 bottle of wine daily. How would you manage this?

Answer 1

Impression
Concerned about several DDX in this presentation. Notably, want to rule out complicated UTI with urosepsis as cause for patients confusion, however, in setting of significant EtOH consumption, I am most concerned about alcohol withdrawal. Would want to manage emergently to restrict risk of progression to DT, or wernickes/korsakoffs

DDx

• Delirium
• Cognitive impairment and dementia
• Infective: urosepsis
• Psychotic: schizo, FEP
• SUD; acute intoxication; alcohol, other substances

Goals

• Assess for evidence of withdrawal utilising AWS, rule out systemic infection
• institute appropriate withdrawal mx according to severity with IV thiamine TDS initially, +/- bento’s.
• treat intercurrent UTI, through Hx/Ex/Ix to rule out DDs

Question 2

Alcohol withdrawal - History

Answer 2

History

• PC: timing, onset, progression, features (likely collateral hx here). Fluctuating? Temporally related to UTI? when was last drink? had sx when previously had period of abstinence?
• infective sx: fevers, sweats, rigors, chills
• Alcohol history
• PMHx: liver disease, past psych hHx
• FamHx: dementia, psychiatric
• Sociocultural

Question 3

Alcohol withdrawal - Examination

Answer 3

Examination
- General appearance + vitals (evidence of systemic infection
- Mental state exam
- Cognitive assessment (MOCA)
- CAMs or 4AT for Delirium
- AWS
Neurological examination
- Wernickes: Ophthalmoplegia, confusion, ataxia
- Korsakoffs: confabulation, personality change, memory loss
- DT: Seizures

Question 4

Alcohol Withdrawal - Investigations

Answer 4

Investigations

• Bedside: Urine drug screen, ECG
• Bloods: FBC, UEC, Folate/B12, LFT, CRP/ESR
• Imaging: CTB for cerebral atrophy, mamillary body necrosis

Question 5

Alcohol withdrawal - Management

Answer 5

Management

• Consider psych review if ?psychotic illness
• Manage emergently for complicated UTI

Alcohol withdrawal
- Admission for severe withdrawal sx/high risk
- Utilise AWS
- Thiamine 300mg IV TDS prior to dextrose etc
o PO is ineffective due to gastritis
- Benzodiazepines (Diaz 10mg every 2 hrs or until no sx)
o oxazepam, lorazepam are less hepatotoxic (not metabolised as much by CYP450)
- PPI for gastritis
- consider Antipsychotic (olanzapine)

UTI
- ensure optimal management with Empirical ABx (trimethoprim, nitrofurantoin)

Ongoing

• D&A referral
• Pharmacological options for Alcohol abstinence: naltrexone, disulfiram, acamprosate.