Alcoholic Ketoacidosis: Signs, Symptoms & Treatment
Alcoholic ketoacidosis arises as a result of malnutrition brought on by an episode of heavy alcohol use, typically in adults between the ages of 20 and 60 who frequently binge drink (though it can affect adults of any age).1 The condition often comes with unpleasant symptoms, such as nausea, vomiting, and abdominal pain.2 The prevalence of alcoholic ketoacidosis is uncertain, however one study indicated that it occurred in less than 10% of individuals who abused alcohol.3
What is Alcoholic Ketoacidosis?
Alcoholic ketoacidosis, also known as alcoholic ketosis or alcoholic acidosis, tends to occur when people who chronically use alcohol and who have co-occurring liver disease suddenly stop drinking.5 The condition seems to occur with higher frequency in people who are dehydrated and haven’t eaten for 1-3 days; this can result in the low blood sugar (glucose) levels that commonly occur after a bout of heavy alcohol use.4 When the body is malnourished, from not being able to eat and/or as a result of frequent vomiting due to excess alcohol use, it may start to produce ketones in response to the lack of nutrition as a way of maintaining energy.4
Ketones are acidic chemicals, such as acetone, acetoacetate, and beta-hydroxybutyrate, that the body metabolizes from fatty acids to be used as energy when there isn’t enough glucose coming in from food sources.6 Alcohol inhibits the body’s ability to produce glucose leading to significant production of ketones once alcohol levels fall. A person who isn’t eating properly and getting the nutrition the body needs from food because they’re drinking heavy amounts of alcohol instead, starts to get a buildup of excessive amounts of ketones in the body.
The presence of very high levels of ketones can be problematic because it results in a highly acidic environment inside the body. Additionally, individuals can also suffer from increased acidity due to the accumulation of lactic acid caused by dehydration from drinking too much. Another cause comes from a buildup of other metabolic products caused by alcohol breakdown, such as acetate.6,7 Too high a level of acidity in your body can lead to a severe metabolic acidosis, which can ultimately result in unpleasant and potentially life-threatening conditions.6
Symptoms of Alcoholic Ketoacidosis
The development of alcoholic ketoacidosis symptoms depends on different factors, such as the amount of alcohol consumed, food intake, and hydration.1 People who chronically use alcohol may also have liver or pancreatic conditions that make them more vulnerable to alcohol use, triggering an episode of alcoholic ketoacidosis.1,3 In addition, symptoms of alcoholic ketoacidosis can have some overlap with symptoms caused by other conditions, such as diabetic ketoacidosis, uremia (a complication of chronic kidney disease and acute kidney injury), methanol poisoning, or lactic acid buildup in the bloodstream (known as lactic acidosis).1 Some of these conditions may even occur alongside alcoholic ketoacidosis as a result of chronic alcohol use and dehydration, further exacerbating the body’s acidic state. This is why diagnosis and subsequent treatment can sometimes be challenging, but it’s crucial to receive a proper and timely diagnosis to obtain the correct treatment.
Symptoms of alcoholic ketoacidosis can include:1,3,6
- Abdominal pain.
- Hypotension (low blood pressure).
- Tachycardia (rapid heartbeat).
- Increased breath rate.
- Shortness of breath.
- Dry mucous membranes (dehydration).
- Altered mental state.
- Cardiac arrhythmias due to electrolyte disturbance, which can be fatal.
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Causes of Alcoholic Ketoacidosis
There’s no exact quantity of alcohol that causes alcoholic ketoacidosis, but the condition tends to develop most frequently in people who engage in chronic, excessive alcohol use after an episode of binge drinking.8
It can be helpful to understand the basic guidelines for alcohol consumption so you can determine whether you are drinking above recommended levels and engaging in potentially harmful alcohol use.
The Dietary Guidelines for Americans 2020-2025 define moderate drinking as 2 drinks or less for men per day and 1 drink or less for women per day.9 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines problematic alcohol intake by the following criteria:9
- Binge drinking means a pattern of alcohol use that raises the blood alcohol concentration (BAC) to 0.08% or more. For men, this typically means consuming 5 or more drinks in approximately 2 hours. For women, it means having 4 or more drinks in the same 2-hour period.
- Heavy alcohol use for men means consuming 4 or more drinks a day or more than 14 drinks in a week. For women heavy alcohol use is defined as 3 or more drinks a day or 7 or more drinks a week.
