Alcohol Withdrawal

Question 1

What is the pathophysiology of alcohol withdrawal

Answer 1

Chronic alcohol consumption enhances GABA mediated inhibition of the CNS (similar to benzodiazepine) and inhibition of NMDA type glutamate receptors

Question 2

What is the presentation of alcohol withdrawal?

Answer 2

6-12 hours: Tremor, sweating, tachycardia, anxiety.
12-24 hours: Hallucinations.
36 hours - Peak incidence for seizures.
48-72 hours - Delirium tremens : Coarse tremor, confusions, delusions, hallucinations, fever, tachycardia

Question 3

What are the risk factors for alcohol withdrawal?

Answer 3

Excess alcohol use: Take extensive history,
History of alcohol withdrawal,
Poor physical health: signs of liver disease.
Poor nutrition.
Acute intercurrent illness.

Question 4

What is the management of alcohol withdrawal?

Answer 4

If scoring > 2 on GMAWS then First line: Long acting benzodiazepines eg, chlordiazepoxide, diazepine. Second line: Carbamazepine. Also give thiamine to prevent Wernicke’s encephalopathy
If scoring < 2 then give supportive care and thiamine - 2 paired samples, 3x day for 48hours

Question 5

What are the features of Wernicke’s encephalopathy?

Answer 5

Triad: Ophthalmoplegia/nystagmus, ataxia and encephalopathy. However most commonly presents with confusion and altered mental status. Can also get peripheral sensory neuropathy

Question 6

What are the investigations and treatment of Wernicke’s encephalopathy?

Answer 6

Investigations - decreased red cell transketolase and MRI.
Treatment - urgent thiamine replacement.

Question 7

What is a complication of wernicke’s encephalopathy?

Answer 7

Development of Korsakoff syndrome which presents with amnesia and confabulation

Question 8

What are the stages of alcohol related liver disease

Answer 8

1. Alcoholic fatty liver disease (reversible with abstinence)
2. Alcoholic hepatitis
3. Cirrhosis (irreversible)

Question 9

What is Delirium tremens?

Answer 9

Occurs with alcohol withdrawal, presents with: acute confusion, severe agitation, delusions and hallucinations, tremor, tachycardia, hypertension, hyperthermia, ataxia, arrhythmias

Question 10

What are the investigations for alcoholic liver disease?

Answer 10

Gamma-GT elevated
AST:ALT ratio is normally > 2.

Question 11

What is the management of alcoholic hepatitis?

Answer 11

Stop alcohol consumption!
Steroids eg, prednisolone during acute attack (look at scorring tool)
Pentoxyphylline can be used

Question 12

What are the signs and symptoms of alcoholic liver disease?

Answer 12

early - Fatigue, malaise, abdominal pain, anorexia, weakness.
Later - Jaundice, RIQ pain, hepatomegaly, palmer erythema, perioheral oedema, clubbing, pruritis, xanthomas, spiner neavi.
Raised oestrogen can cause: Gynaecomastia and testicular atrophy, loss of body hair, amenorrhoea, loss of libido.
Portal hypertension - Ascites, dilated veins (caput medusa), variceal bleeding, splenomegaly.