Metabolic alkalosis differential diagnosis

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

Overview

Metabolic alkalosis might be consequence of several conditions such as exogenous HCO3 loads, medications and poisoning, gastrointestinal, renal, endocrine, and systemic diseases.

Metabolic Alkalosis

Differential diagnosis of metabolic alkalosis is as follow:

Category Disease Mechanism Clinical Paraclinical Gold standard diagnosis Other findings
Symptoms Signs Lab data
ABG Chemistry Enzyme Renal function
Hydrogen loss Accumulation of base Chloride depletion Mineralocorticoid excess Fever Dyspnea Edema Toxic/ill BP Dehydration HCO3 paCO2 O2 Cl K+ Na+ Ca+ Mg+ Renin Bun Cr Urine Cl
Exogenous HCO3 loads Acute alkali administration[1] + + + Nl Nl Nl Clinical manifestations
Milk−alkali syndrome[2] + + + + + Nl Clinical manifestationsk + exclusion of other causes of hypercalcemia
Transfusion[3] + ± ± + ↓/↑ Nl to ↑ Nl to ↑ Nl History of administration of large quantities of blood products that contain sodium citrate
Drugs/Medication Chloruretic diuretics[4] + + + + Nl Nl Nl Nl to ↑ Nl to ↑ History of diuretic use
Penicillin[5] + Nl Nl Nl Nl Nl Nl History of penicillin use
  • Not applicable
Licorice[6][7] + + + Nl to ↑ Nl Nl Nl Nl to ↑ Nl to ↑ Nl Clinical manifestations
Laxative abuse[8] + + ± + + Nl Nl Nl to ↑ Nl High level of suspicion
Antacids[9][10]
  • Aluminum hydroxide
  • Sodium polystyrene sulfonate  
+ + Nl Nl Nl Nl Nl to ↑ Nl to ↑ Nl Clinical manifestations
  • Not applicable
Category Disease Hydrogen loss Accumulation of base Chloride depletion Mineralocorticoid excess Fever Dyspnea Edema Toxic/ill BP Dehydration HCO3 paCO2 O2 Cl K+ Na+ Ca+ Mg+ Renin Bun Cr Urine Cl Gold standard diagnosis Other findings
Gastrointestinal origin Vomiting[11] + + ± + + Nl Nl Nl Nl to ↑ Nl Clinical manifestations
  • Not applicable
Nasogastric tube suction[12] + + + + Nl Nl Nl Nl to ↑ Nl Clinical manifestations
Zollinger−Ellison syndrome[13] + + + + Nl Nl Nl Nl to ↑ Nl Serum gastrin concentration + secretin stimulation test 
Bulimia nervosa[14] + + ± + + Nl Nl Nl to ↑ Nl High level of suspicion
Congenital chloridorrhea[15] + + ± + + Nl Nl to ↑ Nl to ↑ Nl to ↑ Clinical manifestations+ lab findings
Pyloric stenosis[16] + + + + Nl ↓ ↑ Nl Nl Nl to ↑ Nl Physical exam + imaging
  • Palpation of the “olive”
Villous adenoma[17] + + + + Nl Nl to ↑ Nl Colonoscopy
Gastrocystoplasty[18] + + Nl Nl Nl Nl Nl Nl Nl to ↑ Nl to ↑ Nl History of operation
Category Disease Hydrogen loss Accumulation of base Chloride depletion Mineralocorticoid excess Fever Dyspnea Edema Toxic/ill BP Dehydration HCO3 paCO2 O2 Cl K+ Na+ Ca+ Mg+ Renin Bun Cr Urine Cl Gold standard diagnosis Other findings
Renal origin Posthypercapnic state[19] + + ± Nl ↑↑ Nl Nl Nl Nl Nl Lab findings
Hypomagnesemia[20] + Nl Nl Nl Nl Nl Nl Nl Lab findings
  • Not applicable
Hypokalemia[21] + Nl Nl Nl Nl Nl Nl Nl Lab findings
  • Not applicable
Bartter's syndrome[22] + + Nl + Nl ↓↓ Nl Nl to ↑ Nl to ↑ Nl Genetic testing
Gitelman’s syndrome[23][24] + + + Nl ↓↓ Nl Nl Nl Nl Genetic testing
Renal artery stenosis[25] + + + + + + Nl Nl Clinical manifestations+ imaging
Liddle syndrome[26] + + + Nl ↓↓ Nl Nl Nl Nl Genetic testing
  • Not applicable
Renal tumors[27] + + + + + + Nl Nl Biopsy
  • Not applicable
Endocrine Cushing's syndrome[28] + + + + Nl Nl Nl 24−hour urinary cortisol excretion + low−dose dexamethasone suppression test
Hyperaldosteronism Primary[29] + + + + Nl Nl to ↓ Nl Nl Lab findings
Secondary[30] + + + + + + Nl Nl Nl Lab findings
Congenital adrenal hyperplasia 11β−Hydroxylase deficiency[31] + + + Nl Nl Nl Nl Nl Genetic testing
17α−Hydroxylase deficiency[32] + + + Nl Nl Nl Nl Nl Genetic testing
Systemic Cystic fibrosis[33] + + + + + Nl Nl Nl Nl Nl to ↑ Nl Genetic testing
Category Disease Hydrogen loss Accumulation of base Chloride depletion Mineralocorticoid excess Fever Dyspnea Edema Toxic/ill BP Dehydration HCO3 paCO2 O2 Cl K+ Na+ Ca+ Mg+ Renin Bun Cr Urine Cl Gold standard diagnosis Other findings

References

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