What is the diagnosis and management for a patient with vomiting, abdominal pain, and 2 days of alcohol consumption without food intake?

Diagnosis: Alcoholic Ketoacidosis

This patient most likely has alcoholic ketoacidosis (AKA), a life-threatening metabolic emergency that occurs in alcohol-dependent individuals after binge drinking followed by abrupt cessation of alcohol and food intake. 1, 2

Clinical Presentation

The classic triad of AKA consists of:

• Recent alcohol binge (2 days in this case) followed by cessation 1, 2
• Starvation/poor oral intake (no food for 2 days) 1, 2
• Vomiting and abdominal pain 1, 2

Additional features to assess include:

• Tachycardia, hypotension, and tachypnea (signs of metabolic acidosis) 2
• Dehydration and electrolyte abnormalities 3
• Normal or low blood glucose (distinguishes from diabetic ketoacidosis) 1

Critical Differential Diagnoses to Exclude

While AKA is most likely, you must immediately rule out:

Alcohol withdrawal syndrome (AWS): Symptoms typically begin 6-24 hours after last drink, not after 2 days of drinking 3. AWS presents with autonomic hyperactivity (tremors, tachycardia, hypertension, sweating), anxiety, and potential progression to seizures or delirium tremens 3. This patient's presentation with vomiting and abdominal pain after 2 days of drinking is inconsistent with AWS.

Alcoholic hepatitis: Requires recent onset of jaundice (bilirubin >50 μmol/L), AST >50 IU/mL with AST/ALT ratio >1.5-2.0, and typically occurs after weeks-months of heavy drinking 3. The 2-day timeframe makes this less likely unless underlying chronic liver disease exists.

Acute pancreatitis: Common after binge drinking and presents with severe abdominal pain, vomiting, and elevated lipase/amylase 4. Must be excluded with laboratory testing.

Immediate Diagnostic Workup

Obtain the following immediately:

• Arterial blood gas: Will show metabolic acidosis with increased anion gap 1, 2
• Serum glucose: Normal or low (excludes diabetic ketoacidosis) 1
• Serum ketones and beta-hydroxybutyrate: Elevated 1
• Basic metabolic panel: Assess for electrolyte abnormalities, particularly hypokalemia, hypophosphatemia, and hypomagnesemia 3
• Liver function tests: AST, ALT, bilirubin to assess for alcoholic hepatitis 3
• Lipase: To exclude pancreatitis 4
• Complete blood count: May show neutrophilia if alcoholic hepatitis present 3

Management Protocol

Immediate Life-Saving Interventions

1. Thiamine FIRST, before any glucose administration:

• Administer thiamine 100-500 mg IV immediately to prevent Wernicke encephalopathy 5
• This is absolutely critical and must precede any glucose-containing fluids 5

2. Aggressive fluid resuscitation:

• Start with normal saline or lactated Ringer's solution 1
• Add 5% dextrose once thiamine is given to stimulate insulin release and suppress ketogenesis 1

3. Electrolyte replacement:

• Potassium: Aggressively replace as insulin drives potassium intracellularly 1
• Magnesium: Commonly depleted in chronic alcohol use; give magnesium sulfate 2-4 g IV 5
• Phosphate: Monitor and replace as needed 3

4. Supportive care:

• Antiemetics for nausea/vomiting 1
• Monitor vital signs continuously for hemodynamic instability 3, 5

Ongoing Management (First 24-48 Hours)

• Continue thiamine 100-300 mg/day for 2-3 months following resolution 5
• Monitor for resolution of acidosis with serial blood gases 1
• Watch for complications: hepatic encephalopathy, infection, renal failure 3
• Assess for alcohol withdrawal symptoms starting 6-24 hours after last drink 3

If Alcohol Withdrawal Develops

Benzodiazepines are the gold standard:

• Long-acting agents (diazepam, chlordiazepoxide) provide superior seizure protection 3
• Short-acting agents (lorazepam, oxazepam) are safer if hepatic dysfunction is present 3
• Use symptom-triggered regimen rather than fixed-dose schedule 3
• Do not continue benzodiazepines beyond 10-14 days due to abuse potential 3, 5

Critical Pitfalls to Avoid

Never give glucose before thiamine - this can precipitate acute Wernicke encephalopathy, which is irreversible 5

Do not assume this is simple alcohol withdrawal - the 2-day drinking period with starvation and metabolic presentation points to AKA, which requires different immediate management 1, 2

Untreated AKA is often fatal - aggressive treatment with fluids, dextrose (after thiamine), and electrolyte replacement is essential 1, 2

Monitor for concurrent alcoholic hepatitis - if jaundice develops or liver enzymes are significantly elevated with AST/ALT ratio >1.5, consider this diagnosis and assess severity with mDF or MELD score 3

Post-Acute Management

After stabilization:

• Mandatory psychiatric consultation for evaluation and long-term abstinence planning 3, 5
• Refer to alcohol rehabilitation program to prevent relapse 1
• Screen for alcohol use disorder using validated tools 3
• Consider pharmacotherapy for alcohol dependence (naltrexone, acamprosate) once medically stable, though avoid in severe liver disease 3