AKA is an acute metabolic disorder that occurs in ethanol abusers who have usually had a recent binge and who, because of gastritis or another intercurrent illness, stop eating and drinking and often vomit repeatedly. This causes dehydration and ketoacidosis which, unlike in diabetics, is usually associated with little or no hyperglycemia or glucosuria. Despite the ketoacidosis, blood pH findings are variable, depending on the severity of coexisting metabolic alkalosis (owing to vomiting) and respiratory alkalosis (owing to pain or delirium tremens). The metabolic disorders respond rapidly and gratifyingly to parenteral rehydration and administration of glucose, potassium salts, and thiamine. Insulin is usually not necessary, except in patients known or suspected to have diabetes. Because some patients have serious coexisting acute illnesses (which may even have precipitated the acute metabolic disorder), assiduous search for those and the appropriate treatment are essential. The prognosis for the acute metabolic disorder per se is excellent, that for coexisting illness depends on the illness, and that for the ethanol abuse is still often problematic.
Twenty-four chronic alcohol abusers hospitalized during a twenty-seven-month period were suspected of having "alcoholic ketoacidosis" because they had ketonuria or ketonemia with little or no glucosuria. Twenty-one had moderate or severe ketosis, with plasma 3-hydroxybutyrate of 5.2 to 22.5 mmol/L. Fifteen of this group were not diabetic, while six were later found to have mild postprandial hyperglycemia without glycosuria. Three patients who had continued to drink until shortly before admission, though at first suspected of having alcoholic ketosis, were found to have predominant lactic acidosis, with minor elevations of plasma 3-hydroxybutyrate. In contrast to previously reported patients with "alcoholic ketoacidosis", severe acidemia was uncommon in this series. Indeed, seven patients were alkalemic, because of coexisting respiratory or metabolic alkalosis. Most patients had eaten poorly for several days (and usually longer) and had allegedly decreased their alcohol intake during that period. That history, and the usual rapid clearing of ketosis simply by treatment with solutions of glucose and NaCl, suggested that acute starvation was an important factor in the pathogenesis of this disorder. Four patients were treated with insulin and four with NaHCO3 solutions. In retrospect, the need for either of these treatments was not clear. Two of the twenty-four patients died, one from circulatory failure secondary to hemorrhage and the other from pulmonary edema, but no patient died because of ketoacidosis per se.
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