Toxic Alcohol Ingestions: Clinical Features, Diagnosis, And Management
Abstract Alcohol-related intoxications, including methanol, ethylene glycol, diethylene glycol, and propylene glycol, and alcoholic ketoacidosis can present with a high anion gap metabolic acidosis and increased serum osmolal gap, whereas isopropanol intoxication presents with hyperosmolality alone. The effects of these substances, except for isopropanol and possibly alcoholic ketoacidosis, are due to their metabolites, which can cause metabolic acidosis and cellular dysfunction. Accumulation of the alcohols in the blood can cause an increment in the osmolality, and accumulation of their metabolites can cause an increase in the anion gap and a decrease in serum bicarbonate concentration. The presence of both laboratory abnormalities concurrently is an important diagnostic clue, although either can be absent, depending on the time after exposure when blood is sampled. In addition to metabolic acidosis, acute renal failure and neurologic disease can occur in some of the intoxications. Dialysis to remove the unmetabolized alcohol and possibly the organic acid anion can be helpful in treatment of several of the alcohol-related intoxications. Administration of fomepizole or ethanol to inhibit alcohol dehydrogenase, a critical enzyme in metabolism of the alcohols, is beneficial in treatment of ethylene glycol and methanol intoxication and possibly diethylene glycol and propylene glycol intoxication. Given the potentially high morbidity and mortality of these intoxications, it is important for the clinician to have a high degree of suspicion for these disorders in cases of high anion gap metabolic acidosis, acute renal failure, or unexplained neurologic disease so that treatment can be initiated early. Effect of Alcohols on Serum Osmolality and the Osmolal Gap The normal serum Continue reading >>
Alcoholic Ketoacidosis
Go to: CHARACTERISATION In 1940, Dillon et al1 described a series of nine patients who had episodes of severe ketoacidosis in the absence of diabetes mellitus, all of whom had evidence of prolonged excessive alcohol consumption. It was not until 1970 that Jenkins et al2 described a further three non‐diabetic patients with a history of chronic heavy alcohol misuse and recurrent episodes of ketoacidosis. This group also proposed a possible underlying mechanism for this metabolic disturbance, naming it alcoholic ketoacidosis. Further case series by Levy et al, Cooperman et al, and Fulop et al were subsequently reported, with remarkably consistent features.3,4,5 All patients presented with a history of prolonged heavy alcohol misuse, preceding a bout of particularly excessive intake, which had been terminated several days earlier by nausea, severe vomiting, and abdominal pain. Clinical signs included tachypnoea, tachycardia, and hypotension. In 1974, Cooperman's series of seven ketoacidotic alcoholic patients all displayed diffuse epigastric tenderness on palpation.4 In contrast to patients with diabetic ketoacidosis, the patients were usually alert and lucid despite the severity of the acidosis and marked ketonaemia. When altered mental status occurred, this was clearly attributable to other causes. Laboratory results included absent blood alcohol with normal or low blood glucose level, no glycosuria, and a variably severe metabolic acidosis with a raised anion gap. This acidosis appeared to result from the accumulation in plasma of lactate and ketone bodies including beta‐hydroxybutyrate (BOHB) and acetoacetate (AcAc).3 Cooperman et al found that near patient testing for ketone bodies using nitroprusside test (Acetest, Ketostix) produced a low to moderate result in th Continue reading >>
Alcoholic Ketoacidosis
Alcoholic ketoacidosis is the build up of ketones in the blood. Ketones are a type of acid that form when the body breaks down fat for energy. The condition is an acute form of metabolic acidosis. Alcoholic ketoacidosis is caused by excessive alcohol use. It is most often seen in a malnourished person who drinks large amounts of alcohol every day. Abdominal pain Altered level of alertness, which may lead to coma (unresponsiveness) Fatigue Slow, sluggish, lethargic movement Irregular deep, rapid breathing (Kussmaul's sign) Loss of appetite Nausea and vomiting Symptoms of dehydration, such as dizziness and light-headedness Arterial blood gases Blood alcohol level Blood chemistries, such as CHEM-20 Toxicology (poison) screening Prompt medical attention improves the overall outlook. If you or someone else has symptoms of alcoholic ketoacidosis, seek emergency medical help. This can be a life-threatening disorder. Patients with alcoholic ketoacidosis often have or develop gastrointestinal bleeding, pancreatitis (inflammation of the pancreas), and pneumonia. Treatment may involve fluids (salt and sugar solution) given through a vein. You may need to have your blood taken frequently. People with this condition are admitted to the hospital, often to the intensive care unit (ICU). Cho KC, Fukagawa M, Kurokawa K. Fluid and electrolyte disorders. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment. 48th ed. New York, NY: McGraw-Hill; 2009:chap 21. DuBose TD Jr. Acidosis and alkalosis. In: Fauci A , Kasper D, Longo DL, et al, eds. Harrison's Principals of Internal Medicine. 17th ed. New York, NY: McGraw Hill; 2008:chap 48. Reviewed By: Jacob L. Heller, MD, Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington, Clinic. Also reviewed by David Zi Continue reading >>
