What is Delirium Tremens?

Physically dependent alcoholics, in the process of abstaining, the central nervous system loses the inhibitory effect of alcohol, resulting in overexcitation of the cerebral cortex and / or -adrenergic nerves.

Alcohol withdrawal syndrome

Long-term alcoholics who stop drinking usually show a series of symptoms and signs after 12 to 48 hours. Mild withdrawal syndrome manifests as tremor, fatigue, sweating, hyperreflexia, and gastrointestinal symptoms. Some people also have major seizures, but generally do not have more than two episodes in the short term (alcoholic epilepsy or alcohol cramps).

Causes of alcohol withdrawal syndrome

Pathogenesis of alcohol withdrawal syndrome

1. Alcoholic tremulousness The pathogenesis is thought to be caused by -adrenergic receptors in the central and peripheral nerves after alcohol abstinence. That is, due to the sympathetic nerve excitement, the increase in catecholamines in the blood increases the contraction rate of skeletal muscle, which interferes with nerve-muscle conduction or muscle spindle activity, resulting in increased tremor intensity in these patients.

2. The pathogenesis of alcoholic withdrawal seizure is unclear. It has been proposed that a variety of different pathogenesis, including hypomagnesemia, carbonic acid, and various other metabolic disorders can occur during the epilepsy. However, none of these mechanisms has been proven, and measures such as magnesium supplementation cannot prevent their onset.

3. Delirium tremens (DT) is an acute encephalopathy syndrome that appears on the basis of chronic alcoholism. It can be triggered by trauma, infection and other factors that weaken the body's resistance. ^[1]

Alcohol withdrawal syndrome symptoms

Alcohol withdrawal syndrome alcoholic tremor

Alcoholic tremulousness, or withdrawal tremulousness, is the most common and mildest alcohol withdrawal syndrome. (1) Tremor is the most common symptom of alcohol withdrawal syndrome, accompanied by irritability and gastrointestinal symptoms, especially nausea and vomiting. These symptoms usually begin in the morning after drinking for several days and suddenly abstain from drinking. Resumption of drinking can quickly relieve the symptoms, and the symptoms recur and worsen after stopping drinking again. Symptom duration can vary widely, usually for 2 weeks. The illness peaked 24 to 36 hours after stopping drinking completely.

Generalized tremor is the most obvious feature of the disease. It is a tremor that is rapid (6 to 8 Hz), varies in severity, and is relieved in a quiet environment but aggravated during exercise and emotional stress. The tremor can be so severe that the patient cannot stand on his own, can't pronounce clearly, and can't even eat by himself. Sometimes there is no obvious objective manifestation of tremor, only the patient complains of "internal tremor". Flushing, anorexia, tachycardia, and tremor in the back can be alleviated after a few days, but excessive alertness, frightening, and exercise tremor can last for a week or more. The feeling of restlessness lasted for 10 to 14 days. Elevated levels of norepinephrine and its metabolites in blood and CSF.

(2) The patient was accompanied by characteristic clinical manifestations: deep red face, conjunctival hyperemia, tachycardia, anorexia, nausea, and retching. Patients are completely awake, vulnerable to frightening, insomnia, lack of concentration, unwillingness to answer questions, and may respond to rough or threatening ways. Patients may also have mild temporal disorientation, have no memory of events in the last few days of the drinking period, but have no apparent confusion, and have a good understanding of the surrounding environment and their condition.

Alcohol withdrawal syndrome alcoholic hallucinations

alcoholic hallucinosis, a hallucination caused by long-term heavy drinking, is a rare abstinence syndrome. Patients often have a large number of distinct hallucinations within 24 hours after abruptly stopping drinking or reducing the dose, and clinically, vision and hearing hallucinations are the main. (1) Patients with alcoholic tremor can often be accompanied by various hallucinations. Patients reported having nightmares accompanied by sleep disturbances. Sometimes patients could not distinguish between dreaming and real situations, and hallucinations and reality were confused. Familiar objects are distorted or considered to be unreal (illusions). According to the frequency of occurrence, they are pure visual hallucination type, audiovisual mixed type, tactile or visual type. There is no evidence to support that certain visual hallucinations (such as bugs, red elephants) are specific to alcoholism. In fact, the hallucinations of alcoholism are widespread, more alive than inanimate. People or animals can be single or group; they can be reduced or enlarged; they can be natural and pleasant; they can also be deformed, scary and terrifying.

