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| __NOTOC__ | | __NOTOC__ |
| | {{Metabolic alkalosis}} |
| | '''For patient information, click [[Metabolic alkalosis (patient information)|here]]''' |
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| {| class="infobox" style="float:right;" | | {{CMG}}; {{AE}} [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com] |
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| | [[File:Siren.gif|30px|link=Metabolic alkalosis resident survival guide]]|| <br> || <br>
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| | [[Metabolic alkalosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| |}
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| {{Infobox_Disease | | |
| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = 402 |
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| ICD10 = {{ICD10|E|87|3|e|70}} |
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| ICD9 = {{ICD9|276.3}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = |
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| }}
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| {{SI}}
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| {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com]
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| ==Overview==
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| '''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.
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| ==Pathophysiology==
| | {{SK}} |
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| ===Loss of hydrogen ions=== | | ==[[Metabolic alkalosis overview|Overview]]== |
| ====GI loss====
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| * [[Vomiting]] (excretion of hydrogen ions and the retention of bicarbonate)
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| * [[Nasogastric tube]] suction
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| ====Renal====
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| * Over-[[diuresis]]
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| * [[Hyperaldosteronism]] causing retention of sodium followed with compensatory excretion of hydrogen
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| * Administration of non-resorbable anions such as, [[penicillin]], [[carbenicillin]], which complexs with positively-charged hydrogen ions in the [[renal tubules]].
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| ===Increase in the serum bicarbonate=== | | ==[[Metabolic alkalosis historical perspective|Historical Perspective]]== |
| * Ingestion of [[sodium bicarbonate]], baking soda, citrate, lactate, or acetate.
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| ===Shift of hydrogen ions into intracellular space===
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| * 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.
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| ===Contraction alkalosis===
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| * 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.
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| ===Compensation for Metabolic Alkalosis=== | | ==[[Metabolic alkalosis classification|Classification]]== |
| * The body attempts to compensate for the increase in pH by retaining [[carbon dioxide]] (CO<sub>2</sub>) through [[hypoventilation]] ([[respiratory compensation]]). CO<sub>2</sub> combines with elements in the bloodstream to form carbonic acid, thus decreasing pH.
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| * The pCO2 rises 0.5 - 1 for every 1 unit increase in serum HCO3 from a baseline of 24.
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| * The maximum pCO2 in compensation is 55-60.
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| * [[Renal compensation]] for metabolic alkalosis consists of increased excretion of HCO<sub>3</sub><sup>-</sup> (bicarbonate), because the filtered load of HCO<sub>3</sub><sup>-</sup> exceeds the ability of the renal tubule to reabsorb it.
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| ==Epidemiology and Demographics== | | ==[[Metabolic alkalosis pathophysiology|Pathophysiology]]== |
| It is the most common acid-base disorder seen in hospital in the United States.
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| ==Causes==
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| * [[Urine chloride]] is used to narrow down the differential diagnosis of [[metabolic alkalosis]].
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| ===Low urine chloride (<10mEq/dl)===
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| * 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:
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| ** [[Vomiting]],
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| ** [[Nasogastric tube]] suction
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| ** Over diuresis
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| * Other condition with similar presentation but without volume depletion is [[hypercapnia]]
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| ===Normal urine chloride (> 10mEQ/dL)=== | | ==[[Metabolic alkalosis causes|Causes]]== |
| * With [[hypertension]]
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| ** [[Cushing's syndrome]],
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| ** Primary aldosteronism ([[Conn's syndrome]]),
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| ** [[Renal artery stenosis]]
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| ** [[Renal failure]] + excess supplemented alkali
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| * Without [[hypertension]]
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| ** [[Hypomagnesemia]]
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| ** [[Hypokalemia]],
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| ** [[Bartter's syndrome]] (defect of sodium chloride resorption),
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| ** [[Licorice]] ingestion (increases [[cortisol]])
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| ===Common Causes=== | | ==[[Metabolic alkalosis differential diagnosis|Differentiating Metabolic alkalosis from other Diseases]]== |
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| ===Causes by Organ System=== | | ==[[Metabolic alkalosis epidemiology and demographics|Epidemiology and Demographics]]== |
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| {|style="width:80%; height:100px" border="1"
| | ==[[Metabolic alkalosis risk factors|Risk Factors]]== |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Dilated cardiomyopathy]], [[Malignant hypertension]], [[Renovascular hypertension]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| [[Aldosterone]], [[Carbenoxolone]], [[Diuretics]], [[Ethacrynic Acid]], [[Fludrocortisone]], [[Glucocorticoids]], [[Intravenous Pencillins]], [[Laxatives]], [[Lydia Pinkham's vegetable compound]], [[Mineralocorticoids]], [[Pramipexole]], [[Sodium bicarbonate]], [[Tolazoline]], [[Tromethamine]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| [[Cushing syndrome]], [[Glucocorticoid-remediable hyperaldosteronism]], [[Hyperaldosteronism]], [[11 beta hydroxylase deficiency]], [[C17-hydroxylase deficiency]], [[Conn syndrome]], [[Bilateral adrenal hyperplasia]], [[Adrenal adenoma]], [[Adrenal carcinoma]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| [[Gastric fistula]], [[Villous adenoma]], [[VIPoma]], [[Congenital chloride diarrhea]], [[Cystic fibrosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| [[11 beta hydroxylase deficiency]], [[Bartter syndrome]], [[C17-hydroxylase deficiency]], [[Congenital chloride diarrhea]], [[Cystic fibrosis]], [[Gietelman syndrome]], [[Glucocorticoid receptor defect]], [[Liddle syndrome]], [[SeSAME syndrome]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| [[Massive blood transfusion]], [[Nasogastric suction]]