Alcoholic Ketoacidosis
Background In 1940, Dillon and colleagues first described alcoholic ketoacidosis (AKA) as a distinct syndrome. AKA is characterized by metabolic acidosis with an elevated anion gap, elevated serum ketone levels, and a normal or low glucose concentration. [1, 2] Although AKA most commonly occurs in adults with alcoholism, it has been reported in less-experienced drinkers of all ages. Patients typically have a recent history of binge drinking, little or no food intake, and persistent vomiting. [3, 4, 5] A concomitant metabolic alkalosis is common, secondary to vomiting and volume depletion (see Workup). [6] Treatment of AKA is directed toward reversing the 3 major pathophysiologic causes of the syndrome, which are: This goal can usually be achieved through the administration of dextrose and saline solutions (see Treatment). Continue reading >>
Profound Alcoholic Ketoacidosis In Pregnancy With Survival Of The Fetus
Case report A 31 year old woman, who had booked at 12 weeks of gestation, presented at 27 weeks with sudden onset over the previous eight hours of constant, generalised abdominal pain which radiated to the back. She had been vomiting heavily during the preceding day. In the previous week she had been consuming between one and two bottles of vodka daily, but had stopped drinking at the onset of vomiting. She denied any drug ingestion. There was a history of longstanding alcohol abuse and she had developed acute alcoholic hepatitis with renal failure two years previously. Her hepato-renal function had subsequently recovered and she had been discharged from follow up. At booking she had denied drinking alcohol. Maternal serum alpha-fetoprotein was elevated, but a detailed ultrasound scan at 18 weeks of gestation demonstrated a structurally normal infant. On examination she was distressed, hyperventilating and was clinically dehydrated. She was not jaundiced and vital observations were normal. There was generalised abdominal tenderness but no loin pain. Chest X-ray was normal; Table 1 shows the biochemical results. Specifically, serum bicarbonate was < 5 mmol/L and the arterial blood gases on air showed: [H+] of 91 nmol/L (PH of 7.04) and a P co2 of 0.92 kPa (7 mmHg). The calculated anion gap was 35 mmol/L (normal 8–16 mol/L). Serum salicylate was unrecordable, the estimated serum alcohol was negligible, and the coagulation screen was normal. Urine analysis demonstrated ketonuria and the absence of protein and glucose. Table 1. Serial biochemistry, haematology and blood gas measurements for admission at 27 weeks of gestation. Values in brackets below main values show conversion to SI units. Reference range +0 h +4 h +13 h +20 h +24 h +9 days PH 7.35–7.45 7.04 7.08 7.21 Continue reading >>
Alcoholic Ketoacidosis
Ketoacidosis - alcoholic Alcoholic ketoacidosis is the buildup of ketones in the blood. Ketones are a type of acid that form when the body breaks down fat for energy. Causes Alcoholic ketoacidosis is caused by very heavy alcohol use. It most often occurs in a malnourished person who drinks large amounts of alcohol every day. Symptoms Symptoms of alcoholic ketoacidosis include: Nausea and vomiting Abdominal pain Changed level of alertness, which may lead to coma Slow, sluggish movements Loss of appetite Exams and Tests Tests may include: Arterial blood gases (measure the acid/base balance and oxygen level in blood) Blood alcohol level Blood chemistries, and liver function tests CBC (complete blood count, measures red and white blood cells, and platelets, which help blood to clot) Prothrombin time (PT, a different measure of blood clotting, often abnormal from liver disease) Toxicology (poison) screening Treatment Treatment may involve fluids (salt and sugar solution) given through a vein. You may need to have frequent blood tests. You may get vitamin supplements to treat nutritional deficiencies caused by excess alcohol use. People with this condition are usually admitted to the hospital, often to the intensive care unit (ICU). Additional medicines may be given to prevent alcohol withdrawal. Outlook (Prognosis) Prompt medical attention improves the overall outlook. How severe the alcoholism is, and the presence of liver disease or other problems, may also affect the outlook. Possible Complications This can be a life-threatening condition. Complications may include: When to Contact a Medical Professional If you or someone else has symptoms of alcoholic ketoacidosis, seek emergency medical help. Prevention Limiting the amount of alcohol you drink may help prevent this cond Continue reading >>
