Alcoholic ketoacidosis is attributed to the combined effects of alcohol and starvation Overview of Undernutrition Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more on glucose metabolism.
Pathophysiology of Alcoholic Ketoacidosis
Alcohol diminishes hepatic gluconeogenesis and leads to decreased insulin secretion, increased lipolysis, impaired 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 subnormal... 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
Diagnosis requires a high index of suspicion; similar symptoms in a patient with alcohol use disorder Alcohol Use Disorders and Rehabilitation Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism... read more may result from acute pancreatitis Acute Pancreatitis Acute pancreatitis is acute inflammation of the pancreas (and, sometimes, adjacent tissues). The most common triggers are gallstones and alcohol intake. The severity of acute pancreatitis is... read more , methanol or ethylene glycol poisoning (see table Symptoms and Treatment of Specific Poisons Symptoms and Treatment of Specific Poisons Symptoms and treatment of specific poisons vary (see table Symptoms and Treatment of Specific Poisons ). Including all the specific complexities and details is impossible, although cross-references... read more ), or diabetic ketoacidosis Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with... read more (DKA). Often, blood alcohol levels are no longer elevated when patients present with alcoholic ketoacidosis. 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 measurement.
The absence of hyperglycemia makes diabetic ketoacidosis improbable. Those 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
Hypokalemia Hypokalemia Hypokalemia is serum potassium concentration 3.5 mEq/L ( 3.5 mmol/L) caused by a deficit in total body potassium stores or abnormal movement of potassium into cells. The most common cause is... read more , hypomagnesemia Hypomagnesemia Hypomagnesemia is serum magnesium concentration 1.8 mg/dL ( 0.70 mmol/L). Causes include inadequate magnesium intake and absorption or increased excretion due to hypercalcemia or drugs such... read more , and hypophosphatemia Hypophosphatemia Hypophosphatemia is a serum phosphate concentration 2.5 mg/dL (0.81 mmol/L). Causes include alcohol use disorder, burns, starvation, and diuretic use. Clinical features include muscle weakness... read more
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 causes... 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 thiamin and other vitamins plus magnesium
IV 5% dextrose in 0.9% saline
Patients are initially given thiamin 100 mg IV to prevent development of Wernicke encephalopathy Wernicke Encephalopathy Wernicke encephalopathy is characterized by acute onset of confusion, nystagmus, partial ophthalmoplegia, and ataxia due to thiamin deficiency. Diagnosis is primarily clinical. The disorder... read more or Korsakoff psychosis Korsakoff Psychosis Korsakoff psychosis is a late complication of persistent Wernicke encephalopathy and results in memory deficits, confusion, and behavioral changes. Korsakoff psychosis occurs in 80% of untreated... read more . Then an IV infusion of 5% dextrose in 0.9% saline solution is given. Initial IV fluids should contain added water-soluble vitamins and magnesium, with potassium replacement as required.
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.
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 thiamin to prevent Wernicke encephalopathy or Korsakoff psychosis, then follow up with IV dextrose in 0.9% saline.