Alcoholic Starvation Ketoacidosis

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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 alcoho Continue reading >>

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  1. FlyingPig

    I've been experimenting with a ketogenic diet recently. I've kept my diet pretty low carb for the last 5 days (after eating quite a lot of fruit 17th and 18th August), although I am not sure I ever went into ketosis.
    Anyway, this is just some context as I think it may be related. I woke up with some discomfort in my left kidney area this morning. The Internet being the Internet, I only get more confused when reading up. Too much calcium, too little calcium, kidney stones?
    A few ideas: I had (frozen) spinach 2 days in a row (pretty much my only carbs) and also had cheese (Brie and Danish Blue). Also about 20 hazelnuts. I haven't had cheese in a while. Could the calcium in the spinach and cheese have anything to do with this?
    I've also been supplementing with vitamin D (5000UI) for the last month or so as we don't get much sun over here at all. Vitamin D consumption also seems to be linked to kidney stones.
    Would appreciated some feedback from people who have any advice.

  2. Penady

    A few months ago I had the same kind of symptoms. I had been having a BAS every day for lunch with baby spinach as my greens. I had to cut back on the spinach because I think it was the extra calcium and my kidney's were overworked. I didn't have a kidney stone or an infection. I just changed up my salad greens and I was all better. Not sure if this is exactly what is happening to you, but it could be similar.

  3. Neckhammer

    Dont completely rule out musculoskeletal issues. Any previous injuries to the area? Previous back, spine, or kidney issues? Does it hurt more in certain positions? More upon certain movements? Have you had noticeable change in urinary output? Are you dehydrated? What makes the pain better?
    Just a few of the pertinent questions to a good history here.

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What is DIABETIC KETOACIDOSIS? What does DIABETIC KETOACIDOSIS mean? DIABETIC KETOACIDOSIS meaning - DIABETIC KETOACIDOSIS definition - DIABETIC KETOACIDOSIS explanation. Source: Wikipedia.org article, adapted under https://creativecommons.org/licenses/... license. SUBSCRIBE to our Google Earth flights channel - https://www.youtube.com/channel/UC6Uu... Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness. A person's breath may develop a specific smell. Onset of symptoms is usually rapid. In some cases people may not realize they previously had diabetes. DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances. Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids. DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies. DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine. The primary treatment of DKA is with intravenous fluids and insulin. Depending on the severity, insulin may be given intravenously or by injection under the skin. Usually potassium is also needed to prevent the development of low blood potassium. Throughout treatment blood sugar and potassium levels should be regularly checked. Antibiotics may be required in those with an underlying infection. In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended. Rates of DKA vary around the world. About 4% of people with type 1 diabetes in United Kingdom develop DKA a year, while in Malaysia the condition affects about 25% a year. DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost universally fatal. The risk of death with adequate and timely treatment is currently around 1–4%. Up to 1% of children with DKA develop a complication known as cerebral edema. The symptoms of an episode of diabetic ketoacidosis usually evolve over a period of about 24 hours. Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine production and abdominal pain that may be severe. Those who measure their glucose levels themselves may notice hyperglycemia (high blood sugar levels). In severe DKA, breathing becomes labored and of a deep, gasping character (a state referred to as "Kussmaul respiration"). The abdomen may be tender to the point that an acute abdomen may be suspected, such as acute pancreatitis, appendicitis or gastrointestinal perforation. Coffee ground vomiting (vomiting of altered blood) occurs in a minority of people; this tends to originate from erosion of the esophagus. In severe DKA, there may be confusion, lethargy, stupor or even coma (a marked decrease in the level of consciousness). On physical examination there is usually clinical evidence of dehydration, such as a dry mouth and decreased skin turgor. If the dehydration is profound enough to cause a decrease in the circulating blood volume, tachycardia (a fast heart rate) and low blood pressure may be observed. Often, a "ketotic" odor is present, which is often described as "fruity", often compared to the smell of pear drops whose scent is a ketone. If Kussmaul respiration is present, this is reflected in an increased respiratory rate.....


