🔑 Key Learning

  • Alcohol withdrawal occurs due to rebound CNS excitation following loss of GABAergic and NMDA antagonism
  • Delirium tremens is a severe complication with coarse tremor, hallucinations and delirium.
  • Benzodiazepines are first-line for alcohol withdrawal management, guided by symptom severity scoring (e.g. CIWA) - diazepam, chlordiazepoxide 
  • Korsakoff dementia is a late complication of chronic thiamine deficiency — characterised by memory loss, anterograde amensia and confabulation

🧬 Alcohol Withdrawal

Pathophysiology

  • Alcohol enhances GABA activity and inhibits NMDA glutamate receptors → overall CNS depression
  • Withdrawal causes:
    • ↓ GABA activity → CNS hyperexcitability
    • ↑ NMDA activity → disinhibition and agitation

đź‘€ Clinical Features

  • Symptoms begin 6–12 hours after last drink, peak at ~36 hours
    • Tremor
    • Tachycardia
    • Sweating
    • Confusion and agitation
  • Delirium tremens (48–72 hours)
    • Coarse tremor
    • Confusion, delusions
    • Visual or tactile hallucinations
    • Autonomic instability

đź’Š Management

  • Symptom-guided approach using CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scale
  • Benzodiazepines are first-line
    • Chlordiazepoxide
    • Diazepam
  • Some protocols now use alcohol-based regimens (e.g. supervised drinking on medical wards) — varies by trust

🧠 Korsakoff Dementia

Pathophysiology

  • Due to thiamine (vitamin B1) deficiency
  • Associated with haemorrhage and neuronal loss in the mammillary bodies of the thalamus and hypothalamus
  • Often follows an episode of Wernicke’s encephalopathy. Triad of:
    • Ophthalmoplegia
    • Confusion
    • Ataxia

đź‘€ Clinical Features

  • Anterograde amnesia – inability to form new memories
  • Retrograde amnesia – loss of past memories
  • Confabulation – fabrication of stories to fill memory gaps
  • May have accompanying peripheral neuropathy

đź“ť Exam Clues & Clinchers

  • Tremor + tachycardia + confusion 6–12 hours after last drink → think alcohol withdrawal
  • Visual hallucinations + coarse tremor + agitation at 72 hours → classic for delirium tremens
  • CIWA score â†’ 1st line: chlordiazepoxide or diazepam
  • Memory loss + confabulation in a chronic alcoholic → think Korsakoff’s syndrome
  • Wernicke’s encephalopathy (confusion, ataxia, ophthalmoplegia) may precede Korsakoff’s
  • Always give parenteral thiamine (B1) before glucose in at-risk patients