Alcohol withdrawal overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2] Aditya Govindavarjhulla, M.B.B.S. [3]
Overview
Alcohol withdrawal refers to symptoms that can occur when a person who has been drinking alcohol every day suddenly stops drinking alcohol.
Overview
Historical Perspective
Classification
Stages of Alcohol Withdrawal Syndrome (AWS) may be classified as:[1]
- Uncomplicated withdrawal (first 6 hours)
- Alcohol hallucinosis (8-12 hours)
- Alcohol withdrawal seizures (12-24 hours)
- Alcohol withdrawal delirium (24-72 hours)
Pathophysiology
Under normal conditions in the brain, there is a balance between excitatory neurotransmitters such as glutamate and inhibitory neurotransmitters such as gamma-aminobutyric acid (GABA).[2]
Chronic alcohol intake and acute discontinuation of alcohol intake affect the balance of the neurotransmitters and cause many of the symptoms observed in alcohol withdrawal.[3] [4][1][2]
Acute Alcohol Consumption
- Increases the GABA neurotransmitter and sensitivity of GABA-A receptor subtypes, which in turn, increases inhibitory neurotransmission.
- Prevents the effects of glutamate (an excitatory neurotransmitter) on the N-methyl-d-aspartate (NMDA) receptors by inhibiting the binding of glycine to the NMDA receptors.[5][6]
Chronic Alcohol Consumption
- Causes tolerance and compensation by downregulation GABA-A receptors and upregulating NMDA receptors, and requires higher blood levels of alcohol to cause the same effect.[5][6]
Alcohol Withdrawal in Chronic Alcohol Consumption
- Exposes the downregulation of GABA-A receptors and the upregulation of NMDA receptors, resulting in hyperexcitability of the neurons that lower the threshold for seizures.[3][7][8]
- Upregulation of noradrenergic and dopaminergic receptors cause the autonomic hyperactivity and hallucinations that are seen in patients with alcohol withdrawal.[9]
- Kindling is increased excitability and sensitivity of the neurons after repeated events of alcohol withdrawal,[10][11] and is suggested to be the reason for progressing from milder to more severe symptoms of alcohol withdrawal in some patients.[3]
Causes
Alcohol withdrawal occurs with sudden discontinuation of alcohol intake after consumption of large quantities of alcohol for more than two weeks.[12]
Differentiating Alcohol Withdrawal from Other Diseases
Alcohol withdrawal must also be differentiated from other diseases that cause seizures, personality changes, altered level of consciousness and hand tremors (asterixis). The differentials include the following:[13][14][15][16][17][18][19][20][21][22][23][24]
- Hepatic encephalopathy
- Alcohol intoxication
- Uremia
- Wernicke encephalopathy
- Toxic encephalopathy from drugs
- Altered intracranial pressure
- Intoxication by chemical agents
- Malnutrition
- Hypoxic brain injury
- Meningitis and encephalitis
- Hypoglycemia
- Diabetic ketoacidosis
- Hypoglycemia
- Sedative, hypnotic, or anxiolytic withdrawal
Epidemiology and Demographics
Risk Factors
Risk factors for alcohol withdrawal include:[24]
- Quantity and frequency of alcohol consumption
- Family history of alcohol withdrawal
- Prior withdrawals
- Sedative, hypnotic, or anxiolytic drugs
Natural History, Complications, and Prognosis
- Symptoms of alcohol withdrawal usually resolve within seven days of alcohol intake discontinuation.[12]
- Most patients with alcohol withdrawal have mild symptoms and may be treated with outpatient management.[25]
- 5% of patients with alcohol withdrawal will present with severe alcohol withdrawal characteristics including:[25]
- 5% of patients with alcohol withdrawal and delirium tremens (DT) die from complications such as:[26][27]
Diagnosis
Diagnostic Criteria
- The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria is used to diagnose alcohol withdrawal.[24]
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scale is used to assess the severity of alcohol withdrawal.[28]
History and Symptoms
The most common symptoms of alcohol withdrawal include:[2]
- Loss of appetite, anorexia
- Craving for alcohol
- Nausea, vomiting
- Agitation
- Anxiety
- Irritability
- Hypervigilance
- Insomnia
- Vivid dreams
- Headache
- Diaphoresis
- Tremor
The most severe symptoms in alcohol withdrawal include [2]
Physical Examination
Signs to consider in the physical examination of patients with alcohol withdrawal may include:[1]
- Anxiety
- Nausea, vomiting
- Tremors
- Autonomic hyperactivity:
- Hallucinations:
- Delusions
- Confusion
- Seizure
- Delirium tremens (DT)
Laboratory Findings
Routine laboratory tests should include:[3]
- Blood or breath alcohol concentration
- Complete blood count (CBC)
- Electrolytes
- Glucose
- Liver function tests
- Renal function tests
- Urinalysis
- Urine toxicology
CT scan
- There are no CT scan findings associated with alcohol withdrawal.