GENERAL ketoacidosis is a high anion gap metabolic acidosis due to an excessive blood concentration of ketone bodies (keto-anions). ketone bodies (acetoacetate, beta-hydroxybutyrate, acetone) are released into the blood from the liver when hepatic lipid metabolism has changed to a state of increased ketogenesis. a relative or absolute insulin deficiency is present in all cases. CAUSES The three major types of ketosis are: (i) Starvation ketosis (ii) Alcoholic ketoacidosis (iii) Diabetic ketoacidosis STARVATION KETOSIS when hepatic glycogen stores are exhausted (eg after 12-24 hours of total fasting), the liver produces ketones to provide an energy substrate for peripheral tissues. ketoacidosis can appear after an overnight fast but it typically requires 3 to 14 days of starvation to reach maximal severity. typical keto-anion levels are only 1 to 2 mmol/l and this will usually not alter the anion gap. the acidosis even with quite prolonged fasting is only ever of mild to moderate severity with keto-anion levels up to a maximum of 3 to 5 mmol/l and plasma pH down to 7.3. ketone bodies also stimulate some insulin release from the islets. patients are usually not diabetic. ALCOHOLIC KE Continue reading >>

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  1. Rcroix

    Hello everyone.
    I have been on the 2:5 for about 6 months and lost about 10kg (over 20lbs) So thank you Dr Mosley!
    A lot of the reviews of the fasting lifesyle seem to suggest that it is just a way to reduce average weekly calories, but I’m sure most of you think there is more going on than simple calorie reduction.
    During the last 10 days I didn’t fast as I was on holiday traveling and found it difficult. Amazingly I did not gain any weight. This has happend on two occasions during the last 6 months.
    I think the fasting days are forcing the body to relearn how to burn fat. I’m a bit confused about the correct scientific terms for this ‘lypolysis’ is I believe the breackdown of fats (into amino acids) and ketosis the burning of
    fat as fuel.
    What ever the terminology it seems like the fasting days teach the body a long forgotten trick of switching from available glucose derived from what we just ate, to reserves stored as fat.
    I suggest that this trait applies to non fast days too, hence the lack of weigh gain during holidays.
    I used to do a bit of distance running and am quite familiar with the concept of ‘hitting the wall’. This is when a runner runs out of glucose and has to switch to fat burning (around the 18mile mark). Often that process is difficult, I have had to sit on the ground for about 3 minutes until my legs felt like they would work again.
    I’m not running now so I can’t try a quick marathon to see if the diet has helped with the switch.
    I welcome your thoughts.
    Good luck
    Perhaps Dr Mosely could weigh in on this with some scientific evidence.

  2. zec4peach

    I love science and this is why I love the 5.2 as it makes so much sense.
    Your body will go into ketosis when fasting for a short time, this is probably why some people get headaches. It will also make you very thirsty and wee a lot as your body tries to flush out the by products from fat metabolism. This is a common symptom of type 1 diabetes but obviously they go into a severe more ketoacidosis due to prolonged lack of insulin and metabolism of glucose and start burning muscle for fuel.
    It’s quite complicated stuff but if you google fasting ketosis there’s loads of interesting info online. Michaels book was lacking in any science stuff which is a shame as I think people are interested.
    I know that athletes or very fit people are more efficient at burning fat as they are used to it so yes I think the 5.2 does reset the metabolism in a similar way.
    I have managed to this this after years of cycling and find I can ride for a few hours on an empty stomach. Always need coffee though !!!

  3. Nika

    Hey Martin!
    I’m also very interested in ketosis. I tried it out a few weeks ago and didn’t eat any carbs for 1,5 week. I lost quite some weight, but felt like I couldn’t sustain it – I started feeling really weak, dizzy, couldn’t walk straight some days and all in all didn’t get the energy boosts some people boast about.
    So now I just cut carbs on my fast days and allow myself fruit and yoghurt on normal days – still prefer not to eat rice, noodles, bread and potatoes though. Sometimes a baked good or chocolate pudding as a treat, but not regularly. I do think this really contributes to my quicker than average weightloss (7kg in 3 weeks, of which most during that first 1,5 week).
    I’ve also started working out fasted. I do this after work before my only meal of the day, so after fasting for over 20 hours. I do HIIT (Insanity), which combines cardio and strength through bodyweight exercises. So far my results have been worse than when I did the program before when eating regularly, but I’m waiting to see how it goes in two weeks when I do my second fit test. My body is most likely also learning how to switch to burning fat efficiently.
    What you said about going on a holiday, this reminded me of the “carb loaders” I know. They basically cut carbs during the week, then they “carbload” on Saturday – eating everything from pizza to ribs to whatever they want. They say that it doesn’t cause them to gain weight, because the body is still in fat burning mode and the glucose from the carbs goes straight to the muscles, giving the muscles the strength to keep working out through the next week. Hence carb ‘loading’. These people are basically in ketosis 3 days a week (it usually takes the body about 3 days to go into full ketosis).
    These are all bodybuilder types though, who do mostly strength training so it doesn’t really sound like a great idea for me. I wanna be lean, not buff.
    Anyway, long post – gonna head over to the next one

