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Alcoholic Ketoacidosis

By

Erika F. Brutsaert

, MD, New York Medical College

Reviewed/Revised Oct 2023
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Topic Resources

Alcoholic ketoacidosis is a metabolic complication of alcohol use and starvation characterized by hyperketonemia and anion gap metabolic acidosis without significant hyperglycemia. Alcoholic ketoacidosis causes nausea, vomiting, and abdominal pain. Diagnosis is by history and findings of ketoacidosis without hyperglycemia. Treatment is IV saline solution and dextrose infusion.

Pathophysiology of Alcoholic Ketoacidosis

Alcohol diminishes hepatic gluconeogenesis and leads to decreased insulin secretion, increased lipolysis, impaired shunting of fatty acids to mitochondria, fatty acid oxidation, and subsequent ketogenesis, causing an elevated anion gap metabolic acidosis High anion gap acidosis Metabolic acidosis is primary reduction in bicarbonate (HCO3), typically with compensatory reduction in carbon dioxide partial pressure (Pco2); pH may be markedly low or slightly... read more . Growth hormone, epinephrine, cortisol, and glucagon are all increased. Plasma glucose levels are usually low or normal, but mild hyperglycemia sometimes occurs.

Symptoms and Signs of Alcoholic Ketoacidosis

Typically, an alcohol binge leads to vomiting and the cessation of alcohol or food intake for 24 hours. During this period of starvation, vomiting continues and abdominal pain develops, leading the patient to seek medical attention. Pancreatitis Overview of Pancreatitis Pancreatitis is classified as either acute or chronic. Acute pancreatitis is inflammation that resolves both clinically and histologically. Chronic pancreatitis is characterized by histologic... read more may occur.

Diagnosis of Alcoholic Ketoacidosis

  • Calculation of anion gap

  • Exclusion of other disorders

In patients suspected of having alcoholic ketoacidosis, serum electrolytes (including magnesium), blood urea nitrogen (BUN) and creatinine, glucose, ketones, amylase, lipase, and plasma osmolality should be measured. Urine should be tested for ketones. Patients who appear significantly ill and those with positive ketones should have arterial blood gas and serum lactate measurements.

The absence of hyperglycemia makes diabetic ketoacidosis improbable. Patients with mild hyperglycemia may have underlying diabetes mellitus Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , which may be recognized by elevated levels of glycosylated hemoglobin (HbA1C).

Typical laboratory findings include

Detection of acidosis may be complicated by concurrent metabolic alkalosis Metabolic Alkalosis Metabolic alkalosis is primary increase in bicarbonate (HCO3) with or without compensatory increase in carbon dioxide partial pressure (Pco2); pH may be high or nearly normal. Common... read more due to vomiting, resulting in a relatively normal pH; the main clue is the elevated anion gap. If history does not rule out toxic alcohol ingestion as a cause of the elevated anion gap, serum methanol and ethylene glycol levels should be measured.

Calcium oxalate crystals in the urine also suggests ethylene glycol poisoning.

Lactic acid levels are often elevated because of hypoperfusion and the altered balance of reduction and oxidation reactions in the liver.

Treatment of Alcoholic Ketoacidosis

  • IV thiamine and other vitamins plus magnesium

  • IV 5% dextrose in 0.9% saline

Ketoacidosis and gastrointestinal symptoms usually respond rapidly. Use of insulin is appropriate only if there is any question of atypical diabetic ketoacidosis or if hyperglycemia > 300 mg/dL (> 16.7 mmol/L) develops.

Key Points

  • Alcoholic ketoacidosis is caused by the combined effects of alcohol and starvation on glucose metabolism; it is characterized by hyperketonemia and elevated anion gap metabolic acidosis without significant hyperglycemia.

  • Measure serum and urine ketones and electrolytes and calculate a serum anion gap.

  • Treat initially with IV thiamine to prevent Wernicke encephalopathy or Korsakoff psychosis, then follow up with IV dextrose in 0.9% saline.

Drugs Mentioned In This Article

Drug Name Select Trade
No brand name available
Advocate Glucose SOS, BD Glucose, Dex4 Glucose, Glutol , Glutose 15 , Glutose 45 , Glutose 5
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NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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