(2) Alcoholic mental disorder composed of more or less simple auditory hallucinations is a special type. Kraepelin calls it alcoholic hallucinations or alcoholic mania. The core manifestation is that although the patient feels normal, such as the patient's directional force, normal responsiveness, and intact memory, he has auditory hallucinations. The nature of hallucinations can be unstructured sounds, such as bee buzzing, ringing, gunshots, or tapping, or music-like, low-key humming or chatting. But the most common voice is human voice. Voice talks directly to the patient, but it is more common to talk about the patient with a third party. In most cases, the voice is malicious, accusatory or intimidating, which severely interferes with the patient's normal life. To the patient, the sound is extremely real. Another characteristic of auditory hallucinations (and visual hallucinations) is that patients respond accordingly to the contents of hallucinations. Patients may call to protect themselves or act against invasion, or they may even attempt suicide to avoid voice intimidation. Its duration varies and can be temporary or retransmit intermittently over several days, and in individual cases can last for weeks or months.

(3) In hallucinations, most people are unaware of the unreality of hallucinations. As the condition improved, patients began to doubt the authenticity of their hallucinations, were willing to tell others about the hallucinations, and wondered if they were conscious. Being able to recognize that the sound you hear is imaginary. If you can recall the abnormal content of thoughts during the onset of mental disorders, it is a sign of complete recovery.

Alcohol withdrawal syndrome seizures

Alcohol withdrawal seizure, also known as rumfits, is a more common symptom during alcohol withdrawal (relative or absolute abstinence after chronic chronic alcoholism). More than 90% of withdrawal seizures occur 7 to 48 hours after stopping drinking, and the peak time is 13 to 14 hours. During the convulsive activity period, the EEG is usually abnormal, but it can be recovered after a few days. It can manifest as a one-time attack, but most cases are sudden 2-6 attacks, sometimes more. 2% of patients develop a state of sustained epilepsy, mostly with major seizures. Focal seizures suggest the presence of local lesions (mostly trauma) in addition to alcohol. About 30% of patients with systemic withdrawal seizures develop a state of tremor and delirium (some reports have a lower percentage), and seizures are a precursor to delirium.

Alcohol withdrawal syndrome tremor delirium

delirium tremens, DT (1) Delirium tremens is the most severe alcoholic disease state that can lead to death. It is an acute encephalopathy syndrome that appears on the basis of chronic alcoholism. It occurs mostly in alcohol-dependent patients who continue to drink a lot. It can be caused by trauma, infection and other factors that weaken the body's resistance. Sudden onset usually occurs 3 to 5 days after abstaining from alcohol or weight loss. It is mainly manifested by severe confusion, loss of orientation, vivid delusions and hallucinations, accompanied by tremors, anxiety, insomnia, and hyperactive sympathetic nerves, such as dilated pupils. , Fever, increased breathing and heartbeat, increased or decreased blood pressure, and sweating.

(2) Most patients have a self-limiting course of delirium. After a few days of restlessness and insomnia, they often stop by entering sleep, and then wake up. After waking up, they are conscious, quiet, and tired. memory. In rare cases, delirium gradually subsides. If delirium tremor is a single episode, 80% of patients last no more than 72 hours. Rare cases can have one or more relapses, several delirium attacks of varying degrees, separated by a relatively awake interval, the entire process lasts several days, and occasionally can last 4 to 5 weeks.

(3) In some cases, tremor and delirium did not fully recover, and the disease progressed to Wernicke's encephalopathy or Korsakov syndrome (about 15%). Cases without complications have a lower case fatality rate (about 3% to 4%) after timely treatment. Once complications occur, the case fatality rate will increase significantly and often die from high fever, pneumonia, or heart failure. May die suddenly and the cause cannot be determined.

(4) Atypical delirium-hallucinations or confusion: It is closely related to typical DT and has the same incidence. Patients may show only transient, quiet confusion, anxiety, or abnormal behavior that lasts for days or months. Unlike the typical delirium tremor, the atypical state often presents as a single localized event and will not be repeated. Occasional seizures do not cause death. It can also be said that this atypical state is partial mild tremor and delirium.

