Acute fulminant lactic acidosis complicating metastatic cholangiocarcinoma

A patient with cholangiocarcinoma, metastatic to the liver and lungs, devel oped acute fulminant lactic acidosis in the absence of overt hepatic failur e, sepsis, hypoxia, or circulatory failure. Despite extensive tumor replace ment of hepatic parenchyma, no acid-base disorder was present during initia l evaluation. The onset of acute lactic acidosis was temporally associated with the development of otherwise asymptomatic episodes of intermittent atr ial arrhythmias. Once established, lactic acidosis was inexorably progressi ve, despite resolution of arrhythmias. Extensive areas of acute necrosis wi thin the large hepatic metastases were demonstrated on postmortem examinati on, suggesting that local tissue ischemia, precipitated by cardiac arrhythm ias, lead to excessive lactic acid production.