Alcoholic ketoacidosis: a case report and review of the literature.

Alcoholic ketoacidosis (AKA) is a cause of severe metabolic acidosis usually occurring in malnourished patients with a history of recent alcoholic binge, often on a background of alcohol dependency. AKA can be fatal due to associated electrolyte abnormalities and subsequent development of cardiac arrhythmias. This is a diagnosis that is often delayed or missed, in patients who present with a severe lactic and ketoacidosis. Here we report the case of a 64-year-old female who presented with generalized abdominal pain, nausea and shortness of breath. Blood gas analysis showed significant acidaemia with a pH of 7.10, bicarbonate of 2.9 mmol/l, and lactate of 11.7 mmol/l. Serum ketones were raised at 5.5 mmol/l. The diagnosis of AKA was suspected, and subsequent aggressive fluid resuscitation, management and monitoring were instituted. Given the early recognition of AKA and appropriate multidisciplinary team management, our patient had a good outcome and was discharged home without any complication.

A rare cause of dysphagia and gastroparesis.

An 82-year-old woman was admitted with severe vomiting and progressive dysphagia mainly to solids. She gave a 3-month history of increasing heartburn, vomiting, tiredness, lethargy, anorexia and 13 kg weight loss. Her past medical history was unremarkable and she was a non-smoker. Physical examination revealed evidence of significant weight loss and dehydration only. Gastroscopy revealed mild oesophagitis, tongues of Barrett oesophagus and mild antral gastritis. CT scan of the thorax and abdomen was normal. Unfortunately her condition deteriorated rapidly and she died from aspiration pneumonia. Postmortem examination revealed thickening of the muscular wall of lower oesophagus and pylorus, but without any malignancy. The histological assessment of the oesophageal as well as gastric biopsies confirmed the diagnosis of gastrointestinal amyloidosis accounting for her symptoms of dysphagia and vomiting respectively.

Is an atypical presentation becoming typical of coeliac disease?

A 38-year-old woman was referred to a gastroenterology clinic for investigation of abnormal liver function test (LFT). She had no history of pre-existing liver disease, diabetes mellitus, hypertension, excess alcohol consumption or use of any hepatotoxic drugs. She was being investigated and treated by oral surgeons for recurrent mouth ulcers which she had for about 18 months. She had been seen by the rheumatology team for pain and early morning stiffness affecting the peripheral small joints. Clinical examination was unremarkable apart from the presence of an increased body mass index of 36 kg/m(2). Her haematological and biochemical profile including liver screen did not reveal any abnormalities. Her anti-endomyseal antibody and duodenal biopsies were consistent with the diagnosis of coeliac disease. Her LFT returned to normal within 3 months of starting on a gluten-free diet and remained normal over the next 12 months. She also remained free of mouth ulcers during this period.