Psychiatry Consultation: Delirium in a Patient with Mallory-Weiss Tear (UGI Bleed)

Step 1 - Frame the Clinical Question

• Alcohol use disorder (AUD) - by far the most common association
• Bulimia nervosa
• Hiatal hernia, gastroparesis, or other conditions causing retching
• Post-endoscopy or post-procedure

Step 2 - Differential Diagnosis of Delirium in This Patient

1. Alcohol withdrawal / delirium tremens
2. Wernicke encephalopathy
3. Hepatic encephalopathy (if underlying cirrhosis)

Step 3 - History (often collateral-dependent in delirium)

• Daily quantity and type of alcohol
• Duration of drinking
• Last drink (time elapsed since last drink is the most critical question for withdrawal timing)
• Prior withdrawal episodes, prior DTs, prior withdrawal seizures
• Prior admissions for detox

• Liver disease / cirrhosis
• Prior GI bleeds
• Nutritional status / weight loss
• Any recent fall or head trauma

• Any pre-existing dementia or cognitive impairment (important because dementia dramatically increases delirium risk)

• Any CNS-active drugs (benzodiazepines, opioids, antipsychotics, anticholinergics)
• Any recent dose changes

Step 4 - Bedside Assessment

Confirm DSM-5 Delirium Criteria:

1. Disturbance in attention and awareness (reduced ability to direct/sustain/shift attention)
2. Acute onset representing a change from baseline, with fluctuating course throughout the day
3. Additional cognitive disturbance (memory deficit, disorientation, language, visuospatial, perception)
4. Not better explained by pre-existing neurocognitive disorder or coma
5. Evidence of physiologic cause (from history, exam, labs)

Motor Subtype:

• Hyperactive delirium: agitation, combativeness, visual hallucinations, attempts to get out of bed - think alcohol withdrawal / drug intoxication
• Hypoactive delirium: withdrawn, lethargic, appears "depressed" - more likely metabolic/hepatic/post-bleed hypoperfusion
• Mixed: fluctuates between both

Validated Screening Tool - CAM (Confusion Assessment Method):

1. Acute onset + fluctuating course AND
2. Inattention AND either:
3. Disorganized thinking OR altered level of consciousness

Key Physical Exam Findings to Look For:

Step 5 - Workup to Request (Communicate to Primary Team)

Step 6 - Identify the Specific Syndrome (Alcohol-Related)

Alcohol Withdrawal Timeline (from Symptom to Diagnosis textbook):

• 6-24 hours: Tremor, anxiety, nausea, diaphoresis, mild autonomic instability
• 12-48 hours: Withdrawal seizures (typically generalized tonic-clonic)
• 24-72 hours: Delirium Tremens - peak risk window; marked by fever, severe agitation, hallucinations (predominantly visual and tactile), severe autonomic instability
• Wernicke encephalopathy: Can develop at any point in malnourished/thiamine-deficient patients

Diagnosing Delirium Tremens requires:

1. History of heavy alcohol use
2. Always preceded by minor withdrawal (may be missed if patient was sedated/anesthetized)
3. Adrenergic overactivity (tachycardia, hypertension, fever) - unless masked by medications
4. Prominent visual/tactile hallucinations, agitation

Wernicke Encephalopathy - diagnose if 2 of 4 present:

1. Dietary deficiency (underweight, thiamine-deficient history)
2. Disorders of ocular movement (ophthalmoplegia, nystagmus, gaze palsy)
3. Cerebellar signs (ataxia)
4. Altered mental state or memory impairment

Critical: Wernicke is notoriously under-diagnosed because the classic triad (ophthalmoplegia + ataxia + confusion) is present in only ~16% of cases. Empirically treat with IV thiamine.

