Difference between revisions of "Wernicke-Korsakoff syndrome"

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*Wernicke-Korsakoff Syndrome (WKS): presence of WE + KP simultaneously
 
*Wernicke-Korsakoff Syndrome (WKS): presence of WE + KP simultaneously
  
==Epidemiology==
+
===Epidemiology===
 
*Only 20% identified before death, failure of dx leads to 20% mortality and 75% permanent damage
 
*Only 20% identified before death, failure of dx leads to 20% mortality and 75% permanent damage
 +
 +
===Pathophysiology===
 +
*Brain lesions/atrophy occurs: mamillary bodies (nearly all cases), thalamus, periaqueductal gray matter, 3rd/4th ventricle, cerebellum, frontal lobe
  
 
==Causes==
 
==Causes==
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**Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis
 
**Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis
  
==Pathophysiology==
+
==Clinical Features==
*Brain lesions/atrophy occurs: mamillary bodies (nearly all cases), thalamus, periaqueductal gray matter, 3rd/4th ventricle, cerebellum, frontal lobe
 
 
 
==Diagnosis==
 
WE/KP/WKS = clinical diagnoses
 
 
 
 
===Wernicke’s Encephalopathy===
 
===Wernicke’s Encephalopathy===
 
*Classic triad: encephalopathy, oculomotor dysfunction, gait ataxia
 
*Classic triad: encephalopathy, oculomotor dysfunction, gait ataxia
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*Sx: combination of WE and KP
 
*Sx: combination of WE and KP
  
==Treatment==
+
==Differential Diagnosis==
If suspect WE/KP/WKS: thiamine 500 mg IV over 30 min TID x 2 days, then 500 mg IV/IM q day for 5 days, then 100 mg PO q day until pt no longer at risk
 
  
 +
==Diagnosis==
 +
WE/KP/WKS = clinical diagnoses
  
If suspect at risk for thiamine deficiency but no sx: thiamine 100 mg PO q day
+
==Treatment==
 +
''If you suspect WE/KP/WKS then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high''
  
 +
*Suspected WE/KP/WKS: thiamine 500 mg IV over 30 min TID x 2 days, then 500 mg IV/IM q day for 5 days, then 100 mg PO q day until pt no longer at risk
 +
**Give magnesium; hypomagnesemic state may be resistant to thiamine administration
 +
**Treatment can take days to weeks to work if at all (despite accurate diagnosis)
 +
**Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly
  
*If you suspect WE/KP/WKS then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high
+
===Vitamin Prophylaxis for Alcoholics===
*Treatment can take days to weeks to work if at all (despite accurate diagnosis)
 
*Give magnesium; hypomagnesemic state may be resistant to thiamine administration
 
 
 
*Give multivitamin; pt at risk for other vitamin deficiencies
 
 
 
 
*For the majority of chronic alcoholics, you should not administer a banana bag (thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W)<ref>Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Rreview. The Journal of Emergency Medicine. 1998; 16(3):419–424.</ref><ref>Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.</ref>
 
*For the majority of chronic alcoholics, you should not administer a banana bag (thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W)<ref>Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Rreview. The Journal of Emergency Medicine. 1998; 16(3):419–424.</ref><ref>Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.</ref>
 
+
**At risk for thiamine deficiency but no symptoms: thiamine 100 mg PO q day
*Remember to give thiamine BEFORE glucose in pts requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly
+
**Give multivitamin; pt at risk for other vitamin deficiencies
  
 
==See Also==
 
==See Also==

Revision as of 12:54, 26 April 2015

Background

  • Wernicke’s Encephalopathy (WE): ACUTE neuro/cardiovascular sx caused by thiamine deficiency
  • Korsakoff’s Psychosis (KP): CHRONIC neurologic symptoms caused by thiamine deficiency
  • Wernicke-Korsakoff Syndrome (WKS): presence of WE + KP simultaneously

Epidemiology

  • Only 20% identified before death, failure of dx leads to 20% mortality and 75% permanent damage

Pathophysiology

  • Brain lesions/atrophy occurs: mamillary bodies (nearly all cases), thalamus, periaqueductal gray matter, 3rd/4th ventricle, cerebellum, frontal lobe

Causes

  • Anything that causes thiamine (vitamin B1) deficiency: poor dietary intake, malabsorption, increased metabolic requirement
    • Chronic alcoholism, dieting/fasting/starvation, anorexia, vomiting/diarrhea, unbalanced TPN, GI surgery, malignancy, dialysis, AIDS, IBD, pancreatitis, liver disease, thyrotoxicosis

Clinical Features

Wernicke’s Encephalopathy

  • Classic triad: encephalopathy, oculomotor dysfunction, gait ataxia
  • werNICke mnemonic:
    • N: Nystagmus/ophthalmoplegia
    • I: Incoordination/ataxia
    • C: Confusion/memory impairment
  • Other sx: hypotension, tachycardia, EKG abnormalities, DOE, CHF sx, hypothermia, coma, dry/wet Beriberi

Korsakoff’s Psychosis

  • Sx: anterograde/retrograde amnesia, confabulation, confusion, apathy

Wernicke-Korsakoff Syndrome

  • Sx: combination of WE and KP

Differential Diagnosis

Diagnosis

WE/KP/WKS = clinical diagnoses

Treatment

If you suspect WE/KP/WKS then treat it! Diagnosis is clinical and difficult to confirm, treatment is simple/inexpensive/effective, there is little risk to treatment, and the risk of morbidity/mortality from not treating is high

  • Suspected WE/KP/WKS: thiamine 500 mg IV over 30 min TID x 2 days, then 500 mg IV/IM q day for 5 days, then 100 mg PO q day until pt no longer at risk
    • Give magnesium; hypomagnesemic state may be resistant to thiamine administration
    • Treatment can take days to weeks to work if at all (despite accurate diagnosis)
    • Give thiamine BEFORE glucose in patients requiring glucose who are at risk for thiamine deficiency; glucose without thiamine can precipitate/worsen WE by driving thiamine intracellularly

Vitamin Prophylaxis for Alcoholics

  • For the majority of chronic alcoholics, you should not administer a banana bag (thiamine 100 mg + magnesium 2-4 g + folate 1 mg + multivitamin; all in 1L NS or D5W)[1][2]
    • At risk for thiamine deficiency but no symptoms: thiamine 100 mg PO q day
    • Give multivitamin; pt at risk for other vitamin deficiencies

See Also

References

  1. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Rreview. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  2. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.