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Alcohol Withdrawal

Alcohol withdrawal syndrome is characterized by onset of symptoms that occurs in individuals who suddenly stop drinking alcohol. It essentially occurs in the alcohol drinking population who all of a sudden either decreases their alcohol intake or stops its consumption.


Presentation

Symptoms of alcohol withdrawal usually develop within 8 hours after the last drink. However, in many instances, symptoms may occur after many days. Symptoms include depression, anxiety, nervousness, mood swings, nightmares, irritability, fatigue, headache, enlarged pupils, pallor, sweating and rapid heart rate. In more severe forms of alcohol withdrawal, delirium tremens may set in. Individuals experience fever, hallucinations, seizures, confusion and agitation [7]. Symptoms continue for several weeks and peak within 24 to 72 hours after the onset of preliminary signs [8].

Fever
  • In more severe cases, individuals experience fever, agitation, seizures and severe confusion which occur due to development of delirium tremens.[symptoma.com]
  • […] peak at 5 days, include: Disorientation, confusion, and severe anxiety Hallucinations (primarily visual) which cannot be distinguished from reality Profuse sweating Seizures High blood pressure Racing and irregular heartbeat Severe tremors Low-grade fever[web.archive.org]
  • Go to the emergency room or call the local emergency number (such as 911) if seizures, fever, severe confusion, hallucinations, or irregular heartbeats occur.[medlineplus.gov]
Fatigue
  • Individuals however, tend to suffer from insomnia, fatigue and irritability for several months. It is necessary that alcohol withdrawal symptoms are treated with appropriate medications and therapies.[symptoma.com]
  • Symptoms such as sleep changes, rapid changes in mood, and fatigue may last for months. People who continue to drink a lot may develop health problems such as liver, heart, and nervous system disease.[medlineplus.gov]
  • If you are concerned that someone you love is suffering from alcohol withdrawal, here are some of the common alcohol withdrawal symptoms to be aware of: Behavior/psychological symptoms: Mood swings Anxiety/nervousness Irritability Fatigue Confusion/unclear[myvictorycenter.com]
Rigor
  • Anticonvulsants seem to have limited side effects, although adverse effects are not rigorously reported in the analysed trials.[ncbi.nlm.nih.gov]
Hypoxemia
  • This method is also beneficial for expectoration and redressing hypoxemia.[ncbi.nlm.nih.gov]
Excessive Daytime Sleepiness
  • The first aim of this review was to focus on current applications of sodium oxybate for the treatment of narcolepsy, with a particular emphasis on the key symptoms of this disorder: cataplexy and excessive daytime sleepiness (EDS).[ncbi.nlm.nih.gov]
Dysphagia
  • We report a very case of a patient with dysarthria, dysphagia and psychiatric symptoms including abnormal behavior starting after alcohol withdrawal, with radiological evidence of CPM and EPM.[ncbi.nlm.nih.gov]
  • A 45-year-old man with a history of alcoholism visited the ER with dysarthria and dysphagia for 2 days. These symptoms occurred 3 days after he had stopped drinking alcohol.[ncbi.nlm.nih.gov]
Liver Fibrosis
  • Stewart Campbell, Peter M Timms, Paul R Maxwell, Elizabeth M Doherty, Mohammad Z Rahman, Michael EJ Lean and Booth J Danesh, Effect of alcohol withdrawal on liver transaminase levels and markers of liver fibrosis, Journal of Gastroenterology and Hepatology[doi.org]
Hypertension
  • Abstract Alcohol withdrawal hypertension is a common clinical problem which often goes unrecognized.[ncbi.nlm.nih.gov]
  • Alcohol withdrawal syndrome begins six to 24 hours after the last intake of alcohol, and the signs and symptoms include tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Dexmedetomidine reduces hypertension and tachycardia in AWS and also reduces benzodiazepine requirements; however, the impact of these findings on important clinical endpoints is yet to be determined.[ncbi.nlm.nih.gov]
  • […] dreams confused hypervigilant Stage III – 48 hrs generalised tonic-clonic seizures Stage IV – after 48 hrs global confusional state autonomic hyperactivity tremors hallucinations seizures hyperadrenergic: diaphoresis, flushing, mydriasis, tachycardia, hypertension[lifeinthefastlane.com]
Tachycardia
  • Alcohol withdrawal syndrome begins six to 24 hours after the last intake of alcohol, and the signs and symptoms include tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Dexmedetomidine reduces hypertension and tachycardia in AWS and also reduces benzodiazepine requirements; however, the impact of these findings on important clinical endpoints is yet to be determined.[ncbi.nlm.nih.gov]
  • There was a trend toward significance of association of complications with tachycardia, history of delirium tremens, and benzodiazepines being administered before psychiatric consultation.[ncbi.nlm.nih.gov]
