Case 26: A man after surgery who sees cockroaches on the walls

Case 26: A man after surgery who sees cockroaches on the walls

A 60-year-old man with a long history of heavy drinking who, three days after an emergency operation for acute pancreatitis, becomes tense, sleepless and thinks he is in a hotel.

  • 2 min read
  • Checked 01 Nov 2026

The case

A 60-year-old man who has drunk heavily for many years is admitted as an emergency to a surgical ward with acute pancreatitis. Three days after the operation he becomes tense, cannot sleep, and keeps trying to get out of bed and pull out his drip. He says he is in a hotel and has a train to catch for a business trip. He complains that the staff do not clean, because his bed is full of fleas and cockroaches are crawling on the walls.

Summary

Diagnosis

Delirium in alcohol withdrawal (delirium tremens).

What points to it

  • Long, heavy drinking, stopped abruptly on admission, and symptoms on the third day: delirium tremens begins one to seven days after the last drink, most often around 48 hours.
  • Disorientation for place and situation (a hotel, a business trip) while he still knows who he is: older texts call this allopsychic disorientation.
  • Vivid visual and tactile hallucinations of small animals (fleas, cockroaches), typical of delirium tremens.
  • Restlessness, sleeplessness, worse at night.
  • Added strain: an illness that weakens him and a recent operation, with nothing given to prevent withdrawal despite his history.

What else it could be

In a surgical patient, delirium from other causes: infection, low oxygen, electrolyte or glucose disturbance, drugs. Wernicke's encephalopathy (confusion, eye signs, unsteady gait), hepatic encephalopathy and a head injury from a fall must also be thought of. They can coexist.

Management

  • Treat it as a medical emergency where he is, on the surgical ward or in intensive care.
  • Parenteral thiamine (for example Pabrinex) before any glucose, to prevent or treat Wernicke's encephalopathy.
  • A benzodiazepine: in the UK oral lorazepam is first line, by injection if he cannot or will not take tablets (diazepam is also widely used, but not if the liver is failing), given against his symptoms on a scale such as CIWA-Ar or front-loaded until he is calm but rousable. The dose is set by his response, not a fixed ceiling.
  • Fluids, and correct potassium, magnesium and glucose. A calm, lit, safe room and close observation.
  • Before discharge, plan treatment of his alcohol dependence.

Outlook

Delirium tremens has a reported mortality of 5 to 10%, lower with prompt treatment, from seizures, arrhythmia, infection and circulatory collapse. With good care it usually settles within days. The outlook depends on his complications and on whether he stops drinking.