Alcohol withdrawal syndrome acute withdrawal syndrome

Acute alcohol withdrawal syndrome occurs when long-term (more than 2 to 3 weeks) heavy drinking occurs, when the drinking suddenly stops or the amount is significantly reduced. The main manifestations are tremor, delirium, convulsions, confusion, psychomotor and autonomic overexcitation. Based on medical history and typical clinical manifestations, diagnosis is generally not difficult. EEG, craniocerebral, chest X-rays, and CT scans are helpful in differential diagnosis. ^[2]

Alcohol withdrawal syndrome classification

(Alcohol withdrawal syndrome, AWS)

The occurrence of alcohol withdrawal syndrome (AWS) may be caused by the abrupt release of alcohol stimulation and the reduction of r-aminobutyric acid (GABA) inhibitory effect in the brain and the activation of sympathetic nervous system. AWS generally starts on the third day after quitting. If you insist on quitting, it usually disappears on the fifth to seventh day after quitting.

The earliest withdrawal symptoms are tremor, which is usually bilateral, and is more pronounced in the morning, so it is called morning tremor. In severe cases, tremor and delirium may also appear, showing a large number of rich hallucinations. Hallucinations are regarded as the main, and may be accompanied by hallucinations and hallucinations. Sometimes there is also a rise in body temperature, called febrile tremor delirium. Although it can be recovered in 3 to 5 days in most cases, there is a certain degree of danger and it should be hospitalized immediately.

According to the severity of symptoms, AWS can be clinically divided into 3 levels: 1 level (physical withdrawal), obvious tremor and sweating, no hallucinations and disturbance of consciousness. Level 2 (impending dilirium tremens). There are obvious tremors, sweats, and hallucinations in the acute stage, but hallucinations can be temporary. Nightmares before bedtime and before waking are not parallel to hallucinations. Level 3 (dilirium tremens), in addition to including level 2 items, should also have conscious disturbances, which can be intermittent, and have directional and memorabilia disorders.

Identification of alcohol withdrawal syndrome

Summary of alcohol withdrawal syndrome

Clinically, in addition to excluding withdrawal syndrome due to drug abuse, people who are highly sensitive to barbiturates or phenobarbitals, obsessive-compulsive conceptions, pregnancy, physical diseases, etc., they should be identified from the following diseases:

Alcohol withdrawal syndrome hepatic encephalopathy

The neuropsychiatric symptoms that occur mostly on the basis of severe liver function damage have no obvious relationship with the time to abstain from alcohol, but are related to important causes such as gastrointestinal bleeding, massive ascites, infection, etc., which is a sign of advanced liver disease.

Werniche korsakoff Alcohol withdrawal syndrome Werniche korsakoff syndrome

Mainly caused by long-term consumption of foods with low or no vitamin B1. Blurred consciousness, ataxia, nystagmus, and abductor nerve palsy can occur clinically. If left untreated, it can lead to irreversible brain damage. Vitamin B1 is the active group of pyrophosphate sulfate (TPP), which in turn is a coenzyme of pyruvate dehydrogenase, which plays a key role in the metabolism of the three major substances. The disease cannot be completely separated from AWS, because alcohol-dependent people often develop hypomagnesemia. Magnesium is a cofactor of TPP, which indirectly reduces the activity of pyruvate dehydrogenase, appears or worsens it.

Clinical manifestations of alcohol withdrawal syndrome

(1) Patients with insanity or schizophrenia often have certain personality tendencies or qualities, develop disease under certain trauma or stimulus, last a long time, and can recover after psychological treatment.

(2) Epilepsy mostly occurs in adolescents, especially children, and AWS patients are mostly adults and are alcohol dependent. But AWS can also be associated with epilepsy, even as high as 46%, the reason is not clear. Laboratory tests can be used to determine the related indicators of alcoholic liver damage, such as r-GT, AST / ALT, and small variations in serum glycoproteins.

(3) Cerebellar degeneration can occur in people with alcoholism (like other malnourished patients). Its pathological and clinical features may be the same as Wernicke's encephalopathy. Gesture and gait ataxia can start slowly over a period of weeks or months, or suddenly. CT showed atrophy of the upper vermicular and cerebellar lobe. Application of thiamine and other vitamins B can improve symptoms.