  • […] irritability vivid dreams confused hypervigilant Stage III – 48 hrs generalised tonic-clonic seizures Stage IV – after 48 hrs global confusional state autonomic hyperactivity tremors hallucinations seizures hyperadrenergic: diaphoresis, flushing, mydriasis, tachycardia[lifeinthefastlane.com]
  • […] fear, irritability, depression Catatonia Confusion Delirium tremens Derealization Euphoria Fever Gastrointestinal upset, nausea and vomiting, diarrhea Hallucinations Headache, migraine High blood pressure Insomnia, increased REM sleep Palpitations, tachycardia[healthyplace.com]
Kidney Failure
Seizure
  • Inpatient management is desirable to eliminate other causes of seizures that occur for the first time in adult life and because such patients are at substantial risk for additional seizures and the development of delirium tremens.[ncbi.nlm.nih.gov]
  • The risk of seizures is especially high in patients who previously have undergone multiple detoxifications.[web.archive.org]
  • Patients with a history of multiple detoxification episodes are more likely to experience seizures and severe withdrawal symptoms.[ncbi.nlm.nih.gov]
  • […] other drugs, there is a trend in favour of benzodiazepines for seizure and delirium control, severe life threatening side effect, dropouts, dropouts due to side effects and patient's global assessment score.[ncbi.nlm.nih.gov]
Agitation
  • A significant number of patients with terminal cancer experience terminal restlessness or an agitated delirium in the final days of life.[ncbi.nlm.nih.gov]
  • He received intravenous fluids and tapering dosages of lorazepam to control agitation and rigidity, and recovered with no significant sequelae after 8 days.[ncbi.nlm.nih.gov]
  • Ibrahim contends that it’s both safe and effective in treating agitation. The physicians at St. Francis use haloperidol only as an adjunct for persisting agitation after the Valium front-loading.[todayshospitalist.com]
  • Downregulation and decreased sensitivity of γ-aminobutyric acid receptors render benzodiazepines less effective at controlling psychomotor agitation.[ncbi.nlm.nih.gov]
  • Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens. The gold-standard treatment for AWS is with benzodiazepines (BZDs).[ncbi.nlm.nih.gov]
Tremor
  • Finally, we evaluated different methods of combining the data from the two hands for obtaining a single tremor rating estimate, and found that simply averaging the tremor ratings of the two hands results in the lowest tremor estimate error (an RMSE of[ncbi.nlm.nih.gov]
  • […] discriminator of real versus factitious tremors.[ncbi.nlm.nih.gov]
  • The symptoms and signs of alcohol withdrawal--autonomic dysfunction, tremor, anxiety, sleep disturbances, insomnia, and abnormal vital signs--may continue for 6 to 12 months after the cessation of alcohol.[ncbi.nlm.nih.gov]
  • Initially, he developed typical alcohol withdrawal syndrome including tremor, disorientation, delirium and visual hallucination of small animals.[ncbi.nlm.nih.gov]
  • Alcohol withdrawal syndrome begins six to 24 hours after the last intake of alcohol, and the signs and symptoms include tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures.[ncbi.nlm.nih.gov]
Insomnia
  • Brower, Alcohol Dependence and Its Relationship With Insomnia and Other Sleep Disorders, Alcoholism: Clinical and Experimental Research, 40, 11, (2271-2282), (2016). Forrest H.[doi.org]
  • The spectrum of alcohol withdrawal symptoms ranges from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens.[ncbi.nlm.nih.gov]
  • This means, the nervous system cannot easily adapt to sudden change in the alcohol consumption pattern causing various symptoms such as delirium, insomnia and anxiety to name a few.[symptoma.com]
  • The symptoms and signs of alcohol withdrawal--autonomic dysfunction, tremor, anxiety, sleep disturbances, insomnia, and abnormal vital signs--may continue for 6 to 12 months after the cessation of alcohol.[ncbi.nlm.nih.gov]
Irritability
  • A 27-year-old man was admitted with tremulousness, diaphoresis, tachypnea (28 breaths/min), full-body rigidity, irritability, paranoia, and auditory and visual hallucinations 2 days after stopping long-term gamma-hydroxybutyrate (GHB) and 8 hours after[ncbi.nlm.nih.gov]
  • Symptoms Symptoms of alcohol withdrawal include headache, anxiety, nervousness, mood swings, depression, irritability, enlarged pupil, sweating, arrhythmia, loss of appetite and insomnia.[symptoma.com]
  • Heroin withdrawal symptoms include dilated pupils, fever, chills, stomach cramps and diarrhea, vomiting, loss of appetite, irritability, panic, nausea, muscle cramps and runny nose.[withdrawal.net]
  • Physical withdrawal symptoms include: hand tremors ('the shakes') sweating nausea visual hallucinations (seeing things that aren’t real) seizures (fits) in the most serious cases Psychological withdrawal symptoms include: depression anxiety irritability[kmpt.nhs.uk]
  • Excessive drinking excites and irritates the nervous system. If you drink daily, your body becomes dependent on alcohol over time. When this happens, your central nervous system can no longer adapt easily to the lack of alcohol.[healthline.com]