- However, it has been suggested that in linear CT scan measurements in patients that are dependent on alcohol and have a history of delirium tremens, the maximum width of the anterior interhemispheric fissure (MIF) and the maximum width of the Sylvian fissure (MSF) are significantly larger compared to those patients that did not have delirium tremens and controls.[29]
Other Imaging Findings
- There are no MRI findings associated with alcohol withdrawal.
- Studies have suggested a decrease in hippocampal volume on a MRI may represent brain atrophy in patients with chronic alcoholism, however, a decrease in hippocampal volume has been suggested to have no association with seizures during alcohol withdrawal.[30]
Other Diagnostic Studies
- There are no other diagnostic studies associated with alcohol withdrawal.
- However, studies with neurochemical brain imaging [with magnetic resonance spectrometry (MRS), positron emission tomography (PET), and single photon emission computed tomography (SPECT)] have shown the neurochemical (GABA, glutamate, and dopamine) effects during alcohol dependence and withdrawal such as:[31]
Treatment
Medical Therapy
Interventions
Surgery
Primary Prevention
Secondary Prevention
References
- ↑ 1.0 1.1 1.2 Wolf C, Curry A, Nacht J, Simpson SA (2020). "Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives". Open Access Emerg Med. 12: 53–65. doi:10.2147/OAEM.S235288. PMC 7093658 Check
|pmc=value (help). PMID 32256131 Check|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 Saitz R (1998). "Introduction to alcohol withdrawal". Alcohol Health Res World. 22 (1): 5–12. PMC 6761824 Check
|pmc=value (help). PMID 15706727. - ↑ 3.0 3.1 3.2 3.3 Mirijello A, D'Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F; et al. (2015). "Identification and management of alcohol withdrawal syndrome". Drugs. 75 (4): 353–65. doi:10.1007/s40265-015-0358-1. PMC 4978420. PMID 25666543.
- ↑ Schmidt KJ, Doshi MR, Holzhausen JM, Natavio A, Cadiz M, Winegardner JE (2016). "Treatment of Severe Alcohol Withdrawal". Ann Pharmacother. 50 (5): 389–401. doi:10.1177/1060028016629161. PMID 26861990.
- ↑ 5.0 5.1 Goodman, Louis (2011). Goodman & Gilman's pharmacological basis of therapeutics. New York: McGraw-Hill. ISBN 978-0-07-162442-8. OCLC 498979404.
- ↑ 6.0 6.1 Nelson, Lewis (2011). Goldfrank's toxicologic emergencies. New York: McGraw-Hill Medical. ISBN 978-0-07-160594-6. OCLC 470694511.
- ↑ Kosten TR, O'Connor PG (2003). "Management of drug and alcohol withdrawal". N Engl J Med. 348 (18): 1786–95. doi:10.1056/NEJMra020617. PMID 12724485.
- ↑ Hall W, Zador D (1997). "The alcohol withdrawal syndrome". Lancet. 349 (9069): 1897–900. doi:10.1016/S0140-6736(97)04572-8. PMID 9217770.
- ↑ McKeon A, Frye MA, Delanty N (2008). "The alcohol withdrawal syndrome". J Neurol Neurosurg Psychiatry. 79 (8): 854–62. doi:10.1136/jnnp.2007.128322. PMID 17986499.
- ↑ Lejoyeux M, Solomon J, Adès J (1998). "Benzodiazepine treatment for alcohol-dependent patients". Alcohol Alcohol. 33 (6): 563–75. doi:10.1093/alcalc/33.6.563. PMID 9872344.
- ↑ Reoux JP, Saxon AJ, Malte CA, Baer JS, Sloan KL (2001). "Divalproex sodium in alcohol withdrawal: a randomized double-blind placebo-controlled clinical trial". Alcohol Clin Exp Res. 25 (9): 1324–9. PMID 11584152.
- ↑ 12.0 12.1 Muncie HL, Yasinian Y, Oge' L (2013). "Outpatient management of alcohol withdrawal syndrome". Am Fam Physician. 88 (9): 589–95. PMID 24364635.
- ↑ Meparidze MM, Kodua TE, Lashkhi KS (2010). "[Speech impairment predisposes to cognitive deterioration in hepatic encephalopathy]". Georgian Med News (181): 43–9. PMID 20495225.
