D-lactic acidosis in a diabetic patient with a short bowel.

Since the initial report by De Wind and Payne in 1976 on intestinal bypass surgery for the treatment of obesity, several cases of d-lactic acidosis have been described. This syndrome is characterized by episodic increases in levels of plasma d-lactate (an isomer of l-lactate) produced from bacterial carbohydrate metabolism. d-Lactate is the anion responsible for the associated metabolic acidosis as described by Oh and colleagues. Surgical procedures that cause anatomic or functional short bowel facilitate the overgrowth of d-lactate-producing gram-positive organisms (such as Lactobacillus species, Streptococcus bovis, Bifidobacterium species, and Eubacterium species) at the expense of the gramnegative flora. Treatment of d-lactic acidosis has been successful with carbohydrate restriction and oral antibiotics, such as vancomycin, metronidazole, clindamycin, tetracycline, neomycin, and kanamycin. In patients who are taking metformin to control their diabetes, the development of metabolic acidosis is an alarming sign, because mortality is high if the acidosis is metformin induced. It is thus important to differentiate between the two conditions, give appropriate treatment, and prevent further recurrences of either condition.