Alcohol withdrawal syndrome

Alcohol withdrawal syndrome is a set of symptoms that can occur after a reduction in or cessation of alcohol use following a period of excessive drinking.酒精戒断综合征（alcohol withdrawal syndrome，简称 AWS）是长期大量饮酒后减少或停止饮酒时可能出现的一组症状。

Symptoms typically include anxiety, shakiness, sweating, vomiting, fast heart rate and mild fever, while more severe cases may involve seizures and delirium tremens, which can be fatal if untreated.症状通常包括焦虑、震颤、出汗、呕吐、心率增快与轻度发热；更严重者可出现癫痫发作与震颤谵妄，若未治疗可致命。

Terminology and classification

• Withdrawal usually begins 6 to 24 hours after the last drink, is worst at 24 to 72 hours, and improves by seven days.戒断通常在末次饮酒后 6 至 24 小时开始，24 至 72 小时最为严重，7 天内逐渐改善。
• To be classified as alcohol withdrawal syndrome, patients must have at least two symptoms, such as increased hand tremor, insomnia, nausea, hallucinations, agitation, anxiety, seizures or autonomic instability.诊断酒精戒断综合征须具备至少两项症状，如手震颤加剧、失眠、恶心、幻觉、激越、焦虑、癫痫发作或自主神经功能紊乱。
• ICD-10 assigns the code F10.3 and ICD-11 (release 2025-01) places the condition at 6C40.4 in Chapter 06.世界卫生组织 ICD-10 编码为 F10.3，ICD-11（2025-01 发布版）编为 6C40.4，属第 06 章。
• Cross-ontology identifiers include MeSH D013375, MONDO:0005433, MedGen 000764 and UMLS C0037763.跨本体标识包括 MeSH D013375、MONDO:0005433、MedGen 000764 与 UMLS C0037763。
• Severe withdrawal is classified into alcohol hallucinosis, withdrawal seizures and delirium tremens.严重戒断分为酒精性幻觉症、戒断性癫痫发作与震颤谵妄三类。

History

• Symptoms of alcohol withdrawal have been described at least as early as 400 BC by Hippocrates, the physician traditionally called the father of medicine.早在公元前 400 年，被誉为「医学之父」的医师希波克拉底就已描述过酒精戒断的症状。
• It is not believed to have become a widespread problem until the 1700s.据信直至 18 世纪，这一问题才变得普遍。
• Kindling, in which repeated detoxifications worsen withdrawal, became an important concept in understanding the condition.「点燃」现象——反复戒酒会使戒断症状加重——成为理解该病的重要概念。
• The Clinical Institute Withdrawal Assessment for Alcohol scale was shortened to the CIWA-Ar while retaining its validity and reliability.临床机构酒精戒断评估量表经精简为 CIWA-Ar，同时保留了其效度与信度。

Epidemiology

• In the Western world about 15% of people have problems with alcoholism at some point in their lives.在西方世界，约 15% 的人一生中曾存在酗酒问题。
• About half of people with alcoholism develop withdrawal symptoms upon reducing their use, and about 4% develop severe symptoms.约半数酗酒者减少饮酒后出现戒断症状，约 4% 出现严重症状。
• Among those with severe symptoms, up to 15% die from the condition.在出现严重症状者中，死亡率可高达 15%。
• Alcohol withdrawal may occur in those who are alcohol dependent, after either a planned or unplanned decrease in intake.酒精依赖者无论计划内还是计划外减少摄入，都可能出现戒断。
• The severity is determined most importantly by the degree of alcohol intake, the length of time drinking, and the history of previous withdrawal.症状严重程度最重要取决于饮酒量、饮酒持续时间以及既往戒断史。
• Withdrawal seizures occur in 3% to 5% of cases, and delirium tremens occurs in 5% to 20% of people undergoing detoxification and in one third of untreated cases.戒断性癫痫发作见于 3% 至 5% 的病例；震颤谵妄见于 5% 至 20% 的戒断者及三分之一未治疗者。
• Protracted withdrawal symptoms may linger for at least a year after alcohol discontinuation in many people with alcohol use disorder.许多酒精使用障碍者在停酒后，迟发性戒断症状可持续至少一年。