Fasting Ketosis And Alcoholic Ketoacidosis
INTRODUCTION Ketoacidosis is the term used for metabolic acidoses associated with an accumulation of ketone bodies. The most common cause of ketoacidosis is diabetic ketoacidosis. Two other causes are fasting ketosis and alcoholic ketoacidosis. Fasting ketosis and alcoholic ketoacidosis will be reviewed here. Issues related to diabetic ketoacidosis are discussed in detail elsewhere. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment".) PHYSIOLOGY OF KETONE BODIES There are three major ketone bodies, with the interrelationships shown in the figure (figure 1): Acetoacetic acid is the only true ketoacid. The more dominant acid in patients with ketoacidosis is beta-hydroxybutyric acid, which results from the reduction of acetoacetic acid by NADH. Beta-hydroxybutyric acid is a hydroxyacid, not a true ketoacid. Continue reading >>
Chapter 221. Alcoholic Ketoacidosis
Woods WA, Perina DG. Woods W.A., Perina D.G. Woods, William A., and Debra G. Perina.Chapter 221. Alcoholic Ketoacidosis. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T Eds. Judith E. Tintinalli, et al.eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e New York, NY: McGraw-Hill; 2011. Accessed March 27, 2018. Woods WA, Perina DG. Woods W.A., Perina D.G. Woods, William A., and Debra G. Perina.. "Chapter 221. Alcoholic Ketoacidosis." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2011, Alcoholic ketoacidosis is a wide anion gap metabolic acidosis most often associated with acute cessation of alcohol consumption after chronic alcohol abuse and is typically associated with nausea, vomiting, and vague GI complaints. 1 Alcohol metabolism combined with little or no glycogen reserves results in elevated ketoacid levels. Although alcoholic ketoacidosis is usually seen in chronic alcoholics, it has been described in first-time binge drinkers. Repeated episodes can occur. 2 Although with proper treatment this illness is self limited, death has been reported from presumed excessive ketonemia. 24 Ethanol metabolism requires nicotinamide adenine dinucleotide (NAD) and the enzymes alcohol dehydrogenase and aldehyde dehydrogenase to convert ethanol to acetyl coenzyme A. Acetyl coenzyme A may be metabolized directly, resulting in ketoacid production, used as substrate for the Krebs cycle, or used for free fatty acid synthesis ( Figu Continue reading >>
Ketoacidosis
Alcoholic ketoacidosis is a severe metabolic complication due to long-term alcohol consumption. The disease is the accumulation of ketones in the blood. Ketones are the by-product of the body when it breaks down fat for energy. A person who drinks alcohol every day can often be malnourished. One of the main reasons for getting the disease is the clear effects of alcoholism and starvation. In this condition, starvation means the glucose starvation of metabolism. Ketoacidosis from alcoholism should be a tigger that you need to seek alcohol addiction treatment. What causes Alcoholic Ketoacidosis? Long-term very heavy alcohol consumption will cause the disease. Prolonged alcohol abuse may cause malnutrition; the combination of these two may lead to Alcoholic Ketoacidosis. How does the body metabolize? For the body to function properly, the cells need glucose (sugar) and insulin. The body can produce glucose when it digests the food, and the pancreas produces insulin. However, when a person drinks alcohol, the pancreas may stop producing insulin for a brief period. Without insulin, the cell cannot produce glucose for the energy that the body needs. To replenish itself with the energy it will start to burn fat. Once the body turns fat for energy, it will produce ketones. Once the body stops producing insulin for long period due to alcohol intake, ketones will start to accumulate in the bloodstream. This buildup will eventually lead to a severe condition called ketoacidosis. Here are the important events when a person drinks heavy for a long period of time: Also, people who drink too much alcohol may not eat properly and regularly. Most often they vomit frequently because of the alcohol intake. Not eating properly and vomiting may result in starvation. Whenever this happens, t Continue reading >>
Alcoholic Ketoacidosis: A Case Report And Review Of The Literature
