Alcohol withdrawal

Question 1

GI presentations of alcohol misuse?

Answer 1

• D, V
• ulcers
• varices (haematemesis and/or melena)
• oesophageal erosions
• pancreatitis
• GI cancer

Question 2

Neurological presentations of alcohol misuse?

Answer 2

• Memory and cognitive impairments.
• Peripheral neuropathy
• Seizures
• Falls
• Wernicke’s encephalopathy and Korsakoff’s syndrome.

Question 3

CV presentations of alcohol misuse?

Answer 3

• Arrhythmia
• HTN
• Cardiomyopathy
Anaemia

Question 4

Ix alcohol misuse?

Answer 4

BEDSIDE
• CAGE questionnaire
• further: AUDIT, SADQ

BLOODS
• FBC: macrocytic anaemia (raised MCV)
• LFT: ↑GGT, ↑↑AST (on the “Sauce”), ↑ALT (ratio AST:ALT >2)

IMAGING
• transient elastography (FibroScan) to diagnose cirrhosis in all persistent heavy drinkers

Question 5

CAGE Qs?

Answer 5

Cut down on your drinking?

Annoyed you by criticizing your drinking?

Guilty about drinking?

Eye-opener to steady your nerves or to get rid of a hangover?

Question 6

Sx withdrawal? (6-24 hours after last drink)

Answer 6

anxiety
nausea or vomiting
autonomic dysfunction - sweats, tremor
insomnia

seizures
psychiatric disturbance
delirium tremens
alcoholic hallucinosis

Question 7

Ix withdrawal?

Answer 7

BEDSIDE
• ECG arrhythmias

BLOODS
• FBC (macrocytic, thrombocytopenia)
• U+E (check for dangerously low K+)
• LFTs
• VBG (Respiratory alkalosis - DTs, respiratory alkalosis - DTs with hyperventilation, low Cl- metabolic acidosis - V, metabolic acidosis + high anion gap - alcohol ketoacidosis)
• blood glucose (Hypoglycaemia)
• blood cultures
• 

IMAGING
• CT head
• CXR

Question 8

Tx alcohol withdrawal

Answer 8

• maintain fluids and correct electrolytes if needed
• do CIWA score
• give benzo (chlordiazepoxide or diazepam) and thiamine if >10
• • antipsychotic if DTs
• manage in community ASAP

Question 9

relapse prevention?

Answer 9

acamprosate (reduced craving)
naltrexone (reduced pleasure)
disulfiram (causes hangover like symptoms 10 min after)

baseline U&E and LFT before starting

Question 10

Sx DTs?

Answer 10

3-7 days after last drink.
Delirium, confusion.
Tremor and seizures.
↑HR and ↓BP.

Question 11

Tx DTs?

Answer 11

• ABC, including fluids.
• Monitor symptoms with CIWA severe is ≥20.
• Benzodiazepines PO for seizures and sedation.
• Chlordiazepoxide or diazepam is 1st line, or oxazepam if there is liver impairment
• Lorazepam IV if seizures are ongoing. Barbiturates and ITU if refractory.
• Nutritional support: thiamine, folate, and correction of any deficiencies in glucose, K+, Mg2+, and PO43-
• Consider IV initially as GI absorption impaired.

Question 12

Sx Wernicke’s encephalopathy? (triad)

Answer 12

• Ophthalmoplegia: nystagmus, lateral rectus palsy.
• Ataxia with Wide-gait
• Confusion

Question 13

Sx Korsakoff’s syndrome?

Answer 13

• Anterograde amnesia: can’t form new memories.
• Retrograde amnesia: can’t remember the past.
• Confabulation: false memories – believed to be true – to fill the memory blanks.