Step 7 - Management Recommendations

Non-Pharmacologic (first-line for all delirium):

• Adequate lighting; avoid sensory deprivation AND sensory overload
• Familiar person (family member) at bedside if possible
• Clock and calendar visible for orientation
• Regular reorientation by staff
• Minimize nighttime awakenings
• Glasses and hearing aids in place
• Encourage early mobility
• "Sitters" (1:1 continuous observation) preferred over physical restraints - restraints increase agitation, injury risk, and death has occurred in restrained delirious patients
• Side rails up; fall precautions

Pharmacologic:

• CIWA-Ar guided (symptom-triggered) therapy is preferred - monitors 10 parameters (tremor, sweating, anxiety, agitation, headache, nausea, perceptual disturbances, orientation, tactile/visual/auditory disturbances). Score >8-10 warrants dosing.
• Diazepam (long-acting): 5-10 mg PO/IV q1-4h PRN, OR
• Chlordiazepoxide (long-acting, oral): 25-100 mg q4-6h in milder cases
• Lorazepam (shorter-acting, IV/IM): preferred in hepatic disease or elderly where long-acting accumulation is dangerous
• For severe DTs: high-dose IV benzodiazepines; ICU-level care may be needed

Caution: In this patient with active UGI bleed, IV access is already present - use IV benzodiazepines. Monitor respiratory status closely.

• Give immediately: 200-500 mg IV thiamine BEFORE or with any glucose
• Prevents and partially reverses Wernicke encephalopathy

• Lactulose (titrate to 2-3 soft stools/day)
• Rifaximin (second-line/adjunct)
• Treat precipitating factors: GI bleed itself is a major precipitant (protein load from digested blood)

• Haloperidol: 2-5 mg IM/IV, may repeat in 1 hour if still agitated; oral equivalent is 1.5x parenteral dose; effective total daily dose typically 5-40 mg
• Monitor QTc (haloperidol can cause QT prolongation, especially IV)
• Avoid phenothiazines (chlorpromazine) - high anticholinergic activity, worsens delirium
• Important: Benzodiazepines are the treatment for alcohol withdrawal delirium - antipsychotics are adjuncts only and do NOT prevent seizures

Do NOT use benzodiazepines as first-line in non-withdrawal delirium - they can worsen delirium severity in other etiologies.

Step 8 - Capacity Assessment

• The patient cannot currently understand, appreciate, reason, or communicate a consistent choice
• Capacity is presumed to return once delirium resolves
• Decisions should be deferred to healthcare proxy/next of kin or default surrogate (per local law)
• If an emergency intervention is needed, proceed under the emergency exception

Step 9 - Safety Considerations

• Fall risk: High - continuous supervision, bed rails, anti-fall mattress
• Self-harm/elopement: Monitor for attempts to remove IV/NG tubes, climb out of bed
• Aspiration risk: Head-of-bed elevation; ongoing vomiting risk with Mallory-Weiss
• Seizure precautions: Padded side rails, oxygen at bedside, suction available - especially in first 24-48 hours of alcohol withdrawal
• Restraints: Document carefully if used; reassess every 15 minutes; transition to chemical restraint as soon as pharmacologically feasible

Step 10 - Psychiatric Consultation Note - Key Points to Document

1. Reason for consultation, time of assessment
2. History from collateral (specify source), including alcohol history, last drink, prior withdrawal
3. Mental status examination: orientation x3, attention (digit span, serial 7s), psychomotor activity, hallucinations, speech, behavior
4. DSM-5 criteria for delirium met/not met; motor subtype
5. CAM score
6. CIWA-Ar score (if alcohol withdrawal suspected)
7. Your etiologic assessment (rank the differentials)
8. Recommendations: labs requested, medications recommended with specific doses, non-pharmacologic measures, monitoring parameters
9. Capacity assessment
10. Follow-up plan (daily reassessment until delirium resolves)

Prognosis

• Delirium typically resolves in 3-7 days once the underlying cause is treated; some symptoms persist up to 2 weeks
• The older the patient and longer the duration of delirium, the slower the resolution
• After resolution, the patient may have fragmented recall of the episode ("like a bad dream")
• Delirium carries significantly increased in-hospital and post-discharge mortality - the primary team should be aware that delirium is a medical emergency, not just a behavioral issue
• Post-delirium: screen for PTSD symptoms and depression at follow-up, as these are recognized sequelae

• Kaplan & Sadock's Synopsis of Psychiatry (delirium criteria, pharmacotherapy, physical exam)
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry (delirium etiologies, special populations)
• Symptom to Diagnosis: An Evidence-Based Guide, 4e (alcohol withdrawal timeline, CIWA-Ar, DTs vs Wernicke)
• Rosen's Emergency Medicine (delirium management, haloperidol use, restraints)
• Tintinalli's Emergency Medicine (delirium vs dementia vs psychiatric disorder, differential)
• Goldman-Cecil Medicine (alcohol withdrawal management, CIWA scoring)