Toxic metabolites of both substances result in severe metabolic acidosis with wide anion gap and wide osmolal gap.18 Neither, however, causes ketosis. Modern fad diets like ketogenic diets are designed to help your body enter a state of ketosis, where it begins burning fat rather than glucose (blood sugar) for fuel. This process releases chemicals known as ketones, including acetone, which can cause a fruity smell. In fact, having fruity or acetone-smelling breath is a reliable sign that your body has entered ketosis. Alcoholic ketoacidosis often presents with a distinct fruity smell in the breath.
Signs and symptoms
Alcohol produces structural changes in human liver mitochondria within days. Fulop and Hoberman5 argued that a functional abnormality is more likely to be responsible, as even severe AKA usually improves rapidly with treatment. They attributed this to the administration of therapy (intravenous dextrose) rather than the withdrawal of the toxin, ethanol. However, following senior medical review, given a recent history of drinking alcohol to excess, the diagnosis of AKA was felt more likely. 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.
- This may include therapy, education, and support groups, to assist you in understanding the nature of addiction and adopting new coping mechanisms to maintain sobriety.
- In severe cases, individuals with AKA may be admitted to the intensive care unit (ICU) to ensure comprehensive treatment.
Alcoholic Ketoacidosis Clinical Presentation
- 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.
- Decreased insulin and elevated glucagon, cortisol, catecholamine, and growth hormone levels can increase the rate of ketogenesis.
- This process leads to the production of ketones, which, if present in high levels, can cause the onset of alcoholic ketoacidosis and its signature smell.
- The presence of a high anion gap, although not specific, is suggestive of AKA in a patient with an appropriate clinical history [9].
Excessive alcohol consumption often causes malnourishment (not enough nutrients for the body to function well). All alcoholic patients presenting with acute illness should be offered contact with addiction services prior to or following discharge wherever possible. 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.
BOX 3 MANAGEMENT OF AKA
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. Upon discharge from the hospital, your doctor may recommend alcoholic ketoacidosis connecting you with resources and support to aid in your recovery from alcohol use disorder. This could include referrals to counseling, therapy, or rehabilitation programs, providing you with a structured path toward sustained sobriety.
- Free fatty acids are either oxidized to CO2 or ketone bodies (acetoacetate, hydroxybutyrate, and acetone), or they are esterified to triacylglycerol and phospholipid.
- If you were to ignore your symptoms, though, you could end up with a life-threatening condition like a heart attack, seizure, Wernicke encephalopathy, or a differential diagnosis.
- Examination should reveal a clear level of consciousness, generalised abdominal tenderness (without peritoneal signs), and tachypnoea.
Other Symptoms
Insulin may be required if you have uncontrolled blood glucose levels. Alcoholic ketoacidosis is a recognised acute complication in alcohol dependent patients. Given the frequency with which the condition is seen in other countries, the possibility exists that many cases may be unrecognised and misdiagnosed in UK EDs. AKA should be included in the differential diagnosis of alcohol dependent patients presenting with acute illness.
- If you have diabetes, managing your blood sugars and taking your medications as prescribed can help reduce your risk of fruity breath.
- If you need help creating a nutritional plan to help control your blood sugar levels, ask your healthcare provider for a referral to a registered dietitian.
- If you’re intentionally fasting or following a ketogenic diet, you should expect fruity breath.
- Both steps require the reduction of nicotinamide adenine dinucleotide (NAD+) to reduced nicotinamide adenine dinucleotide (NADH).
Laboratory tests are essential in diagnosing alcoholic ketoacidosis (AKA). A doctor may order an arterial blood gas test to evaluate the acidity levels in your blood. This test measures the pH and the levels of oxygen and carbon dioxide in your blood, giving your healthcare provider insight on potential issues with your body. As this happens, the liver releases ketones, including acetone, as byproducts.
Free fatty acids are either oxidized to CO2 or ketone bodies (acetoacetate, hydroxybutyrate, and acetone), or they are esterified to triacylglycerol and phospholipid. Carnitine acyltransferase (CAT) transports free fatty acids into the mitochondria and therefore regulates their entry into the oxidative pathway. The decreased insulin-to-glucagon ratio that occurs in starvation indirectly reduces the inhibition on CAT activity, thereby allowing more free fatty acids to undergo oxidation and ketone body formation. When your body doesn’t receive adequate nutrients during episodes of starvation, it relies on stored fat for energy.
When your body burns fat for energy, byproducts known as ketone bodies are produced. If your body is not producing insulin, ketone bodies will begin to build up in your bloodstream. This buildup of ketones can produce a life-threatening condition known as ketoacidosis. Alcoholic ketoacidosis (AKA) is a common reason for investigation and admission of alcohol dependent patients in UK emergency departments. Although well described in international emergency medicine literature, UK emergency physicians rarely make the diagnosis of AKA.