Workup

A preliminary physical exam to evaluate the signs and symptoms of the condition would be carried out. Physical examination would show signs of tremors, fever, dehydration, abnormal movements of eye and arrhythmia.

In addition to physical examination, blood and urine tests would also be carried out to assess the amount of alcohol in body. A toxicology screen is also required to confirm the diagnosis.

Treatment

The type of treatment involved depends on the severity of the symptoms experienced. Some patients with mild to moderate symptoms can be treated at home; while others may require hospitalization to avoid onset of unnecessary complications such as delirium. Treatment of alcohol withdrawal is aimed at relieving symptoms, preventing onset of complications and achieving permanent abstinence from alcohol [9].

Outpatient treatment: In this, the individual gets treated for alcohol withdrawal symptoms, through medications and regular visits to the doctor. It is required that the patient is constantly monitored by a caregiver to look for adverse symptoms of the condition. The individuals are put on sedatives to ease the symptoms and are regularly screened through blood tests. In addition, they are also screened for other medical problems which can worsen the existing condition.

Inpatient treatment: Individuals experiencing severe symptoms may require a hospital stay to be monitored closely for onset of complications. All the vital parameters of the individual such as blood pressure, heart rate, body temperature, and blood levels of chemicals will be tested. In case of dehydration, the individual will be given IV fluids to correct the condition. Administration of sedatives such as benzodiazepines will be employed, until the withdrawal process is completed. Patients are also given nutritional supplements to correct nutritional deficiencies that have occurred due to long term alcohol abuse [10].

Prognosis

The prognosis of the condition is usually favorable when individuals are given prompt treatment. Individuals however, tend to suffer from insomnia, fatigue and irritability for several months. It is necessary that alcohol withdrawal symptoms are treated with appropriate medications and therapies. This is so because, if the patients begin experiencing delirium, it can turn life threatening [6].

Etiology

Sudden cessation of alcohol consumption or significantly reducing the alcohol intake can cause development of alcohol withdrawal symptoms. It is more common in individuals who drink regularly and are unable to gradually decrease the consumption. Individuals who are suffering from certain underlying disease conditions are also at risk of developing alcohol withdrawal symptoms when they suddenly stop its consumption. In addition to adults, even teenagers and children who drink excessive alcohol are also susceptible to develop alcohol withdrawal symptoms [2].