- ↑ Kattimani S, Bharadwaj B (2013). "Clinical management of alcohol withdrawal: A systematic review". Ind Psychiatry J. 22 (2): 100–8. doi:10.4103/0972-6748.132914. PMC 4085800. PMID 25013309.
- ↑ Roldán J, Frauca C, Dueñas A (2003). "[Alcohol intoxication]". An Sist Sanit Navar. 26 Suppl 1: 129–39. PMID 12813481.
- ↑ Seifter JL, Samuels MA (2011). "Uremic encephalopathy and other brain disorders associated with renal failure". Semin Neurol. 31 (2): 139–43. doi:10.1055/s-0031-1277984. PMID 21590619.
- ↑ Handler CE, Perkin GD (1983). "Wernicke's encephalopathy". J R Soc Med. 76 (5): 339–42. PMC 1439130. PMID 6864698.
- ↑ Kim Y, Kim JW (2012). "Toxic encephalopathy". Saf Health Work. 3 (4): 243–56. doi:10.5491/SHAW.2012.3.4.243. PMC 3521923. PMID 23251840.
- ↑ Hartmann A, Buttinger C, Rommel T, Czernicki Z, Trtinjiak F (1989). "Alteration of intracranial pressure, cerebral blood flow, autoregulation and carbondioxide-reactivity by hypotensive agents in baboons with intracranial hypertension". Neurochirurgia (Stuttg). 32 (2): 37–43. doi:10.1055/s-2008-1053998. PMID 2497395.
- ↑ Kumar N (2011). "Acute and subacute encephalopathies: deficiency states (nutritional)". Semin Neurol. 31 (2): 169–83. doi:10.1055/s-0031-1277986. PMID 21590622.
- ↑ Chiu GS, Chatterjee D, Darmody PT, Walsh JP, Meling DD, Johnson RW; et al. (2012). "Hypoxia/reoxygenation impairs memory formation via adenosine-dependent activation of caspase 1". J Neurosci. 32 (40): 13945–55. doi:10.1523/JNEUROSCI.0704-12.2012. PMC 3476834. PMID 23035103.
- ↑ Peate I (2004). "An overview of meningitis: signs, symptoms, treatment and support". Br J Nurs. 13 (13): 796–801. doi:10.12968/bjon.2004.13.13.13501. PMID 15284663.
- ↑ Abdelhafiz AH, Rodríguez-Mañas L, Morley JE, Sinclair AJ (2015). "Hypoglycemia in older people - a less well recognized risk factor for frailty". Aging Dis. 6 (2): 156–67. doi:10.14336/AD.2014.0330. PMC 4365959. PMID 25821643.
- ↑ 24.0 24.1 24.2 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
- ↑ 25.0 25.1 Schuckit MA (2014). "Recognition and management of withdrawal delirium (delirium tremens)". N Engl J Med. 371 (22): 2109–13. doi:10.1056/NEJMra1407298. PMID 25427113.
- ↑ VICTOR M, ADAMS RD (1953). "The effect of alcohol on the nervous system". Res Publ Assoc Res Nerv Ment Dis. 32: 526–73. PMID 13134661.
- ↑ Cutshall BJ (1965). "The Saunderssutton syndrome: an analysis of delirium tremens". Q J Stud Alcohol. 26 (3): 423–48. PMID 5858249.
- ↑ Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM (1989). "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)". Br J Addict. 84 (11): 1353–7. doi:10.1111/j.1360-0443.1989.tb00737.x. PMID 2597811.
- ↑ Maes M, Vandoolaeghe E, Degroote J, Altamura C, Roels C, Hermans P (2000). "Linear CT-scan measurements in alcohol-dependent patients with and without delirium tremens". Alcohol. 20 (2): 117–23. doi:10.1016/s0741-8329(99)00066-x. PMID 10719790.
- ↑ Bleich S, Sperling W, Degner D, Graesel E, Bleich K, Wilhelm J; et al. (2003). "Lack of association between hippocampal volume reduction and first-onset alcohol withdrawal seizure. A volumetric MRI study". Alcohol Alcohol. 38 (1): 40–4. doi:10.1093/alcalc/agg017. PMID 12554606.
- ↑ Hillmer AT, Mason GF, Fucito LM, O'Malley SS, Cosgrove KP (2015). "How Imaging Glutamate, γ-Aminobutyric Acid, and Dopamine Can Inform the Clinical Treatment of Alcohol Dependence and Withdrawal". Alcohol Clin Exp Res. 39 (12): 2268–82. doi:10.1111/acer.12893. PMC 4712074. PMID 26510169.