Alcohol Withdrawal

Question 1

Define alcohol withdrawal

Answer 1

SYMPTOMS (physical and psychological) that occurs in patients who are alcohol dependant and experience a sudden cessation of intake

Question 2

Aetiology of Alcohol withdrawal

Answer 2

Overactivity of the sympathetic nervous system
Alcohol enhances GABA activity -> inhibit excitatory glutamate transmission
Reduced GABA function + upregulation of NMDA receptors
Abrupt cessation -> overactivitation

Question 3

Symptoms of Alcohol withdrawal

Answer 3

Minor withdrawal (6hrs) - anxiety, agitation, palpitations, GI upset, sweating + tremor, N+V

Hallucinations (12h) - visual/tactile

Seizures (46h) - short generalised tonic-clonic

Delirium tremens (48-72h)

Question 4

What is delirium tremens

Answer 4

Profound confusion/delirium
Visual, auditory and tactile hallucinations, characteristically frightening
Pins and needles, burning and numbness
Coarse tremor

Question 5

Investigations for Alcohol withdrawal

Answer 5

CIWA-Ar for severity
CAGE and AUDIT

ECG: tachyarrhythmias

VBG: assess for corrections (respiratory alkalosis, metabolic acidosis + high anion gap
Glucose: rule out hypoglycaemia
FBC: macrocyclic anaemia, thrombocytopenia
U+Es: Mg, K and phosphate low
LFTs: Elevated AST/ALT/GGT
Bone profile: hypocalcaemia, vit D
Coagulation screen: prolonged INR and PT
Blood cultures: Check for infectious cause
Amylase/lipase: acute pancreatitis

CXR; consolidation (pneumonia)
CT head: those with seizures, altered cognition or suspected head injury

Question 6

Management of Alcohol withdrawal if CIWA-Ar >10

Answer 6

1. Supportive: quiet room, correct abnormalities and electrolytes
2. Benzodiazepine
3. Pabrinex (thiamine, vit B1)
4. Glucose if hypo

Question 7

Outpatient management of alcohol withdrawal

Answer 7

Manage the alcohol dependence, Drug and Alcohol Liaison Specialist (DALS)
Community services e.g. AA
Therapy

Question 8

Complications of alcohol withdrawal

Answer 8

Delirium tremens
Over-sedation
Status epilepticus
Persistant insomnia and autonomic symptoms for months

Question 9

Prognosis of alcohol withdrawal

Answer 9

Delirium tremens-related mortality is <1% if early and treated, but fatal in 15-20% of patients if untreated

50% of patients remain abstinent from alcohol for a year

Question 10

Signs of Alcohol withdrawal + delirium tremens

Answer 10

Abnormal BP, anorexia
Signs of CLD: palmar erythema, Dupuytren’s contracture, clubbing, bruising, spider naevi, scleral icterus, gynaecomastia

Delirium tremens: tachycardia, fever, ketoacidosis, circulatory collapse