Alcoholic Ketoacidosis Clinical Presentation

  • Author: George Ansstas, MD; Chief Editor: George T Griffing, MD   more...
 
Updated: May 19, 2011
 

History

Patients with alcoholic ketoacidosis (AKA) almost always are alcoholics who, prior to the development of ketoacidosis, have engaged in a period of very heavy drinking, with subsequent abrupt cessation of alcohol consumption 1-2 days before presentation. Such presentations typically result from physical complaints, such as the following:

  • Nausea, vomiting, and abdominal pain (each found in 60-75% of patients)
  • Dyspnea, tremulousness, and/or dizziness (10-20% each)
  • Muscle pain, diarrhea, syncope, and seizure (1-8% each)
  • Hematemesis or melena

These symptoms usually are attributed to alcoholic gastritis or pancreatitis.

Example case of alcoholic ketoacidosis: A 35-year-old man who chronically abuses alcohol presents with abdominal pain and intractable emesis for the past 2 days. The pain and emesis developed after 5 days of heavy drinking. Since their onset, he stopped eating and drinking altogether. He complains of epigastric pain that radiates through to his back. He is afebrile, tachycardic, and borderline hypotensive. He is sleepy, but awakens easily to verbal stimuli.

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Physical Examination

Generally, the physical findings relate to volume depletion and chronic alcohol abuse. Typical characteristics of the latter may include rhinophyma, tremulousness, hepatosplenomegaly, peripheral neuropathy, gynecomastia, testicular atrophy, and palmar erythema. The patient might be tachycardic, tachypneic, profoundly orthostatic, or frankly hypotensive as a result of dehydration from decreased oral intake, diaphoresis, and vomiting.

The patient's breath may carry the fruity odor of ketosis. Tachypnea in the form of the Kussmaul respiration varieties is usually present when the pH is less than 7.2.[9]

Hypothermia is common in AKA. A fever can be a sign of an underlying infectious process.

Abdominal tenderness consistent with a diagnosis of alcoholic liver disease, pancreatitis, gastritis, or peptic ulcer disease may be found on abdominal examination and may mimic an abdominal emergency. Hemoccult-positive stools may be present.

Mental status may be normal or slightly impaired as a result of derangements in electrolytes or vital signs. Severe obtundation; fixed, dilated pupils; and finally, death may occur.

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Complications

Complications associated with AKA include the following:

  • Seizures
  • Life-threatening arrhythmias
  • Cardiac arrest[12, 13]
  • Shock
  • Infection
  • Pulmonary edema
  • Delirium tremens
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Contributor Information and Disclosures
Author

George Ansstas, MD  Chief Resident, Department of Internal Medicine, St Louis University Hospital; Assistant Professor, Department of Internal Medicine, St Louis University School of Medicine

George Ansstas, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Irina Robinson  MD, Fellow, Department of Endocrinology and Metabolism, University of New Mexico School of Medicine and Health Sciences Center

Irina Robinson is a member of the following medical societies: American Association of Clinical Endocrinologists and American College of Physicians

Disclosure: Nothing to disclose.

Sofya M Rubinchik, MD  Consulting Staff, Department of Behavioral Health, Lovelace Medical Center

Sofya M Rubinchik, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, American Neuropsychiatric Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

David S Schade, MD  Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS  Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Nutrition, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

References

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  5. Al-Sanouri I, Dikin M, Soubani AO. Critical care aspects of alcohol abuse. South Med J. Mar 2005;98(3):372-81. [Medline].

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  8. Iten PX, Meier M. Beta-hydroxybutyric acid -- an indicator for an alcoholic ketoacidosis as cause of death in deceased alcohol abusers. J Forensic Sci. May 2000;45(3):624-32. [Medline].

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  11. Ngatchu T, Sangwaiya A, Dabiri A, et al. Alcoholic ketoacidosis with multiple complications: a case report. Emerg Med J. Nov 2007;24(11):776-7. [Medline].

  12. Diltoer MW, Troubleyn J, Lauwers R, et al. Ketosis and cardiac failure: common signs of a single condition. Eur J Emerg Med. Jun 2004;11(3):172-5. [Medline].

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  15. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. May 22 2003;348(21):2074-81. [Medline].

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  19. Kelly AM. The case for venous rather than arterial blood gases in diabetic ketoacidosis. Emerg Med Australas. Feb 2006;18(1):64-7. [Medline].

  20. Pounder DJ, Stevenson RJ, Taylor KK. Alcoholic ketoacidosis at autopsy. J Forensic Sci. Jul 1998;43(4):812-6. [Medline].

 
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