Pathophysiology

• The underlying mechanism involves a decreased responsiveness of gamma-aminobutyric acid receptors in the brain.其机制涉及脑内 γ-氨基丁酸（GABA）受体反应性降低。
• Chronic alcohol use causes changes in the GABAergic system, including downregulation of GABA-A receptors and changes in gene expression.长期饮酒引起 GABA 能系统的改变，包括 GABA-A 受体下调与基因表达变化。
• During acute withdrawal alpha4-containing GABA-A receptors are upregulated while alpha1 and alpha3-containing receptors are downregulated.急性戒断期含 α4 的 GABA-A 受体上调，而含 α1 与 α3 的受体下调。
• Adaptations in the NMDA system contribute to the hyper-excitability of the central nervous system during withdrawal.NMDA 系统的适应导致戒断期中枢神经系统过度兴奋。
• Homocysteine levels rise further during withdrawal and may cause excitotoxicity, and ECG changes such as an increased QT interval may occur.戒断期同型半胱氨酸水平进一步升高并可能引起兴奋性毒性；还可能出现 QT 间期延长等心电图改变。
• Dysfunction of the hypothalamic-pituitary-adrenal axis and increased corticotropin-releasing hormone release contribute to both acute and protracted withdrawal symptoms.下丘脑-垂体-肾上腺轴功能障碍与促肾上腺皮质激素释放激素释放增多，参与急性与迟发性戒断症状。
• Kindling from repeated withdrawals produces increasingly gross neurochemical imbalances through sensitisation of some neuronal systems and desensitisation of others.反复戒断所致的「点燃」通过部分神经元系统的敏化与其他系统的脱敏，造成日益严重的神经化学失衡。

Clinical features

• Milder symptoms include insomnia, muscle aches, trembling and anxiety, while severe symptoms include alcoholic hallucinosis, delirium tremens and autonomic instability.较轻症状包括失眠、肌肉酸痛、震颤与焦虑；严重症状包括酒精性幻觉症、震颤谵妄与自主神经功能紊乱。
• Withdrawal typically begins 6 to 24 hours after the last drink, with symptoms worst at 24 to 72 hours and improving by seven days.戒断通常在末次饮酒后 6 至 24 小时开始，症状在 24 至 72 小时最重，并于 7 天内改善。
• Alcohol hallucinosis consists of transient visual, auditory or tactile hallucinations while the patient is otherwise clear.酒精性幻觉症表现为短暂的视、听或触幻觉，而患者意识在其他方面清楚。
• Withdrawal seizures occur within 48 hours of cessation, either as a single generalised tonic-clonic seizure or a brief episode of multiple seizures.戒断性癫痫发作在停酒后 48 小时内出现，可为单次全身强直-阵挛发作或短暂的多发发作。
• Delirium tremens features a hyperadrenergic state, disorientation, tremor, diaphoresis, impaired attention and visual and auditory hallucinations.震颤谵妄以肾上腺素能过度激活状态、定向力障碍、震颤、发汗、注意力受损以及视听幻觉为特征。
• Delirium tremens is characterised by hallucinations indistinguishable from reality, severe confusion, seizures, high blood pressure and fever persisting 4 to 12 days.震颤谵妄的特征是幻觉与现实难以区分、严重意识混乱、癫痫发作、高血压与发热，可持续 4 至 12 天。
• Protracted withdrawal, sometimes called post-acute withdrawal syndrome, includes craving, anhedonia, clouding of sensorium, disorientation, nausea and headache.迟发性戒断亦称急性戒断后综合征，包括渴求、快感缺失、感知混浊、定向障碍、恶心与头痛。
• Insomnia is a common protracted symptom that influences relapse rates, and cigarette smoking may interfere with recovery of brain pathways.失眠是常见的迟发症状并影响复发率；吸烟则可能干扰脑通路的恢复。

• At 12 to 24 hours after cessation the condition may progress to confusion and hallucinations with awareness of reality, while tremor, agitation and insomnia may persist.停酒后 12 至 24 小时，病情可进展为意识模糊与伴现实感的幻觉，同时震颤、激越与失眠可能持续。
• Although the condition usually improves after 48 hours, in some cases symptoms escalate to delirium tremens, which occurs in 5% to 20% of people undergoing detoxification.尽管病情通常在 48 小时后开始好转，但部分病例症状加重至震颤谵妄；该情况见于 5% 至 20% 的戒断者。
• Symptoms carry the risk of major complications and death for individuals with an alcohol use disorder.对于酒精使用障碍者，这些症状可带来严重并发症与死亡风险。

