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 (toxic alcohols, salicylates)
  • Concomitant metabolic alkalosis can occur from dehydration (volume depletion) and emesis, so a normal blood pH may be found

Pathophysiology

• Ethanol metabolism depletes NAD stores
  • Results in inhibition of Krebs cycle, depletion of glycogen stores, and ketone formation
  • Suppresses gluconeogenesis and may result in hypoglycemia
  • 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%)
• Typically, history of binge drinking ending in nausea, vomiting, and decreased intake
• Not hyperosmolar as opposed to DKA

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

• Labs
  • Anion gap acidosis
    • Typically wide anion gap
    • Positive serum ketones + lactic acidosis
      • Lab measured ketone is acetoacetate
      • May miss beta-hydroxybutyrate
      • Urine ketones may be falsely negative or low
  • Typically normal osmolal gap
  • Alcohol level usually zero or not considerably high
  • BMP, Mg/phos
    • Often have concomitant electrolyte abnormalities

• ECG
  • May show dysrhythmias or QT interval/QRS changes secondary to electrolyte abnormalities

• Imaging
  • Consider CXR if concern for aspiration pneumonia
  • Consider CT head if presentation associated with trauma

Management

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

• Thiamine (100mg IV or IM)
  • Prior to glucose to decrease risk of Wernicke encephalopathy or Korsakoff syndrome
• Hydration (D5NS)
  • IVF should include 5% dextrose to treat starvation ketosis
  • Large IVF admin does not predispose to cerebral edema
  • 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 bicarbonate if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy

Disposition

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

See Also

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

External Links

• Merk Manual - Alcoholic Ketoacidosis
• EMRA - Alcoholic Ketoacidosis: Mind the Gap, Give Patients What They Need