eric niederhoffer siu-som how does ethanol ingestion cause nutrition problems? a 38-year-old woman...
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Eric Niederhoffer
SIU-SOM
How does ethanol ingestion cause nutrition problems?
A 38-year-old woman is brought to the physician because of frequent falls, increasing confusion, and
incontinence
Alcoholic Ketoacidosis
• Ketone body processing overview
• Ketogenesis and ketone body utilization
• Clinical features
Ketone Body Processing Overview
TAG
FAKetone Bodies
adipose tissue
muscle
LeuIle
Lys
PheTyr
Trp αKAliverAT
HSL
Albumin
EpinephrineNorepinephrine
Energy for the Brain and Nerves
β-oxidation
ketogenesis
Thr
Ketogenesis and Ketone Body Utilization
TCA
neuronmitochondrion
TAG
Acetyl CoA
AACoA
HMGCoA
AA 3HB
β-oxidation
AA CoA thiolase
HMG CoA synthase
HMG CoA lyase
3HBDH
Acetone
Ile, Thr
Lys, Trp
Leu
Tyr, Phe
hepatocytemitochondrion
AA 3HB3HBDH
AACoA
Acetyl CoA
Generates lots of ATP
AACoAT
3KACoAT
SCoASuc
NADH NAD+ NADH NAD+
Clinical Features (H&P)
• History(Typical symptoms reflect poor nutritional status from long-term alcohol abuse)• poor nutrition• volume depletion• ketone bodies buildup
Nausea, vomiting, and abdominal pain (each found in 60-75% of patients)
Dyspnea, tremulousness, and/or dizziness (10-20% each)
Muscle pain, diarrhea, syncope, and seizure (1-8% each)
• Physical examinationTachycardia, tachypnea, and/or abdominal tenderness (30-40% each)
Hypotension, hypothermia, fever, abdominal distention, rebound tenderness, hepatomegaly,
ascites, and/or heme-positive stools (1-15% each.)
Clinical Features (Laboratory Studies)• Arterial blood gas
Look for Macid, may have mixed acid-base disorder (Macid from ketone formation, Malk from vomiting/volume
depletion, Ralk secondary to hyperventilation)
• Serum ketones
Order specific test of [3HB]; ([3HB]/[AA] > 5)
• Glucose and electrolytes
Decreased, normal, or increased serum [Glc] (in DKA, serum [Glc] increased)
Increased anion gap
Increased serum [lactate]
Increased serum [urea nitrogen] and [creatinine]
• Complete blood count
Looking for anemia, intravascular volume depletion
• Liver and pancreatic function tests
Total bilirubin, ALT, AST, LDH, AP, PA, PL
• Alcohol levels
Patient may have decreased drinking; generally does not change approach
Review Questions• What are ketone bodies?
• Which amino acids are ketogenic?
• How are ketone bodies generated (substrates,
enzymes, pathways, location)?
• How are ketone bodies metabolized (enzymes,
pathways, location)?
• What is the effect of NADH levels on ketone bodies?
• How does the metabolism of ketone bodies
correlate with clinical findings?
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