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What is KETOACIDOSIS? What does KETOACIDOSIS mean? KETOACIDOSIS meaning - KETOACIDOSIS definition - KETOACIDOSIS explanation. Source: Wikipedia.org article, adapted under https://creativecommons.org/licenses/... license. SUBSCRIBE to our Google Earth flights channel - https://www.youtube.com/channel/UC6Uu... Ketoacidosis is a metabolic state associated with high concentrations of ketone bodies, formed by the breakdown of fatty acids and the deamination of amino acids. The two common ketones produced in humans are acetoacetic acid and ß-hydroxybutyrate. Ketoacidosis is a pathological metabolic state marked by extreme and uncontrolled ketosis. In ketoacidosis, the body fails to adequately regulate ketone production causing such a severe accumulation of keto acids that the pH of the blood is substantially decreased. In extreme cases ketoacidosis can be fatal. Ketoacidosis is most common in untreated type 1 diabetes mellitus, when the liver breaks down fat and proteins in response to a perceived need for respiratory substrate. Prolonged alcoholism may lead to alcoholic ketoacidosis. Ketoacidosis can be smelled on a person's breath. This is due to acetone, a direct by-product of the spontaneous decomposition of acetoacetic acid. It is often described as smelling like fruit or nail polish remover. Ketosis may also smell, but the odor is usually more subtle due to lower concentrations of acetone. Treatment consists most simply of correcting blood sugar and insulin levels, which will halt ketone production. If the severity of the case warrants more aggressive measures, intravenous sodium bicarbonate infusion can be given to raise blood pH back to an acceptable range. However, serious caution must be exercised with IV sodium bicarbonate to avoid the risk of equally life-threatening hypernatremia. Three common causes of ketoacidosis are alcohol, starvation, and diabetes, resulting in alcoholic ketoacidosis, starvation ketoacidosis, and diabetic ketoacidosis respectively. In diabetic ketoacidosis, a high concentration of ketone bodies is usually accompanied by insulin deficiency, hyperglycemia, and dehydration. Particularly in type 1 diabetics the lack of insulin in the bloodstream prevents glucose absorption, thereby inhibiting the production of oxaloacetate (a crucial molecule for processing Acetyl-CoA, the product of beta-oxidation of fatty acids, in the Krebs cycle) through reduced levels of pyruvate (a byproduct of glycolysis), and can cause unchecked ketone body production (through fatty acid metabolism) potentially leading to dangerous glucose and ketone levels in the blood. Hyperglycemia results in glucose overloading the kidneys and spilling into the urine (transport maximum for glucose is exceeded). Dehydration results following the osmotic movement of water into urine (Osmotic diuresis), exacerbating the acidosis. In alcoholic ketoacidosis, alcohol causes dehydration and blocks the first step of gluconeogenesis by depleting oxaloacetate. The body is unable to synthesize enough glucose to meet its needs, thus creating an energy crisis resulting in fatty acid metabolism, and ketone body formation.

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis Damian Baalmann, 2nd year EM resident A 45-year-old male presents to your emergency department with abdominal pain. He is conscious, lucid and as the nurses are hooking up the monitors, he explains to you that he began experiencing abdominal pain, nausea, vomiting about 2 days ago. Exam reveals a poorly groomed male with dry mucous membranes, diffusely tender abdomen with voluntary guarding. He is tachycardic, tachypneic but normotensive. A quick review of the chart reveals a prolonged history of alcohol abuse and after some questioning, the patient admits to a recent binge. Pertinent labs reveal slightly elevated anion-gap metabolic acidosis, normal glucose, ethanol level of 0, normal lipase and no ketones in the urine. What are your next steps in management? Alcoholic Ketoacidosis (AKA): What is it? Ketones are a form of energy made by the liver by free fatty acids released by adipose tissues. Normally, ketones are in small quantity (<0.1 mmol/L), but sometimes the body is forced to increase its production of these ketones. Ketones are strong acids and when they accumulate in large numbers, their presence leads to an acidosis. In alcoholics, a combination o Continue reading >>