It’s important to note that people who present with alcoholic ketoacidosis often have low or absent BAC because the condition usually develops after drinking stops.1,8
Certain conditions that have similar symptoms, and that may occur together with or precipitate alcoholic ketoacidosis include:1
- Peptic ulcer disease, a condition in which painful ulcers develop in the lining of the stomach.
- Acute cholecystitis, or inflammation of the gallbladder.
- Acute mesenteric ischemia, a condition characterized by an interruption of blood supply to the small intestine.
- Alcohol withdrawal.
As mentioned before, risk factors for alcoholic ketoacidosis can include liver or pancreatic conditions, chronic alcohol use and binge drinking, as well as a history of recurring episodes of alcoholic ketoacidosis.8
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Diagnosis and Treatment
People who have alcoholic ketoacidosis are typically chronic alcohol users who present with nausea, vomiting and abdominal pain following a recent episode of binge drinking. Symptoms and history of alcohol use indicates to the doctor the presence of the disorder, and doctors will then conduct a clinical exam to confirm the diagnosis.1 Laboratory analysis can also help to confirm or verify the diagnosis, including a complete blood count, metabolic panel, arterial blood gas, or urinalysis.1
Treatment of alcoholic ketoacidosis involves administering IV fluids, monitoring electrolyte levels, and administering thiamine followed by glucose, if needed. Medications (i.e., benzodiazepines) may be administered to minimize the risk of experiencing severe symptoms of alcohol withdrawal.1 Anti-nausea or antiemetic medications, such as ondansetron or metoclopramide, may help alleviate nausea or prevent vomiting.1
People may also be referred to treatment for alcohol use disorder (AUD), a medical condition defined by the uncontrollable use of alcohol despite negative consequences, so they can stop drinking and avoid the additional negative effects alcohol has on the body.1
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Long-Term Impacts and Prevention
People can recover from alcoholic ketoacidosis if they receive a timely diagnosis and appropriate treatment.1 Individuals who do not receive a prompt diagnosis followed by treatment may develop potentially fatal conditions associated with electrolyte disturbances, including kidney failure, cardiac arrest, or hypovolemic shock, a serious and life-threatening condition in which the heart loses the ability to effectively pump blood.1,10
Alcoholic ketoacidosis can be prevented by avoiding alcohol consumption or limiting alcohol intake if you choose to drink. If you or someone you care about are struggling with alcohol use, it’s important to seek proper treatment so you can learn how to limit your alcohol intake or stop drinking completely.1
Treatment for AUD looks different for everyone but can include inpatient programs, outpatient rehab, participation in mutual-help groups like Alcoholics Anonymous or SMART Recovery, attending individual or group counseling sessions, or a combination of these methods. The most important consideration is finding a treatment that’s best suited to you and your individual needs and also takes into account your specific mental health or other medical concerns so you can start the path to recovery.
- Howard, R. & Bokhari, S. (2021). Alcoholic Ketoacidosis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.
- Palmiere, C., & Augsburger, M. (2014). The postmortem diagnosis of alcoholic ketoacidosis. Alcohol and alcoholism (Oxford, Oxfordshire), 49(3), 271–281.
- Kraut, J. A., & Kurtz, I. (2008). Toxic alcohol ingestions: clinical features, diagnosis, and management. Clinical journal of the American Society of Nephrology, 3(1), 208–225.
- Yokoyama, A., Yokoyama, T., Mizukami, T., Matsui, T., Shiraishi, K., Kimura, M., Matsushita, S… & Maruyama, K. (2014). Alcoholic ketosis: prevalence, determinants, and ketohepatitis in Japanese alcoholic men. Alcohol and alcoholism (Oxford, Oxfordshire), 49(6), 618–625.
- Ghimire, P. & Dhamoon, A. (2021). Ketoacidosis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.
- Noor, N. M., Basavaraju, K., & Sharpstone, D. (2016). Alcoholic ketoacidosis: a case report and review of the literature. Oxford medical case reports, 2016(3), 31–33.
- Ghimire, P. & Dhamoon, A. (2021). Biochemistry: Ketogenesis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing.
- McGuire, L. C., Cruickshank, A. M., & Munro, P. T. (2006). Alcoholic ketoacidosis. Emergency medicine journal, 23(6), 417–420.
- National Institute on Alcohol Abuse and Alcoholism. (n.d.). Drinking levels defined.
- Standl, T., Annecke, T., Cascorbi, I., Heller, A. R., Sabashnikov, A., & Teske, W. (2018). The nomenclature, definition and distinction of types of shock. Deutsches Arzteblatt international, 115(45), 757–768.