Go to: CASE REPORT We present a 64-year-old female who presented with generalized abdominal pain, nausea, vomiting and shortness of breath. Arterial blood gas analysis showed significant acidaemia with a pH of 7.10, bicarbonate of 2.9 mmol/l and lactate of 11.7 mmol/l. Serum ketones were raised at 5.5 mmol/l. Capillary blood glucose was noted to 5.8 mmol/l. The anion gap was calculated and was elevated at 25 mmol/l. The diagnosis of DKA was queried after initial triage. However, following senior medical review, given a recent history of drinking alcohol to excess, the diagnosis of AKA was felt more likely. Whilst a decreased conscious level may have been expected, our patient was lucid enough to report drinking one to two bottles of wine per day for the past 30 years, with a recent binge the day prior to admission. Subsequent fluid resuscitation and monitoring were instituted. Further biochemical investigation after treatment showed a rapid decline in the level of ketones and normalization of pH. Our patient had a multidisciplinary team (MDT) looking after her care, whilst she was an inpatient, including acute medical and gastroenterology doctors and nurses, dietitians, alcohol specialist nurse, physiotherapists and occupational therapists. Following resuscitation, our patient had plasma electrolyte levels corrected, nutritional supplementation provided and completed an alcohol detoxification regimen. Given the early recognition of AKA and concurrent management, our patient had a good outcome. She was discharged home and has been well on follow-up appointments. Continue reading >>
Alcoholic Ketoacidosis
Workup When a chronic alcoholic presents with signs of AKA, the clinician should carefully evaluate the patient, obtain a history, perform a physical exam, and order the appropriate laboratory tests. Laboratory tests and results A comprehensive metabolic profile will allow the medical team to determine the overall clinical picture of the patient. This includes measurement of serum electrolytes, glucose, blood urea nitrogen (BUN), creatinine, lipase, amylase, and plasma osmolality. Also, urinalysis is helpful to detect ketones. Another useful tool is the blood alcohol level [8]. Finally, critically ill patients with positive ketones must have an analysis of their arterial blood gas (ABG) and serum lactate levels. With regards to expected findings, all patients demonstrate ketonuria and a majority display ketonemia. Also common are electrolyte imbalances such as hypokalemia, hyponatremia, hypophosphatemia, and hypomagnesemia. Additionally, the serum glucose may range from low to modest elevation while another abnormality is an increased osmolar gap (secondary to increased acetone and possibly ethanol). Most importantly, AKA is typically characterized by a high anion gap metabolic acidosis, which may be complicated by metabolic alkalosis secondary to concurrent vomiting. In cases where the pH is normal, the increased anion gap is an indicator of ketoacidosis. If there is a normal gap, this is the result of the excretion of ketoacid ions. Additionally, lactic acidosis is observed in more than 50% of cases due to hypoperfusion [9]. Differential diagnoses Differentials include diabetic ketoacidosis (DKA),however, the absence of hyperglycemia excludes this. Pancreatitis may also present similar to AKA and should be ruled out. If alcohol intoxication is not conclusive, serum me Continue reading >>
Alcoholic Ketoacidosis: Causes, Symptoms, Treatment, Prognosis
Ketoacidosis is a medical condition in which the food that is ingested by an individual is either metabolized or converted into acid. Alcoholic Ketoacidosis is a condition in which there is development of Ketoacidosis as a result of excessive alcohol intake for a long period of time and less ingestion of food resulting in malnutrition. Drinking excessive alcohol causes the individual to be able to eat less food. Additionally, if excess alcohol is ingested then it may lead to vomiting which further worsens the nutritional status of the individual which results in formation of excess acids resulting in Alcoholic Ketoacidosis. The symptoms caused by Alcoholic Ketoacidosis include abdominal pain, excessive fatigue, persistent vomiting, and the individual getting dehydrated due to frequent vomiting episodes and less fluid intake. If an individual has a history of alcohol abuse and experiences the above mentioned symptoms then it is advised that the individual goes to the nearest emergency room to get evaluated and if diagnosed treated for Alcoholic Ketoacidosis. As stated above, the root cause of Alcoholic Ketoacidosis is drinking excessive amounts of alcohol for a prolonged period of time. When an individual indulges in binge drinking he or she is not able to take in enough food that is required by the body to function. This eventually results in malnourishment. Additionally, vomiting caused by excessive drinking also results in loss of vital nutrients and electrolytes from the body such that the body is not able to function normally. This results in the insulin that is being produced by the body becoming less and less. All of these ultimately results in the development of Alcoholic Ketoacidosis. An individual may develop symptoms within a day after binge drinking, dependin Continue reading >>
Alcoholic Ketoacidosis
