The diagnosis is established in the classic presentation of the chronic alcoholic, with recent anorexia, vomiting, abdominal pain, unexplained metabolic acidosis with a positive nitroprusside test, elevated anion gap, and a low or mildly elevated serum glucose level. However, this presentation is uncommon. Establishing this diagnosis can be difficult for several reasons. First, the blood alcohol level may be zero, and the patient may not voluntarily provide the history of alcohol consumption. Second, urine nitroprusside testing may be negative or weakly positive, despite significant ketoacidosis. Third, the pH may vary from reflecting significant acidemia to mild alkalemia, depending on how advanced the pathophysiology is and the degree of ketone body production, as explained above.

Initial laboratory studies usually include determination of electrolyte, blood urea nitrogen, creatinine, white blood cell, hematocrit, hepatic and pancreatic enzyme levels, and urinalysis. The anion gap should be calculated. Determination of serum lactic acid level and serum osmolarity may also be helpful. Further laboratory studies may be needed to delineate the cause of the increased anion-gap acidosis if other ingestions besides ethanol are suspected (see the following section on differential diagnosis). An arterial blood-gas determination is unnecessary unless a primary respiratory acid-base disturbance is suspected ( Table 204-2).

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