Osmolal gap in alcoholic ketoacidosis.

Severe metabolic acidosis in the setting of alcoholism raises diagnostic and therapeutic problems [Levinsky 1994]. Alcoholic ketoacidosis and toxic alcohol ingestion can be difficult to distinguish on initial presentation [Litovitz 1986]. A high osmolal gap associated with increased anion gap acidosis is said to be indicative of toxic alcohol poisoning though this is not at all specific [Salem and Mujais 1992]. Invasive therapeutic manoeuvers as for toxic alcohol poisoning have been recommended empirically before toxicological confirmation when very high osmolarity gaps are reached. Herein, we report two cases of high anion gap metabolic acidosis with very high osmolal gap due to alcoholic ketoacidosis without any evidence of toxic alcohol ingestion.