12 Non-Anion Gap

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S. Faubel and J. Topf 12 Metabolic Acidosis: Non-Anion Gap

12

Metabolic Acidosis:12 Non-Anion Gap

288

The Fluid, Electrolyte and Acid-Base Companion

Introduction



Loss of bicarbonate from either the GI tract or kid-ney causes non-anion gap metabolic acidosis.

Non-anion gap metabolic acidosis is due to the loss of bicarbonate fromeither the GI tract or the kidney. The differential diagnosis of the commoncauses of non-anion gap metabolic acidosis is listed above. Each of thesedisorders is reviewed in detail in this chapter. As reviewed in Chapter 11,

Metabolic Acidosis: The Overview

, the loss of bicarbonate has two primary effects: increased hydrogen ion (



pH) and in-creased chloride concentration. Hydrogen ion concentration increases be-cause the loss of bicarbonate drives the bicarbonate buffer system towardthe production of hydrogen. Chloride concentration increases in order tomaintain electroneutrality for the loss of bicarbonate. Because chloride con-centration increases, the anion gap is normal.

The two types of metabolic acidosis both cause a decreased bi-carbonate and a(n) __________ (increased/decreased) pH.If bicarbonate is lost from the body, then the chloride concentra-tion ___________ (increases/decreases).aaadecreasedincreases

GI loss of HCO

3 –

diarrheasurgical drainsfistulasureterosigmoidostomyobstructed ureteroileostomycholestyramine

Renal loss of HCO

3 –

renal tubular acidosisproximaldistalhypoaldosteronismLoss of bicarbonateshifts the bicarbonatebuffer equation to-ward the productionof hydrogen ion, de-creasing pH.

HCO

3

H

+

HCO

3

H

+

C

HCO

3

H

+

HCO

3

H

+

C

cations==anionsHCO

3

Cl

–

Na

+

K

+

cationsanionsHCO

3

Cl

–

Na

+

K

+

A

-

otheranions

A

-

otheranions

H

+

Loss of bicarbonatecauses the chlorideconcentration to in-crease, maintainingplasma electroneu–trality.

Cl

–

289

S. Faubel and J. Topf 12 Metabolic Acidosis: Non-Anion Gap

Introduction



Loss of fluid from the lower GI tract is a commonsource of bicarbonate loss.

All GI tract secretions below the stomach are rich in bicarbonate. Meta-bolic acidosis can occur from the loss of any of these lower GI fluids: bile,pancreatic secretions or fluid from the small or large intestines.The liver produces bile which is stored in the gallbladder. When needed(after a meal), bile is secreted via the common bile duct into the secondportion of the duodenum at the ampulla of Vater. Pancreatic secretions arealso released into the second part of the duodenum. The function of thesealkaline secretions is to neutralize the acidic fluid of the stomach.The small intestine absorbs nutrients and the large intestine (colon) ab-sorbs water. The fluid of the small intestine has the same electrolyte compo-sition as pancreatic secretions.

Any process which increases lower GI fluid loss can cause a non-anion gapmetabolic acidosis.

Diarrhea is the most common cause. Fistulas, ureterosig-moidostomy, obstructed ureteroileostomy and cholestyramine can also in-crease lower GI bicarbonate loss. These disorders are discussed further onthe following pages.

The lower GI tract is below the _______.Secretions from the liver, _________ and the small and _______intestine all have a bicarbonate concentration which is________ (lower/higher) than plasma.stomachpancreaslargehigher

30 - 40 mEq/L

130 - 140 mEq/L4 - 6 mEq/L95 - 105 mEq/L

HCO

3 –

Na

+

K

+

Cl

–

Liver (bile)

80 - 100 mEq/L