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Increased Osmolal Gap in Alcoholic Ketoacidosis and Lactic Acidosis

Jeffrey R. Schelling, MD; Randy L. Howard, MD; Sara D. Winter, MD; and Stuart L. Linas, MD
[+] Article and Author Information

Requests for Reprints: Stuart L. Linas, MD, Department of Medicine, Box 4000, 777 Bannock Street, Denver, CO 80204.

Current Author Addresses: Drs. Schelling and Howard: University of Colorado Health Sciences Center, 4200 E. Ninth Avenue, Box C281, Denver, CO 80262.

Dr. Winter: Denver General Hospital, Department of Laboratories, 777 Bannock Street, Denver, CO 80204.

Dr. Linas: Denver General Hospital, Department of Medicine, Box 4000, 777 Bannock Street, Denver, CO 80204.


© 1990 American College of PhysiciansAmerican College of Physicians


Ann Intern Med. 1990;113(8):580-582. doi:10.7326/0003-4819-113-8-580
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Objective: To determine whether an elevated osmolal gap is specific for toxic alcohol ingestion.

Design: Cross-sectional.

Setting: Emergency room and medical and surgical inpatient wards at a university-affiliated hospital.

Patients: Twenty-three patients with lactic acidosis, 19 with alcoholic ketoacidosis, and 10 randomly selected controls.

Measurements and Main Results: Calculated and measured serum osmolality was determined in all study participants. The osmolal gap was increased in patients with lactic acidosis (17.4 ± 5.4 mmol/kg) and alcoholic ketoacidosis (26.9 ±7.6 mmol/kg) when compared with controls (- 1.7 ±1.7 mmol/kg, P < 0.05 for both comparisons). When ethanol was included in the calculation, the osmolal gap remained elevated in the lactic acidosis (10.3 ±2.0 mmol/kg) and alcoholic ketoacidosis (11.1 ±3.2 mmol/kg) groups (P < 0.05 for both comparisons).

Conclusions: The osmolal gap is often used as a screen for toxic alcohol ingestion. When calculating the osmolal gap, the contribution of ethanol should be considered. An elevated osmolal gap is not specific for toxic alcohol ingestion, as the osmolal gap was elevated in patients with lactic acidosis and alcoholic ketoacidosis. These two conditions should be considered when using the osmolal gap to design therapy (for example, hemodialysis) in the setting of anion gap metabolic acidosis and suspected toxic alcohol ingestion.

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