Epidemiology

Alcohol withdrawal is a common phenomenon. It has been estimated that about 500,000 episodes of alcohol withdrawal symptoms occur each year in the US. About 5% of these individuals are known to fall prey to delirium tremens. The symptoms are so severe that they require pharmacologic intervention [3]. It has also been reported that about 50% patients who drink alcohol develop clinically relevant symptoms. In addition, less than 1 in 20 individuals who drink alcohol are also at risk of developing grand mal seizures or delirium tremens. Another statistical report revealed that mortality rate was as high as 20% in drinker’s population who suffered from delirium tremens [4].

Sex distribution
Age distribution

Pathophysiology

Drinking excessive alcohol on regular basis is known to gradually excite the nervous system. Over time when such a phenomenon continues, the body is unable to tolerate sudden cessation of alcohol. This means, the nervous system cannot easily adapt to sudden change in the alcohol consumption pattern causing various symptoms such as delirium, insomnia and anxiety to name a few [5].

Prevention

Individuals are advised to gradually and slowly decrease their dependence of alcohol. This can be achieved by making conscious efforts by decreasing alcohol intake steadily. Such a practice will help prevent symptoms of alcohol withdrawal from setting in. It is also advised that individuals who wish to completely quit alcohol should seek medical advice to ensure a healthy withdrawal.

Summary

Alcoholism is a common occurrence with an estimated 140 million people throughout the world which suffer from alcohol dependence. The practice of drinking alcohol is certainly not good for the human system and has debilitating effects on the nervous system and other body organs. Alcohol withdrawal can produce various physical and emotional symptoms, which if not managed appropriately can get life threatening. Such a kind of phenomenon is common in adults; however teenagers and children can also often fall prey to it [1].

Patient Information

Definition

Alcohol withdrawal is a condition wherein individuals experience a group of symptoms when they suddenly stop drinking alcohol. An estimated 15.2 million Americans are alcoholic. Of these 1.2 million of hospital admissions occur due to alcohol withdrawal. Symptoms of alcohol withdrawal should be promptly treated to avoid onset of complications.

Cause

Sudden cessation of alcohol or significant decrease in alcohol intake causes alcohol withdrawal symptoms to set in. Individuals with certain underlying disease conditions experience more severe forms of alcohol withdrawal symptoms as compared to the normal population.

Symptoms

Symptoms of alcohol withdrawal include headache, anxiety, nervousness, mood swings, depression, irritability, enlarged pupil, sweating, arrhythmia, loss of appetite and insomnia. In more severe cases, individuals experience fever, agitation, seizures and severe confusion which occur due to development of delirium tremens.

Diagnosis

Diagnosis of alcohol withdrawal symptoms is done through a preliminary physical examination to categorize the signs and symptoms. In addition, blood and urine tests are also carried out to assess the level of alcohol in the system.

Treatment

Mild form of the condition is treated through medications and patients are allowed to stay at home. In severe cases, hospitalization is also required to manage the symptoms of the conditions. Medications such as benzodiazepines are recommended for patients with alcohol withdrawal.

References

Article

  1. VICTOR M, ADAMS RD. The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis 1953; 32:526.
  2. Hack JB, Hoffmann RS, Nelson LS. Resistant alcohol withdrawal: does an unexpectedly large sedative requirement identify these patients early?. J Med Toxicol. Jun 2006;2(2):55-60.
  3. Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003; 348:1786.
  4. Monte R, Rabunal R, Casariego E, Lopez-Agreda H, Mateos A, Pertega S. Analysis of the factors determining survival of alcoholic withdrawal syndrome patients in a general hospital. Alcohol Alcohol. Mar-Apr 2010;45(2):151-8.
  5. Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician. Mar 15 2004;69(6):1443-50.
  6. ISBELL H, FRASER HF, WIKLER A, et al. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol 1955; 16:1.
  7. Abraham E, Shoemaker WC, McCartney SF. Cardiorespiratory patterns in severe delirium tremens. Arch Intern Med 1985; 145:1057
  8. Turner RC, Lichstein PR, Peden JG Jr, et al. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med 1989; 4:432.
  9. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. Jul 12 2004;164(13):1405-12.
  10. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2010; :CD005063.

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Last updated: 2019-07-11 21:23