Alcohol Withdrawal Syndrome

Question 1

Define AWS

Answer 1

• The symptoms that may occur when a person has been drinking too much alcohol on a regular basis and suddenly stops drinking

Question 2

Explain the aetiology of AWS

Answer 2

• Chronic alcohol use results in up-regulation of post-synaptic N-methyl-D-aspartate (NMDA) receptors and down-regulation of post-synaptic gamma-aminobutyric acid (GABA) receptors. A decrease in blood ethanol concentration due to abrupt cessation in alcohol consumption results in an imbalance between stimulatory (NMDA) and inhibitory (GABA) systems in the central nervous system. Excessive stimulatory effect leads to the development of the clinical signs and symptoms of alcohol withdrawal syndrome.
• As a result, excessive glutamatergic stimulation with diminished inhibitory (GABA) activity leads to the development of clinical symptoms of alcohol withdrawal syndrome (AWS), including autonomic hyperactivity, tremors, hallucinations, and seizure. [26]

Question 3

What are the risk factors for AWS?

Answer 3

Sudden withdrawal of alcohol and previous history of AWS

Question 4

Epidemiology of AWS

Answer 4

• Approximately 8% of all patients admitted to hospital are at risk of alcohol withdrawal. Among ICU patients, some studies have shown that 16% to 31% are at risk of alcohol withdrawal; 31% of trauma patients may be at risk of alcohol withdrawal
• If untreated, 6% of alcohol-dependent patients develop clinically relevant symptoms of withdrawal

Question 5

What are the presenting symptoms of AWS?

Answer 5

•	History of high alcohol intake 
•	Symptoms may start as early as 4-6hrs after last drink
•	Mild Symptoms:
o	Insomnia and fatigue 
o	Tremor 
o	Mild anxiety/feeling nervous 
o	Mild restlessness/agitation 
o	Nausea and vomiting 
o	Headache 
o	Sweating 
o	Palpitations 
o	Anorexia 
o	Depression 
o	Craving alcohol
•	More severe symptoms (usually occur after 24hrs):
o	Hallucinations 
o	Withdrawal seizures (generalised tonic-clonic)
o	Delirium tremens

Question 6

What is delirium tremens and what are it’s features?

Answer 6

an acute confusional state often seen as withdrawal syndrome in chronic alcoholics and caused by sudden cessation of drinking alcohol. It can be precipitated by a head injury or an acute infection causing abstinence from alcohol.
• FEATURES:
 Anxiety
 Tremor
 Sweating
 Vivid and terrifying visual and sensory HALLUCINATIONS (usually of animals and insects)
 Can be FATAL

Question 7

What investigations would you do for AWS?

Answer 7

• Bloods – U+E (elevated or normal, dehydration, uraemic encephalopathy, metabolic acidosis, hypokalaemia), LFT (alcoholic hepatitis, elevated or normal), toxicology screen,
• Can also do CT head and chest x-ray to exclude intracranial and cardio causes of clinical presentation

Question 8

What’s the management plan for AWS?

Answer 8

• Chlordiazepoxide (benzo)/ clomethiazole - reduces symptoms of alcohol withdrawal
• Barbiturates may be used if refractory to benzodiazepines
• Propfol (anaesthetic) can be used if refractory to benzo therapy ( can cause resp depression)
• Thiamine (Pabrinex) - prevents progression to Wernicke-Korsakoff syndrome

Question 9

What are the possible complications of AWS?

Answer 9

• Patients can have seizures and die if it is left untreated (delirium tremens)

Question 10

What’s the prognosis for AWS?

Answer 10

• Delirium tremens has a mortality of 35% if untreated
• Mortality is < 2% with early detection and treatment
• Patients may complain of persistent insomnia and autonomic symptoms for a few months after acute withdrawal phase. These symptoms usually last about 6 months. About 50% of patients remain abstinent for a year. Relapse prevention can be achieved by counselling strategies, self-help groups (e.g., Alcoholics Anonymous), and pharmacotherapy.