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Metabolic alkalosis

Metabolic alkalosis


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High Yield Notes
8 pages

Metabolic alkalosis

10 flashcards

USMLE® Step 1 style questions USMLE

1 questions

A 43-year-old woman is brought to the emergency department after being found down on the side of the street. The patient is able to provide her name and date of birth but no additional information. Review of the medical record reveals a history of alcohol use disorder, hypertension, and type II diabetes mellitus. Her medications include acetazolamide, furosemide, and insulin. Her temperature is 37.6°C (99.7°F), pulse is 85/min, and blood pressure is 141/76 mmHg. The patient is oriented to self but not time or place. The abdomen is nondistended and nontender. Vomitus and the smell of alcohol is noticed on the patient’s clothing. Laboratory testing is ordered and reveals the following findings:

 Laboratory value  Result 
 Serum chemistry 
 Sodium   139 mEq/L 
 Potassium   3.4 mEq/L 
 Chloride   93 mEq/L 
 Bicarbonate  31 mEq/L 
 Calcium  9.9 mg/dL 
 Arterial blood gas  
 pH  7.49 
 PaCO2  42 mmHg 
 PaO2  104 mmHg 

Which of the following pathophysiologic mechanisms is the most likely cause of this patient’s laboratory findings?  

External References

Content Reviewers:

Rishi Desai, MD, MPH

With metabolic alkalosis, “alkalosis” refers to a process that raises blood pH above 7.45, and “metabolic” refers to the fact that it’s caused by an increase in the concentration of bicarbonate HCO3− in the blood.

Normally, blood pH depends on the balance or ratio between the concentration of bases, mainly bicarbonate HCO3−, which increases the pH, and acids, which decrease the pH.

The blood pH needs to be constantly between 7.35 and 7.45.

Now, metabolic alkalosis can typically happen from two main causes - loss of hydrogen H+ ions and gain of HCO3− bicarbonate ions, or, most often, a combination of these two.

Loss of hydrogen H+ ions can occur either from the gastrointestinal tract or from the kidneys.

The first case most commonly happens during vomiting, because the gastric secretions are very acidic, meaning that they have lots of hydrogen H+ ions.

On top of that, normally, as gastric secretions flow into the pancreas, they’re met with HCO3− bicarbonate secretions which neutralize the acid so that the various pancreatic enzymes like trypsin and chymotrypsin, can work effectively.

So during vomiting, not only is the stomach acid lost, but in addition the pancreas doesn’t secrete HCO3− bicarbonate into the intestines, and so it builds up in the blood instead.

Another way that hydrogen H+ ions can be lost is through the urine, in the context of having too much of the hormone aldosterone.

This can happen, when there’s an adrenal tumor that secretes excess aldosterone.

The aldosterone makes the α- intercalated cells of the distal convoluted tubule and collecting duct dump out hydrogen H+ ions and reabsorb more bicarbonate HCO3− ions.

The result is that the urine becomes more acidic and the blood becomes more basic.

Now, the second cause - a primary gain of HCO3− bicarbonate ions - is usually caused by an increased reabsorption of HCO3− bicarbonate ions from the kidneys.

There are various things that could stimulate the kidneys to do that.

One of them is volume contraction or excessive loss of extracellular fluid, which can happen with loop diuretics and thiazide diuretics, as well as in cases of severe dehydration.

The resulting alkalosis is called a contraction alkalosis.

Sometimes, dehydration occurs in combination with other causes of metabolic alkalosis, like prolonged vomiting.

Another stimulus is hypokalemia, or decreased levels of potassium in the blood, which can be due to excessive loss from the gastrointestinal tract, like in diarrhea, or from the kidneys due to diuretic use.

In any case, when there’s less volume or less potassium in the extracellular space, it triggers the renin-angiotensin-aldosterone mechanism.

As a result, angiotensin II and aldosterone levels rise, and the kidneys start to retain water and reabsorb more bicarbonate HCO3− ions in the proximal convoluted tubule.

In addition, the α- intercalated cells of the distal convoluted tubule and the collecting ducts secrete some hydrogen H+ ions into the urine, but, most importantly, also make new bicarbonate HCO3− ions, which will again get reabsorbed.

Now, in other cases, excess bicarbonate HCO3− ions don’t come from within our bodies at all, but are ingested in large amounts, usually in the form of antacids, like NaHCO3 sodium bicarbonate.


Metabolic alkalosis is a condition in which the blood pH is above 7.45, following an increase in blood HCO3 concentration to over 27 mEq/L. Common causes of metabolic alkalosis include excessive loss of hydrogen ions like when vomiting, abnormal renal function, loop, and thiazide diuretics, excessive use of antacids, etc. Symptoms of metabolic alkalosis include nausea, vomiting, muscle weakness, and confusion.

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