VOL: 99, ISSUE: 23, PAGE NO: 31
Aetiology and risk factors
- Physical dependence upon alcohol results in withdrawal symptoms if alcohol intake is suddenly stopped or reduced sharply.
- Withdrawal symptoms commence within 12 hours of stopping alcohol; these can be unpleasant even in their most minor forms.
- Most dependent drinkers will experience the minor forms of withdrawal, while some will suffer severe symptoms that require detoxification in an inpatient setting.
- Risks can include dehydration from vomiting or diarrhoea, convulsions, hallucinations and or confusion, leading to agitation and sometimes aggression.
- Minor withdrawal symptoms often peak between the second and fourth days of withdrawal and subside after this, disappearing by the eighth to tenth day.
- Major withdrawal symptoms can appear between the first and fifth days, with rapid onset. A previous history of these symptoms is the best predictor of their recurrence.
Signs and symptoms
- The quantity of alcohol consumed does not necessarily dictate the severity of symptoms.
- Agitation or anxiety;
- Morning retching or vomiting;
- Sweating, particularly at night;
- Frequent loose bowel motions.
- Withdrawal convulsions;
- Confusion, possible Wernicke’s encephalopathy or Korsakoff’s psychosis;
- Delirium tremens - a serious effect of withdrawal displaying many of the above symptoms, including sweating, tachycardia, tachypnoea and pyrexia. It may also include dehydration, concurrent infection, hepatic disease or Wernicke-Korsakoff syndrome. The patient is often disorientated, with agitation, marked tremor and vivid hallucinations. The condition can be fatal if untreated.
- The international criteria for psychiatric diagnosis classifies alcohol withdrawal as ICD-10 (F10.3). The number 10 indicates mental illness, F10 relates to mental disorders due to alcohol, and F10.3 refers to the withdrawal state.
- The ICD states that any three of the listed symptoms are useful in making a diagnosis of alcohol dependence, in conjunction with a verbal history from the patient or relatives, a previous medical history, high blood alcohol, alcohol on the breath and deranged liver function tests (LFTs).
- Sedation with appropriate benzodiazepines (often chlordiazepoxide). The regimen should dampen symptoms while avoiding over sedation and should be reduced to zero over eight to 10 days.
- Management of hallucinations with suitable neuroleptics.
- Maintenance of hydration.
- Vitamin treatment of dietary neglect, and as prophylaxis, to prevent Wernicke-Korsakoff syndrome. Where confusion is present, or if there is a history of dietary neglect, vitamins are given parenterally.
- Treatment of concurrent infections.
- The observation of symptoms and titration of medication accordingly (in collaboration with medical staff).
- Administration of parenteral vitamins and intravenous medications and fluids, particularly if delirium tremens is present.
- Management of confusion or hallucinations, orientation via explanation, liaison with specialist services and psychiatry regarding treatment and follow-up options.
Royal College of Physicians (2001) Alcohol - Can the NHS Afford it? Recommendations for a coherent alcohol strategy for hospitals. London: RCP.