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| [[Hypercalcemia]], [[Hypokalemia]], [[Hypomagnesemia]], [[Refeeding syndrome]], [[Glucocorticoid receptor defect]], [[Glycyrrhizic acid]], [[Licorice]]
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| [[Adrenal adenoma]], [[Adrenal carcinoma]], [[Conn syndrome]], [[Hemangiopericytoma]],[[VIPoma]], [[Juxtaglomerular cell tumor]]
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| [[Aldosterone]], [[Carbenoxolone]], [[Diuretics]], [[Fludrocortisone]], [[Glucocorticoids]], [[Intravenous Pencillins]], [[Laxatives]], [[Lydia Pinkham's vegetable compound]], [[Mineralocorticoids]], [[Sodium bicarbonate]], [[Tolazoline]], [[Tromethamine]]
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| [[Cystic fibrosis]]
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| [[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]]
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue" | |
| | '''Sexual'''
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| |bgcolor="Beige"| [[Cystic fibrosis]]
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Dental'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| [[Chewing tobacco]], [[Glycyrrhizic acid]], [[Licorice]], [[Posthypercapnia]], [[Vomiting]], [[Laxatives]], [[Refeeding syndrome]], [[Milk-alkali syndrome]]
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| |-
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| |}
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| ===Causes in Alphabetical Order=== | | ==[[Metabolic alkalosis screening|Screening]]== |
| {{MultiCol}}
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| *[[11 beta hydroxylase deficiency]]
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| *[[Adrenal adenoma]]
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| *[[Adrenal carcinoma]]
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| *[[Aldosterone]]
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| *[[Bartter syndrome]]
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| *[[Bilateral adrenal hyperplasia]]
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| *[[C17-hydroxylase deficiency]]
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| *[[Carbenoxolone]]
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| *[[Chewing tobacco]]
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| *[[Congenital chloride diarrhea]]
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| *[[Conn syndrome]]
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| *[[Cushing syndrome]]
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| *[[Cystic fibrosis]]
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| *[[Dilated cardiomyopathy]]
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| *[[Diuretics]]
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| *[[Fludrocortisone]]
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| *[[Gastric fistula]]
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| *[[Gietelman syndrome]]
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| *[[Glucocorticoid receptor defect]]
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| *[[Glucocorticoid-remediable hyperaldosteronism]]
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| *[[Glucocorticoids]]
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| *[[Glycyrrhizic acid]]
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| *[[Hemangiopericytoma]]
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| *[[Hyperaldosteronism]]
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| *[[Hypercalcemia]]
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| {{ColBreak}}
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| *[[Hypokalemia]]
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| *[[Hypokalemic distal renal tubular acidosis]]
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| *[[Hypomagnesemia]]
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| *[[Intravenous Pencillins]]
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| *[[Juxtaglomerular cell tumor]]
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| *[[Laxatives]]
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| *[[Licorice]]
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| *[[Liddle syndrome]]
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| *[[Lydia Pinkham's vegetable compound]]
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| *[[Malignant hypertension]]
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| *[[Massive blood transfusion]]
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| *[[Milk-alkali syndrome]]
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| *[[Mineralocorticoids]]
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| *[[Nasogastric suction]]
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| *[[Posthypercapnia]]
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| *[[Refeeding syndrome]]
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| *[[Renovascular hypertension]]
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| *[[SeSAME syndrome]]
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| *[[Sodium bicarbonate]]
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| *[[Tolazoline]]
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| *[[Tromethamine]]
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| *[[Villous adenoma]]
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| *[[VIPoma]]
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| *[[Vomiting]]
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| {{EndMultiCol}}
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| ==References== | | ==[[Metabolic alkalosis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| {{Reflist|2}}
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| | ==Diagnosis== |
| | [[Metabolic alkalosis diagnostic study of choice|Diagnostic study of choice]] | [[Metabolic alkalosis history and symptoms|History and Symptoms]] | [[Metabolic alkalosis physical examination|Physical Examination]] | [[Metabolic alkalosis laboratory findings|Laboratory Findings]] | [[Metabolic alkalosis electrocardiogram|Electrocardiogram]] | [[Metabolic alkalosis x ray|X-Ray Findings]] | [[Metabolic alkalosis echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Metabolic alkalosis CT scan|CT-Scan Findings]] | [[Metabolic alkalosis MRI|MRI Findings]] | [[Metabolic alkalosis other imaging findings|Other Imaging Findings]] | [[Metabolic alkalosis other diagnostic studies|Other Diagnostic Studies]] |
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| | ==Treatment== |
| | [[Metabolic alkalosis medical therapy|Medical Therapy]] | [[Metabolic alkalosis surgery|Surgery]] | [[Metabolic alkalosis primary prevention|Primary Prevention]] | [[Metabolic alkalosis secondary prevention|Secondary Prevention]] | [[Metabolic alkalosis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Metabolic alkalosis future or investigational therapies|Future or Investigational Therapies]] |
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| | ==Case Studies== |
| | [[Metabolic alkalosis case study one|Case #1]] |
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| ==Related Chapters== | | ==Related Chapters== |