View source for 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|metabolic alkalosis]] can occur from dehydration (volume depletion) and emesis, so a normal blood pH may be found

===Pathophysiology===
*Ethanol metabolism depletes NAD stores<ref>McGuire LC, Cruickshank AM, Munro PT. Alcoholic ketoacidosis. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564331/ Emerg Med J. 2006 Jun;23(6):417-20.]</ref>
**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
[[File:AKA_crashingpatient.JPG|thumbnail]]

==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 DDX}}

==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 or IM) 
**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 abnormalities|Electrolyte replacement]]
**K, Mag and Phos
*Monitor for signs of [[Alcohol Withdrawal|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]]

==References==
<references/>

[[Category:Endocrinology]]
[[Category:FEN]]
[[Category:Toxicology]]