Metabolic alkalosis

Metabolic alkalosis
ICD-10	E87.3
ICD-9	276.3
DiseasesDB	402

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.D. [2]

Overview

Metabolic alkalosis is an elevation of the pH in the bloodstream which results from decreased hydrogen ion concentration leading to increased bicarbonate and carbon dioxide concentrations, or alternatively a direct result of increased bicarbonate concentrations.

Pathophysiology

Loss of hydrogen ions

GI loss

• Vomiting (excretion of hydrogen ions and the retention of bicarbonate)
• Nasogastric tube suction

Renal

• Over-diuresis
• Hyperaldosteronism causing retention of sodium followed with compensatory excretion of hydrogen
• Administration of non-resorbable anions such as, penicillin, carbenicillin, which complexs with positively-charged hydrogen ions in the renal tubules.

Increase in the serum bicarbonate

• Ingestion of sodium bicarbonate, baking soda, citrate, lactate, or acetate.

Shift of hydrogen ions into intracellular space

• Seen in hypokalemia. Due to a low extracellular potassium concentration, potassium shifts out of the cells, and in order to maintain electrical neutrality, hydrogen shifts into the cells, leaving behind bicarbonate.

Contraction alkalosis

• This results from a loss of water in the extracellular space which is poor in bicarbonate, typically from diuretic use. Since water is lost while bicarbonate is retained, the concentration of bicarbonate increases.

Compensation for Metabolic Alkalosis

• The body attempts to compensate for the increase in pH by retaining carbon dioxide (CO₂) through hypoventilation (respiratory compensation). CO₂ combines with elements in the bloodstream to form carbonic acid, thus decreasing pH.
• The pCO2 rises 0.5 - 1 for every 1 unit increase in serum HCO3 from a baseline of 24.
• The maximum pCO2 in compensation is 55-60.
• Renal compensation for metabolic alkalosis consists of increased excretion of HCO₃^- (bicarbonate), because the filtered load of HCO₃^- exceeds the ability of the renal tubule to reabsorb it.

Epidemiology and Demographics

It is the most common acid-base disorder seen in hospital in the United States.

Causes

• Urine chloride is used to narrow down the differential diagnosis of metabolic alkalosis.

Low urine chloride (<10mEq/dl)

• Patients with low urine chloride and metabolic alkalosis respond well to treatment with volume repletion with saline, thus these conditions are often referred as saline-responsive metabolic alkalosis. Some conditions of volume depletions are:
  • Vomiting,
  • Nasogastric tube suction
  • Over diuresis
• Other condition with similar presentation but without volume depletion is hypercapnia

Normal urine chloride (> 10mEQ/dL)

• With hypertension
  • Cushing's syndrome,
  • Primary aldosteronism (Conn's syndrome),
  • Renal artery stenosis
  • Renal failure + excess supplemented alkali
• Without hypertension
  • Hypomagnesemia
  • Hypokalemia,
  • Bartter's syndrome (defect of sodium chloride resorption),
  • Licorice ingestion (increases cortisol)

Causes by Organ System

Cardiovascular	Dilated cardiomyopathy, Malignant hypertension, Renovascular hypertension
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Aldosterone, Carbenoxolone, Diuretics, Fludrocortisone, Glucocorticoids, Intravenous Pencillins, Laxatives, Lydia Pinkham's vegetable compound, Mineralocorticoids, Sodium bicarbonate, Tolazoline, Tromethamine
Ear Nose Throat	No underlying causes
Endocrine	Cushing syndrome, Glucocorticoid-remediable hyperaldosteronism, Hyperaldosteronism, 11 beta hydroxylase deficiency, C17-hydroxylase deficiency, Conn syndrome, Bilateral adrenal hyperplasia, Adrenal adenoma, Adrenal carcinoma
Environmental	No underlying causes
Gastroenterologic	Gastric fistula, Villous adenoma, VIPoma, Congenital chloride diarrhea, Cystic fibrosis
Genetic	11 beta hydroxylase deficiency, Bartter syndrome, C17-hydroxylase deficiency, Congenital chloride diarrhea, Cystic fibrosis, Gietelman syndrome, Glucocorticoid receptor defect, Liddle syndrome, SeSAME syndrome
Hematologic	No underlying causes
Iatrogenic	Massive blood transfusion, Nasogastric suction
Infectious Disease	No underlying causes
Musculoskeletal / Ortho	No underlying causes
Neurologic	No underlying causes
Nutritional / Metabolic	Hypercalcemia, Hypokalemia, Hypomagnesemia, Refeeding syndrome, Glucocorticoid receptor defect, Glycyrrhizic acid, Licorice
Obstetric/Gynecologic	No underlying causes
Oncologic	Adrenal adenoma, Adrenal carcinoma, Conn syndrome, Hemangiopericytoma,VIPoma, Juxtaglomerular cell tumor
Opthalmologic	No underlying causes
Overdose / Toxicity	Aldosterone, Carbenoxolone, Diuretics, Fludrocortisone, Glucocorticoids, Intravenous Pencillins, Laxatives, Lydia Pinkham's vegetable compound, Mineralocorticoids, Sodium bicarbonate, Tolazoline, Tromethamine
Psychiatric	No underlying causes
Pulmonary	Cystic fibrosis
Renal / Electrolyte	Bilateral adrenal hyperplasia, Hypokalemic distal renal tubular acidosis, Juxtaglomerular cell tumor, Milk-alkali syndrome, Renovascular hypertension, Bartter syndrome, Gietelman syndrome, Liddle syndrome, Adrenal adenoma, Adrenal carcinoma
Rheum / Immune / Allergy	No underlying causes
Sexual	Cystic fibrosis
Trauma	No underlying causes
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Chewing tobacco, Glycyrrhizic acid, Licorice, Posthypercapnia, Vomiting, Laxatives, Refeeding syndrome, Milk-alkali syndrome

Causes in Alphabetical Order

11 beta hydroxylase deficiency Adrenal adenoma Adrenal carcinoma Aldosterone Bartter syndrome Bilateral adrenal hyperplasia C17-hydroxylase deficiency Carbenoxolone Chewing tobacco Congenital chloride diarrhea Conn syndrome Cushing syndrome Cystic fibrosis Dilated cardiomyopathy Diuretics Fludrocortisone Gastric fistula Gietelman syndrome Glucocorticoid receptor defect Glucocorticoid-remediable hyperaldosteronism Glucocorticoids Glycyrrhizic acid Hemangiopericytoma Hyperaldosteronism Hypercalcemia

Hypokalemia Hypokalemic distal renal tubular acidosis Hypomagnesemia Intravenous Pencillins Juxtaglomerular cell tumor Laxatives Licorice Liddle syndrome Lydia Pinkham's vegetable compound Malignant hypertension Massive blood transfusion Milk-alkali syndrome Mineralocorticoids Nasogastric suction Posthypercapnia Refeeding syndrome Renovascular hypertension SeSAME syndrome Sodium bicarbonate Tolazoline Tromethamine Villous adenoma VIPoma Vomiting

References

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