How can I differentiate between Wernicke's encephalopathy and other causes of acute confusion in a patient with a history of alcohol use?

When a patient with a history of alcohol use presents with acute confusion, it is crucial for General Practice staff to maintain a high level of suspicion for Wernicke's encephalopathy (Lindberg and Oyler, 1990), particularly if the person is intoxicated ¹. This condition requires immediate attention.

Key differentiating factors and considerations include:

• Wernicke's Encephalopathy (WE): The NICE guideline strongly advises offering parenteral thiamine to people with suspected WE ¹. This treatment should be given for a minimum of 5 days, unless WE is definitively excluded ¹. A high index of suspicion is paramount, and treatment should not be delayed while awaiting definitive diagnosis or exclusion of other conditions ¹. Prophylactic parenteral thiamine followed by oral thiamine is also recommended for harmful or dependent drinkers who are malnourished, at risk of malnourishment, or have decompensated liver disease, especially if they attend an emergency department or are admitted to hospital with an acute illness or injury ¹.
• Acute Alcohol Withdrawal and Delirium Tremens: Acute confusion can also be a symptom of acute alcohol withdrawal, which refers to the physical and psychological symptoms experienced when alcohol intake is suddenly reduced or stopped after prolonged excessive drinking ¹. Delirium tremens is a severe form of alcohol withdrawal ¹. These conditions are typically managed with a symptom-triggered regimen of drug treatment, often involving benzodiazepines like oral lorazepam as first-line for delirium tremens ¹. The onset of confusion in these cases is usually linked to a reduction or cessation of alcohol intake ¹.
• Hepatic Encephalopathy: This is a complication of decompensated liver disease, which is defined as liver disease complicated by jaundice, ascites, or variceal bleeding ¹. The presence of these additional signs of liver failure would strongly suggest hepatic encephalopathy as a cause of acute confusion ¹. People with decompensated liver disease who are undergoing treatment for acute alcohol withdrawal should receive advice from a healthcare professional experienced in liver disease management ¹.

In summary, while multiple conditions can cause acute confusion in patients with alcohol use history, the immediate and critical action for suspected Wernicke's encephalopathy is to offer parenteral thiamine, even while other potential causes are being investigated or excluded ¹.