(5) Marchiafava-Bignami disease is a rare corpus callosum demyelinating disease, which occurs in cases of chronic alcoholism, mainly in men. Originally seen in Italy, it was thought to be caused by drinking a natural red wine, but it was later found that the disease also occurred in many other countries and involved a variety of other alcoholic beverages. It has been speculated that the disease is related to a nutritional cause, but the exact nature is unknown. Pathology and the pathological environment linking it to central pontine demyelination may be a variant of the latter. The patient showed agitation, insanity, and signs of progressive dementia with release of frontal function. Some patients recovered after several months; others developed convulsions and coma, and eventually died.

(6) Pathological drunkenness is a relatively rare syndrome. It is characterized by repeated spontaneous actions, extreme excitement, and offensive or uncontrollable unreasonable behavior after drinking a small amount of alcohol. Each episode lasts from several minutes to several hours, followed by a long period of deep sleep, and loses memory of the morbid manifestations after waking.

Alcohol withdrawal syndrome medication

(1) Pioglitazone significantly attenuates steatosis and lipid peroxidation caused by chronic alcohol abuse. The mechanism of action may be that ethanol induces methionine signaling pathway down-regulation and restores stearoyl-CoA dehydrogenase (SCD) up-regulation. Through the upregulation of tyrosine phosphorylation and the lipid mobilization of hepatocytes mediated by apolipoprotein B and the down-regulation of SREBP-1c and SCD levels, TG synthesis in the liver is reduced. Therefore, it may become a useful drug for the treatment of alcoholic fatty liver.

(2) The use of anti-TNF antibodies to neutralize cytokines and antioxidants to treat severe fatty liver and alcoholic hepatitis has achieved some satisfactory results, but a large number of clinical trials are still needed to confirm.

(3) Animal experiments have shown that IL-6 can reduce liver steatosis and normalize transaminase. IL-6 can not reduce the lipid content of isolated and cultured steatosis hepatocytes, indicating that it is not a separate effect on liver cells, and the effects on fatty liver are comprehensive, including increasing liver PPAR-, reducing liver and serum TNF- in the liver enhances beta-oxidation of mitochondrial fatty acids and increases triglyceride and cholesterol output in the liver.

(4) Animal experiments show that green tea can affect the fat accumulation of liver cells, prevent steatosis and fat mobilization, and prevent liver damage, but it cannot prevent the damage of liver on ethanol.

(5) Many domestic basic and clinical studies have shown that Chinese medicine is effective in the treatment of alcoholic fatty liver. Traditional Chinese medicine can effectively improve liver steatosis caused by alcohol by relaxing the liver, promoting blood circulation, and reducing phlegm.

Alcohol withdrawal syndrome hormone therapy

Alcohol withdrawal syndrome reports hormone therapy

Patients with acute severe alcoholic hepatitis and concurrent hepatic encephalopathy can reduce recent mortality. But not suitable for mild to moderate alcoholic hepatitis. Some people used prednisone to treat 32 cases of severe hepatitis and 29 cases of severe hepatitis without prednisone as a control. The one-year survival rate of the prednisone treatment group was significantly higher than that of the control group, but there was no difference after two years. The specific usage is prednisone 30-45mg / d, one or three times. After 3-6 weeks, liver function and other laboratory indicators are normal, and then gradually reduce it to 5-10mg / d, which is to maintain this. The amount is 1-2 years. For cases of intrahepatic cholestasis, hormone therapy is also effective.

TEN+ Alcohol withdrawal syndrome TEN + hormones

A randomized controlled experimental study showed that for patients with severe alcoholic hepatitis, prednisone (40 mg / d) was given simultaneously with TEN (2000 kcal, or 8374 kJ, daily). TEN lasts for an average of about 22 days. Short-term treatment with TEN combined with prednisone can rapidly improve the clinical symptoms of severe alcoholic hepatitis. Although 2/3 of the patients developed infection during the treatment, it was not related to their own treatment.

However: proper drinking is good for the body, for example, refreshing, appetizing and strengthening the spleen, and promoting blood circulation.