Diagnosis

• Many hospitals use the Clinical Institute Withdrawal Assessment for Alcohol protocol to assess the level of withdrawal and the amount of medication needed.许多医院采用临床机构酒精戒断评估（CIWA）方案评估戒断程度及所需药量。
• When alcohol overuse is suspected but the drinking history is unclear, elevated carbohydrate-deficient transferrin or gamma-glutamyl transferase can help clarify the diagnosis.当怀疑酒精滥用而饮酒史不清时，缺糖转铁蛋白或 γ-谷氨酰转移酶的升高有助于明确诊断。
• The shortened CIWA-Ar retains validity and reliability and helps assess patients more efficiently.精简版 CIWA-Ar 保留了效度与信度，可更高效地评估患者。
• The severity depends on prior drinking quantity and duration and on the number and severity of previous withdrawal episodes.严重程度取决于既往饮酒量与持续时间，以及既往戒断发作的次数与严重程度。
• Electrolyte problems and low blood sugar should be assessed and treated, as early treatment improves outcomes.应评估并处理电解质紊乱与低血糖，因为早期治疗可改善结局。

Management

• Benzodiazepines are the most commonly used medication and are effective both for symptoms and for preventing seizures.苯二氮䓬类是最常用的药物，对控制症状与预防癫痫发作均有效。
• The most commonly used agents are long-acting benzodiazepines such as chlordiazepoxide and diazepam, though intermediate half-life drugs such as lorazepam may be safer in liver disease.最常用者为氯氮䓬（chlordiazepoxide）与地西泮（diazepam）等长效苯二氮䓬类；而劳拉西泮（lorazepam）等中间半衰期药物在肝病患者中可能更安全。
• Symptom-triggered regimens are as safe and effective as fixed dosing and reduce treatment duration and the amount of medication used.症状触发给药方案与固定剂量同样安全有效，并可缩短疗程、减少用药量。
• Thiamine is recommended routinely, and multivitamins with sufficient thiamine and folic acid help prevent Wernicke syndrome.常规推荐补充硫胺素（thiamine）；含足量硫胺素与叶酸的复合维生素有助于预防韦尼克综合征。
• Prophylactic intravenous thiamine, folic acid and pyridoxine should be given before carbohydrate-containing fluids or food, often combined as a "banana bag".在给予含碳水化合物的液体或食物前，应预防性静脉给予硫胺素、叶酸与吡哆醇（pyridoxine），常合并为「香蕉袋」。
• Limited evidence supports gabapentin or carbamazepine for mild or moderate withdrawal, but gabapentin is not effective for severe withdrawal.有限证据支持加巴喷丁（gabapentin）或卡马西平（carbamazepine）用于轻度或中度戒断，但加巴喷丁对重度戒断无效。
• Three medications help prevent a return to drinking: naltrexone, acamprosate and disulfiram, used after withdrawal has occurred.有三种药物有助于防止重新饮酒：纳曲酮（naltrexone）、阿坎酸（acamprosate）与双硫仑（disulfiram），在戒断后使用。
• Clonidine may be combined with benzodiazepines, while antipsychotics such as haloperidol are used cautiously because they lower the seizure threshold.可乐定（clonidine）可与苯二氮䓬类联用；氟哌啶醇（haloperidol）等抗精神病药因降低癫痫阈值而须慎用。

• Severe symptoms often require inpatient care, while milder cases may be managed at home with daily visits from a healthcare provider.严重症状常需住院治疗，而较轻病例可在医护人员每日上门随访下居家处理。
• Hypertension is common, and some doctors also prescribe beta blockers during withdrawal.戒断期高血压常见，部分医师还会处方 β 受体阻滞剂。

Research and controversies

• Kindling may increase the risk of relapse, alcohol-related brain damage and cognitive deficits, and may cause permanent alterations in GABA-A receptors.「点燃」可能增加复发、酒精相关脑损伤与认知缺陷的风险，并可能导致 GABA-A 受体永久改变。
• Brain damage from withdrawal may be prevented by NMDA antagonists, calcium antagonists and glucocorticoid antagonists, though this remains proposed rather than established.戒断所致脑损伤或可经 NMDA 拮抗剂、钙拮抗剂与糖皮质激素拮抗剂预防，但这仍属假说而非定论。
• The amygdala and prefrontal cortex are the brain regions most sensitive to harm from binge drinking.杏仁核与前额叶皮质是对暴饮伤害最敏感的脑区。
• Insomnia in protracted withdrawal may be treated with magnesium or trazodone, which unlike many sleep aids is not cross-tolerant with alcohol.迟发性戒断的失眠可用镁剂或曲唑酮（trazodone）治疗，后者与酒精无交叉耐受，不同于多数助眠药。
• No conclusions can be drawn about the efficacy or safety of baclofen for alcohol withdrawal because of insufficient and low-quality evidence.由于证据不足且质量低，尚无法就巴氯芬（baclofen）治疗酒精戒断的有效性或安全性得出结论。