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  1. JeiCR

    I am sad to discover that I must stop doing 5:2 intermittent fasting because it appears to have caused my blood pressure to become uncontrollably high. I had lost 10 pounds (4.5 kg) over the course of 12 weeks, which I was very happy about. I found the program to be very easy, and the hunger pangs not that difficult to endure, and was enjoying the results of the program so much that I did not want to believe that my steadily rising blood pressure could be caused by 5:2. I am a 53 year old female who has been controlling my tendency toward high blood pressure through weight loss, diet, and exercise. My BMI was on the upper half of the healthy range when I started the fast diet, but I wanted to start training to run a 5k, and thought it would be helpful to first lose some unnecessary weight I was carrying. My goal was to lose 15 pounds (6.8 kg)…still keeping my BMI within the healthy range. I was, fortunately, keeping an eye on my BP with my home blood pressure monitor, had I not been monitoring it, I would not have known it had reached over 180/100! For the first time in my life I had to go on blood pressure medication! Even then, the medication still was not keeping it under control. My husband pointed out that the only change I had made was the 5:2 diet, so I reluctantly stopped, and after about a week my blood pressure returned to normal, and is still normal now, after two weeks. I am very relieved, as it was quite scary to have it so out of control, but at the same time I am disappointed because the Fast Diet had been such an easy way for me to lose weight. I still have 5(2.3 kg) pounds to go, and at least want maintain the weight I have lost, so I need to figure out a plan that doesn’t involve fasting. I don’t know for certain why 5:2 was apparently raising my BP, but it vaguely felt as if the level of stress hormones in my body kept rising over time the longer I was on the diet, my pulse had also been higher than normal. I am wondering if anyone else has experienced this problem?

  2. char6

    Hi, JeiCR. I am a doctor, and that really does sound strange! Do you think extra sodium could have been sneaking into your diet, such as in soups? Or a lot of extra caffeine? Were you taking a decongestant medication, by any chance, or any weight loss supplements that could contain stimulants? Are your ankles swelling a lot, in which case you would need to get your kidneys checked? (I know you said nothing else had changed, but just checking.)
    What is your current BMI? Could it be that you are stressing your body by trying to force it too low (although I don’t think I have ever heard of such a thing)?
    If your BMI is well within the normal range, maybe you could maintain your loss just by training for the 5K, or by fasting only 6:1.

  3. SAMM

    I don’t have a medical opinion.
    Im wondering about wether you were close to your TDEE on non fasting days. Also curious as to the foods on fasting days and feeding days.
    The only thing I can think of is your protein intake may need to be spread out.
    Again not advice I understand having 25g 25g 25g of protein on feed days has an effect on the vascular system. Is the new standard.
    This points to the type of protein intake I use on fasting days. I use non flavored whey protein as it is said in general to metabolize quicker for the the body to use. On fasting days I aim for 10g 10g 10g when planning my menu.
    On another note if what’s happening to you was happening to me. I would make sure to get a Flu shot. Reason is typically having the flu increases inflammation. There is a greater percentage of heart attacks occurring when having the flu. Avoiding 30 flu strains over ten years lowers to exposer to the inflamation caused by flu. Your 50% less likely over ten years to have heart attack. So wether it’s 5:2 or losing weight in any other way cholesterol lvl may raise when fat is released for energy. So there could be a combination of conditions to keep watch over. Inflamatory foods, flu inflammation, elevated blood pressure. So If it were me I would be more sedentary on fasting days, but eating anti inflammatory foods on feed day especially.
    Here’s a link to a list of the most anti inflammatory foods and their nutrition data.
    Again I can’t be more clear about the fact that I can’t give any medical advice whatsoever. I’m not qualified at all. I do however have an opion that what is on my fork is just as important to consider as medication. Especially when were prone to health issues.
    I’ll make a huge guess and wild assumption. If I eat a fry up , of greasy greasy greasy ,bacon,sausage,burger,BBQ. Just as poor fat as possible, and flood my blood with fat. I may also influence the level of fat in my blood by eating lower fat protein such as whey protein.
    I go as far to boil my chicken breast in water and skim off the fat before I put it in my chicken soup when I have the flu.
    The biggest change I’ve made since watching The Truth About Exercise. Is to do better on my N.E.A.T, trying to also become healthy enough to accomplish H.I .T.T. So I can do it regularly. My experience trying this has made me more conscious about my meals , how to enjoy what’s good for me even more that what’s bad.
    Best wishes hope to see you around for five more decades.

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