Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
Differential includes sepsis/infection, hypotension, medication side-effect and
withdrawal. For the majority of alcohol-dependent patients, withdrawal begins 8-12 hours
after cutting back or abstaining, peaks at 24-48 hours and resolves within 72-96 hours.
Clues to the alcohol with withdrawal syndrome in this patient include acute elevation in
BP, tachycardia, fever, tremor and agitation.
Answer 2
Identify clues to previous alcohol withdrawal syndrome, dependence, tolerance:
eye-opener, morning tremulousness, increasing pattern with less effect, etc. If she had
experienced DT’s or withdrawal seizures in the past, her risk for DT’s is
increased, and therefore would adversely affect her postoperative morbidity/mortality if
undiagnosed and untreated. Concomitant medical problems such as liver disease and
infection, malnutrition, and fluid and electrolyte disturbances are also risk factors for
the development of DT’s which should be included in the perioperative assessment.
Focusing on amount and frequency of use prior to admission is unlike to be fruitful at
this point and can wait until the patient is calmer.
Answer 3
The most serious complications of withdrawal are seizures and delirium
tremens. Withdrawal seizures may precede DT’s but do not always, nor do they imply
inevitable progression to DT’s. Seizures do require acute treatment, mainly with
benzodiazepines, to prevent complications such as aspiration and trauma, but are not a
harbinger of epilepsy and do not require long-term treatment with antiepileptic meds such
as phenytoin. Delirium tremens occur in 5% and consists of disorientation, confusion and
hallucinations along with much more severe autonomic dysregulation than is seen in typical
withdrawal. It presents later, usually after 48-96 hours. There is also a risk of cardiac
dysrhythmias with sudden death. Other more minor complications you might see include
nausea and vomiting, and headache. The withdrawing patient requires close monitoring!
Answer 4
Refer to references for more details.
GI:
esophagitis, gastritis, dyspepsia, upper GI bleeding, anorexia, abdominal pain,
Mallory-Weiss tear, esophageal varices, diarrhea, malabsorption, pancreatitis, cirrhosis,
steatosis, hepatitis, cancers of the head and neck, esophagus, stomach, liver, and
pancreas (breast).
Heme:
Elevated MCV, mild anemia, folic acid deficiency, reticulocytopenia, pancytopenia.
Cardiovascular:
mild to moderate HTN, cardiomyopathy, dysrhythmias.
Answer 5
She is at risk for postoperative complications of alcohol withdrawal syndrome. If
she had DT’s or withdrawal seizures in the past her risk would be increased for
DT’s. She requires treatment and monitoring for DT’s. For uncomplicated
withdrawal, use of an oral benzodiazepine, particularly one with a longer half-life such
as chlordiazepoxide or Librium, is appropriate. Additional measures should include
reassurance, thiamine (preceded by glucose), a multivitamin and oral hydration with
frequent vitals and orientation checks.
Answer 6
All of the above but IV and with much closer monitoring. Be sure to look for
associated electrolyte and fluid abnormalities that can contribute to morbidity if left
untreated. If severely agitated, addition of haloperidol or Haldol may be necessary.
Answer 7
AA, inpatient vs. outpatient treatment referral, counseling. Special consideration
for professional/physician meetings, treatment centers may be very important. Give more
consideration to inpatient rehab if the patient has concurrent medical problems, comorbid
psychiatric illness such as depression or psychosis, has failed outpatient treatment in
the past or is at risk of harming self or others.
Abstinence is the preferred goal but is not always attainable. Like any other chronic illness, alcoholism tends to have remissions and relapses and evidence does not suggest that any one specific treatment is superior to another in terms of long-term outcome. After treatment, about 60% of middle-class alcoholics are abstinent for 1 year or more and a somewhat lesser percentage abstain for a lifetime. Those who continue to drink have a 15-year shortening of their life-expectancy.
Medication adjuncts to psychological treatment programs have been studied with limited success to date, except for acamprosate which is currently available only in Europe.
Answer 8
Answer 9
Differential diagnosis of memory loss in an alcoholic includes most notably,
Korsakoff’s syndrome secondary to thiamine deficiency, as well as organic brain
syndrome and psychiatric disturbances. Korsakoff’s syndrome classically presents with
profound anterograde and milder retrograde amnesia with possible impairment in
visuospatial abstract and conceptual reasoning but normal intelligence. Recent memory loss
is out of proportion to the global level of cognitive impairment. Response to thiamine
replacement is variable, and up to 25% may show a full recovery when thiamine
supplementation is accompanied by abstinence. Korsakoff’s syndrome is frequently
accompanied by Wernicke’s disorder which consists of ataxia and cranial nerve VI
palsy. Additionally, there can be prolonged (even up to 6 months) memory and sleep
disruption following acute withdrawal as well as cognitive impairment in recent and remote
memory for weeks after an alcohol binge. Cortical functioning may improve with abstinence,
but permanent alcoholic dementia may by irreversible. Associated depression is common in
the alcoholic and may be a reversible cause for memory disturbance; in one study, 45% of
alcoholics were found to have an associated psychiatric diagnosis - particularly anxiety
and depression - and these conditions were often more pronounced in the recent period
after a withdrawal episode.