Recently I had quite an interesting case. I was very excited about it and I am not sure if that was because it was different than my usual hospital admits or because it is really cool physiology (to me!)

A middle aged gentleman presented to our facility acting confused. His family was convinced he was drunk. He passed medical history included hypertension and a gastric bypass surgery in the early 1970s. On admission, the significant lab findings were an elevated anion gap metabolic acidosis with a normal lactic acid level and without ketones (and a normal alcohol level). His evaluation of this gap acidosis did not reveal any of the usual causes (ie MUDPILES). He was seen by Nephrologist; hydrated with bicarbonate fluid. He recovered and was discharged to home.

He then represented again about 3 days later…with the same thing. Again he had no obvious source of a gap acidosis. He was hydrated with bicarb; improved and was discharged.

About 3 days later, it happened again. This time a different Nephrologist happened to be present for his admission. He said "I think this might be d-lactic acidosis". What?!

D- Lactic acidosis is a unique form of lactic acidosis that can occur in patients with jejunoileal bypass. The mechanism is that glucose and starch are metabolized in the colon to d-lactic which is absorbed into the circulation. D-lactic acid does not respond to LDH and therefore does not get broken down and it builds up in our system. Patients will present with an encephalopathy and they say they "feel drunk". The reason why this becomes an issue in patients with small bowel resection is because usually glucose and starch are absorbed in the small intestine and the colon does not see it. If there is a small bowel resection, the colon sees more glucose and starch and cannot handle.

Another reason why the overproduction of d-lactic acid can occur is due to an overgrowth of gram positive anaerobes, in particular Lactobacilli.

Upon further interviews with my patient, he had been treated as an outpatient for "recurrent" sinus infections and "had been on more antibiotics in the last 6 months then he had been his whole life". As we know antibiotics can lead to an overproduction Lactobacilli. Also he had had his gastric bypass surgery in the 1970s which he said was " a big surgery".

The diagnosis of d-lactic acidosis is made by a special assay. This was ordered on my patient and is still pending.

The treatment of d-lactic acidosis is bicarbonate therapy and antimicrobials to reduce organisms that produce d-lactate. My patient was treated acutely with IV fluids with bicarb and started on Flagyl. He has not been back since which is great for him!
So, there are truly are instances when a patient can look drunk and act drunk but he/she is NOT drunk!