Alcoholic ketoacidosis

Background

• Seen in patients with recent history of binge drinking with little/no nutritional intake
• Anion gap metabolic acidosis associated with acute cessation of ETOH consumption after chronic abuse
• Characterized by high serum ketone levels and an elevated AG
  • Consider other causes of elevated AG, as well as co-ingestants
  • Concomitant metabolic alkalosis can occur from dehydration (volume depletion) and emesis

Pathophysiology

• Ethanol metabolism depletes NAD stores
  • Results in inhibition of Krebs cycle, depletion of glycogen stores, and ketone formation
  • High NADH:NAD also results in increased lactate production
    • Lactate higher than normal but not as high as in shock or sepsis
  • Acetoacetate is metabolized to acetone so elevated osmolal gap may also be seen

Clinical Features

• Nausea (75%)
• Vomiting (73%)
• Abdominal pain (62%)
• Not hyperosmolar as opposed to DKA
• Large IVF admin does not predispose to cerebral edema

Differential Diagnosis

• Isopropyl Alcohol
  • Results in ketosis
• Methanol, Ethylene Glycol
  • Do not produce ketosis
• Sepsis
• Salicylate Toxicity
• DKA
• Hyperosmolar hyperglycemic state
• Starvation Ketosis
• Uremia

Ethanol related disease processes

• Ethanol toxicity
• Alcohol use disorder
• Alcohol withdrawal
  • Alcohol withdrawal seizures
  • Delerium tremens
• Electrolyte/acid-base disorder
  • Alcoholic ketoacidosis
  • Beer potomania syndrome
  • Beriberi
  • Thiamine deficiency
  • Wernicke-Korsakoff syndrome

Evaluation

• Binge drinking ending in nausea, vomiting, and decreased intake
• Wide anion gap metabolic acidosis (ketonemia, lactic acidosis)
• Positive serum ketones
• Wide anion gap metabolic acidosis without alternate explanation
• Urine ketones may be falsely negative or low
  • Lab measured ketone is acetoacetate
  • May miss beta-hydroxybutyrate
• Typically normal osmolal gap
• Alcohol level usually zero or not considerably high

Management

Consider associated diseases (ie pancreatitis, rhabdomyolysis, hepatitis, infections)

• Thiamine (100mg IV)
  • Prior to glucose to decrease risk of Wernicke encephalopathy or Korsakoff syndrome
• Hydration (D5NS)
  • IVF should include 5% dextrose since there is a lack of glucose
  • Glucose stimulates insulin which stops lipolysis
• Oral nutrition if able to tolerate
• Electrolyte replacement
  • K, Mag and Phos
• Monitor for signs of alcohol withdrawal
• Consider bicarb if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy

Disposition

• Discharge home after treatment if able to tolerate POs and acidosis resolved
• Consider admission for those with severe volume depletion and/or acidosis
• Hypoglycemia is poor prognostic feature, indicating depleted glycogen stores

See Also

• Metabolic Acidosis
• Anion Gap (High)
• Acid-Base Disorders