D-lactic acidosis 23 years after jejuno-ileal bypass

Accumulation of D-lactate after gastrointestinal surgery, particularly jeju no-ileal bypass, is an uncommon and often misdiagnosed clinical disturbance . The syndrome may be complicated by dizziness, ataxia, confusion, headache , memory loss, and aggressive behavior. Serum chemistries are often decepti ve because the anion gap is frequently normal in spite of severe metabolic acidosis. Moreover, the urine anion gap may be positive, incorrectly sugges ting a defect in renal net acid excretion. Indeed, the combination of a nor mal anion gap metabolic acidosis and positive urine anion gap may erroneous ly suggest a diagnosis of renal tubular acidosis. Importantly, all reported cases of D-lactic acidosis secondary to bypass surgery have been encounter ed within 5 to 10 years following the surgery. Here we present an unusual c ase of D-lactic acidosis (complicated by encephalopathy) presenting 23 year s after a jejuno-ileal bypass procedure. The patient was Initially diagnose d with a drug intoxication secondary to benzodiazepines. Ultimately, the di agnosis of D-lactate encephalopathy was established after challenging the p atient with a carbohydrate load, Thus, administration of 40 kcal/kg over 16 hours reproduced the clinical syndrome and was accompanied by a marked inc rement in serum and urine D-lactate concentration. The patient had sustaine d resolution of her symptoms after treatment with oral vancomycin. (C) 2000 by the National Kidney Foundation, Inc.