Alternative Names: Ketoacidosis - alcoholic Causes, incidence, and risk factors: Alcoholic ketoacidosis is caused by excessive alcohol use. It is most often seen in a malnourished person who drinks large amounts of alcohol every day. Symptoms: Abdominal pain Changed level of alertness, which may lead to coma Fatigue Slow, sluggish, lethargic movement Irregular deep, rapid breathing (Kussmaul's sign) Loss of appetite Nausea and vomiting Symptoms of dehydration , such as dizziness, light-headedness, and thirst Treatment: Treatment may involve fluids (salt and sugar solution) given through a vein. You may need to have your blood taken often. You may get vitamin supplements to treat nutritional deficiencies caused by excess alcohol use. People with this condition are admitted to the hospital, often to the intensive care unit (ICU). Expectations (prognosis): Prompt medical attention improves the overall outlook. How severe the alcoholism is, and the presence of liver disease or other complications also affect the outlook. Calling your health care provider: If you or someone else has symptoms of alcoholic ketoacidosis, seek emergency medical help. Prevention: Limiting the amount of alcohol you drink may help prevent this condition. References: Cho KC, Fukagawa M, Kurokawa K. Fluid and electrolyte disorders. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment. 48th ed. New York, NY: McGraw-Hill; 2009:chap 21. DuBose TD Jr. Acidosis and alkalosis. In: Fauci A , Kasper D, Longo DL, et al, eds. Harrison's Principals of Internal Medicine. 17th ed. New York, NY: McGraw Hill; 2008:chap 48. Wiener SW, Hoffman RS. Alcoholic ketoacidosis. In: Wolfson Ab, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, Pa Continue reading >>
Metabolic Abnormalities In Alcoholic Patients: Focus On Acid Base And Electrolyte Disorders
1Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece 2Department of Internal Medicine, Medical School, University of Ioannina, 451 10, Ioannina, Greece *Corresponding Author: Moses Elisaf Professor of Internal Medicine Department of Medicine, Medical School University of Ioannina 451 10 Ioannina, Greece Tel: +302651007509 Fax: +302651007016 E-mail: [email protected], [email protected] Citation: Moses Elisaf MD, Rigas Kalaitzidis MD (2015) Metabolic Abnormalities in Alcoholic Patients: Focus on Acid Base and Electrolyte Disorders. J Alcohol Drug Depend 3:185. doi:10.4172/2329-6488.1000185 Copyright: ©2015 Moses Elisaf MD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Visit for more related articles at Journal of Alcoholism & Drug Dependence Abstract Alcoholic patients commonly develop a variety of acid-base and electrolyte disturbances. The aim of this review is to describe the most commonly encountered abnormalities and their significant role in the patients’ morbidity and mortality. Physicians should be aware of these clinically important disturbances caused by alcohol abuse and their underlying pathophysiological mechanisms involved for their appropriate management. Alcoholic Keto Acidosis (AKA) is a medical emergency is more common than previously thought and is characterized by an increased anion gap metabolic acidosis. However, in AKA mixed acid-base disorders are commonly observed. Alcoholic patients also exhibit severe electrolyte derangements. Multifactorial origin hypomagnesaemia is the most common electrolyte abnormality observed. Hypocalca Continue reading >>
Alcoholic Ketoacidosis
Alternative Names: Ketoacidosis - alcoholic Causes, incidence, and risk factors: Alcoholic ketoacidosis is caused by excessive alcohol use. It is most often seen in a malnourished person who drinks large amounts of alcohol every day. Symptoms: Abdominal pain Changed level of alertness, which may lead to coma Fatigue Slow, sluggish, lethargic movement Irregular deep, rapid breathing (Kussmaul's sign) Loss of appetite Nausea and vomiting Symptoms of dehydration , such as dizziness, light-headedness, and thirst Treatment: Treatment may involve fluids (salt and sugar solution) given through a vein. You may need to have your blood taken often. You may get vitamin supplements to treat nutritional deficiencies caused by excess alcohol use. People with this condition are admitted to the hospital, often to the intensive care unit (ICU). Expectations (prognosis): Prompt medical attention improves the overall outlook. How severe the alcoholism is, and the presence of liver disease or other complications also affect the outlook. Calling your health care provider: If you or someone else has symptoms of alcoholic ketoacidosis, seek emergency medical help. Prevention: Limiting the amount of alcohol you drink may help prevent this condition. References: Cho KC, Fukagawa M, Kurokawa K. Fluid and electrolyte disorders. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment. 48th ed. New York, NY: McGraw-Hill; 2009:chap 21. DuBose TD Jr. Acidosis and alkalosis. In: Fauci A , Kasper D, Longo DL, et al, eds. Harrison's Principals of Internal Medicine. 17th ed. New York, NY: McGraw Hill; 2008:chap 48. Wiener SW, Hoffman RS. Alcoholic ketoacidosis. In: Wolfson Ab, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, Pa Continue reading >>
