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Metabolic acidosis, increased anion gap


  • Gap >12 meq


  • Lactic acidosis
    • Type A (tissue hypoxia): cardiogenic, septic, or hemorrhagic shock; seizure; carbon monoxide or cyanide poisoning
    • Type B (nonhypoxic): hepatic or renal failure, intestinal ischemia, diabetes especially with metformin use, ketoacidosis, infection, leukemia or lymphoma, drugs (ethanol, methanol, salicylates, isoniazid), AIDS, idiopathic (usually in debilitated patients)
  • Diabetic ketoacidosis
  • Starvation ketoacidosis
  • Alcoholic ketoacidosis
    • Frequently with mixed disorders (10% have triple acid-base disorder)
    • Acid-base disorders in alcoholism include: three types of metabolic acidosis (ketoacidosis, lactic acidosis, or hyperchloremic acidosis from bicarbonate loss in urine from ketonuria); metabolic alkalosis from volume contraction and vomiting; respiratory alkalosis from alcohol withdrawal, pain, sepsis, or liver disease
  • Uremic acidosis (usually at GFR <20 mL/min)
  • Ethylene glycol toxicity
  • Methanol toxicity
  • Salicylate toxicity (mixed metabolic acidosis with respiratory alkalosis)
  • Other: paraldehyde, isoniazid, iron, rhabdomyolysis

See related DDx

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Last updated: December 1, 2014


Zeiger, Roni F.. "Metabolic Acidosis, Increased Anion Gap." Diagnosaurus, 4th ed., McGraw-Hill Education, 2014. Emergency Central, emergency.unboundmedicine.com/emergency/view/Diagnosaurus/114286/all/Metabolic_acidosis__increased_anion_gap.
Zeiger RF. Metabolic acidosis, increased anion gap. Diagnosaurus. 4th ed. McGraw-Hill Education; 2014. https://emergency.unboundmedicine.com/emergency/view/Diagnosaurus/114286/all/Metabolic_acidosis__increased_anion_gap. Accessed April 20, 2019.
Zeiger, R. F. (2014). Metabolic acidosis, increased anion gap. In Diagnosaurus. Available from https://emergency.unboundmedicine.com/emergency/view/Diagnosaurus/114286/all/Metabolic_acidosis__increased_anion_gap
Zeiger RF. Metabolic Acidosis, Increased Anion Gap [Internet]. In: Diagnosaurus. McGraw-Hill Education; 2014. [cited 2019 April 20]. Available from: https://emergency.unboundmedicine.com/emergency/view/Diagnosaurus/114286/all/Metabolic_acidosis__increased_anion_gap.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Metabolic acidosis, increased anion gap ID - 114286 A1 - Zeiger,Roni F, Y1 - 2014/12/01/ BT - Diagnosaurus UR - https://emergency.unboundmedicine.com/emergency/view/Diagnosaurus/114286/all/Metabolic_acidosis__increased_anion_gap PB - McGraw-Hill Education ET - 4 DB - Emergency Central DP - Unbound Medicine ER -