Withdrawal Syndromes Workup

Updated: Nov 27, 2017
  • Author: Nathanael J McKeown, DO; Chief Editor: David Vearrier, MD, MPH  more...
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Laboratory Studies

A serum glucose or fingerstick glucose test is indicated. Patients with liver disease due to alcoholism have reduced glycogen stores, and ethanol impairs gluconeogenesis. As a consequence, these patients are susceptible to hypoglycemia. Patients in alcohol withdrawal develop anxiety, agitation, tremor, seizure, and diaphoresis, all of which can occur with hypoglycemia.

Analysis of arterial blood gases may be indicated. Mixed acid-base disorders are common and usually result from alcoholic ketoacidosis (AKA), volume-contraction alkalosis, and respiratory alkalosis. Hypoxia may occur due to aspiration pneumonitis.

A complete blood cell count (CBC) is recommended. Findings may include the following:

  • Long-term alcohol ingestion leads to myelosuppression with a slight reduction in all cell lines; thrombocytopenia is common.
  • Blood loss from the gastrointestinal (GI) tract and nutritional deficiencies producing anemia are common in alcohol withdrawal.
  • Many patients have dehydration, and hemoconcentration and anemia may become apparent only when rehydration is accomplished.
  • Megaloblastic anemia is observed in patients with alcoholism, due to dietary deficiency of vitamin B-12 and folate; increased mean corpuscular volume suggests this condition

A comprehensive metabolic panel or its equivalent is indicated to look for acidosis, dehydration, concurrent renal disease, and other abnormalities that can occur in patients with chronic alcoholism. It also provides data needed to calculate anion and delta gaps, which are helpful in differentiating mixed acid-base disorders. Other findings may include the following:

  • A low blood urea nitrogen (BUN) value is expected in alcoholic liver disease. Obtain lipase levels if pancreatitis is suspected. Obtain the blood ammonia level if hepatic encephalopathy is suspected.
  • Determination of magnesium and calcium levels and liver function tests (LFTs) may be indicated because patients with chronic alcoholism usually have dietary magnesium deficiency and possibly concurrent alcoholic hepatitis. Alcoholic pancreatitis may cause hypocalcemia.
  • An article in the Journal of Trauma reported that a normal microcytic volume (MCV) and aspartate aminotransferase (AST) level in an intoxicated trauma patient admitted to the hospital predicated a low risk for developing delirium tremens. [8] However, this has not been studied in nontrauma patients.

Urinalysis is indicated, as follows:

  • Routinely check for ketones, as patients may have associated AKA.
  • Ketonuria without glycosuria must be investigated further to exclude AKA and the ingestion of isopropyl alcohol.
  • Myoglobinuria from rhabdomyolysis may first be suspected when hematuria is noted on urinalysis.

Cardiac markers may be indicated. Findings may include the following:

  • Elevated creatine kinase (CK) and cardiac troponin levels may indicate myocardial infarction resulting from increased demands placed on the heart from hypertension associated with alcohol withdrawal or from hypertension produced by cocaine intoxication prior to the patient's presentation.
  • An elevated CK level can also be from rhabdomyolysis, which may be secondary to psychomotor agitation in alcohol and sedative-hypnotic withdrawal or due to limb compression with skeletal muscle injury in patients with depressed mental status. 

Measurement of prothrombin time (PT) may be indicated, as follows:

  • The PT is a useful index of liver function; patients with cirrhosis are at risk for coagulopathy.
  • PT testing should be considered in a patient with active bleeding in the gastrointestinal tract or central nervous system.

Toxicology screening may be indicated, as follows:

  • Consider measuring serum osmolality and testing for toxic alcohols if the history is suspicious for toxic alcohol ingestion or if the patient has a widened anion gap metabolic acidosis.
  • The ethanol concentration is frequently zero. However, some patients that are habituated to alcohol can be in severe alcohol withdrawal even with a positive serum ethanol concentration.
  • Urine drug immunoassay is of limited utility but may be considered to assess for co-ingestion of other medications (eg, benzodiazepines) and other recreational drugs. 
  • Gamma hydroxybutyrate (GHB), fentanyl, and many other drugs of abuse are not targeted in routine urine drug immunoassays. Send-out testing to a reference laboratory is typically unnecessary from a clinical perspective.

Imaging Studies

Imaging studies should be directed to the patient's clinical course.

Chest radiography findings may include the following:

  • Aspiration pneumonia is common in patients with alcohol withdrawal syndrome.
  • Patients with chronic alcoholism may have cardiomyopathy and chronic heart failure
  • Patients using intravenous drugs are prone to pneumonia due to non-sterile injection practices and immunosuppression (eg, HIV infection).

Head computed tomography (CT) findings may include the following:

  • Patients with alcohol withdrawal syndrome are at risk for intracranial bleeding because of cortical atrophy and coagulopathy.
  • Consider obtaining a head CT in patients with an inappropriate level of consciousness, in those with multiple seizures, in those with signs of head trauma, and in those with an unexpected failure to respond to treatment.
  • Cocaine can cause intracerebral bleeding due to hypertension. The symptoms may closely resemble those of the cocaine wash-out syndrome.

Abdominal CT or ultrasonography in patients with a history of intravenous drug abuse and unexplained hip pain may reveal intra-abdominal pathology, including psoas abscess.

Spinal MRI may be required to rule out epidural abscess in patients with unexplained back pain, intravenous drug abuse, and fever, particularly if focal neurologic deficits are also present.

Other imaging may be indicated if trauma or other associated conditions are suspected.


Other Tests

Electrocardiography findings may include the following:

  • Adrenergic storm produced by alcohol withdrawal increases demands on the heart and may precipitate infarction or fatal ventricular dysrhythmia in susceptible individuals [9]
  • Takotsubo cardiomyopathy with resulting CHF has also been reported [10]
  • A prolonged QTc interval has been described in patients with alcohol withdrawal syndrome [11] ; the interval gradually reverts to normal as withdrawal symptoms remit

Other tests may include the following:

  • Lumbar puncture: One should have a low threshold for lumbar puncture and spinal-fluid analysis to rule out meningitis or subarachnoid hemorrhage because individuals in withdrawal are at increased risk
  • Blood cultures may also be indicated if sepsis or endocarditis is suspected in this group of often immunosuppressed patients
  • Additional tests may be indicated based on a patient's presentation