Self-disembowelment during delirium tremens: why early diagnosis is vital

Delirium tremens is a serious yet treatable complication of alcohol withdrawal. Timely diagnosis is critical as there are well-established treatment regimens that provide symptomatic relief within hours to days. We report the case of a 34-year-old man with an undisclosed history of alcohol dependency. He presented with paranoid beliefs and was transferred to a psychiatric inpatient unit with suspected schizophrenia. Classic features of delirium tremens such as sympathetic overdrive and visual hallucinations were not salient features of his presentation. Within 24 hours of admission, he sustained major self-inflicted abdominal stab wounds and extracted a metre of small bowel as a result of command hallucinations. The possibility of delirium tremens was raised by the receiving trauma team and he responded rapidly to benzodiazepines. Emergency jejunal reanastomosis was successful. This case highlights the fact that delirium tremens may present atypically and that associated command hallucinations can confer grave risks.