Got diabetes questions? You came to the right place! Ask D'Mine is our weekly advice column, hosted by veteran type 1, diabetes author and educator Wil Dubois.

This week, Wil has his eye on high blood sugars and what "diabetes ketoacidosis" (see DKA) really means. It's not as simple as you might think... But he has his DKA detective hat on, so read on!

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Morgan, type 1 from California, writes: I enjoy your column immensely and have a question for you. I am hoping you could explain exactly why and how DKA causes abdominal pain. I have tried to research this myself, but found myself lost in the wilds of medical articles' incomprehensible to a scientifically-challenged individual like myself. This is an issue of some personal interest to me, as several times my pump has stopped delivering and the first sign I had that something was wrong (before I checked and found ketones) was mild abdominal pain. I am also interested in knowing why this symptom only seems to occur in some individuals.

Wil@Ask D'Mine answers: Of course, we all know that one of the DKA symptoms is nausea, and sometimes vomiting. I've been teaching that for years. But the cause? I never even thought to wonder about it before you asked! What an awesome question! And as soon as I read your letter, I was dying to know the answer myself. But no wonder you had a hard time lost in the wilds of the incomprehensible medical articles, as when I began to research your question I found that the experts disagree about the cause.

That said, after looking at the various theories, one stood out to me because it made sense. It was logical to my understanding of the nuts and bolts of the human body. But in the interest of fair play, I'll share the competing views with you, too. However, before we get to that, we need to review just what diabetic ketoacidosis, known as DKA, is.  Often we are given the Cliffs Notes version: With no insulin cells can't process sugar for energy. When cells can't get to sugar they turn to burning fat for fuel. Burning fat releases ketones. Too many ketones poison blood.

But it's really not that simple.

A few months ago we got a blood ketone meter at our clinic to use as a scientific triage system to help us determine what degree of DKA we could handle in-house, and which ones we needed to ship out to the regional trauma center, because fixing DKA involves a lot more than topping off the insulin tank and adding some fluids. One of my tasks was to read up on DKA, look at various guidelines, and establish a protocol for whom we treat and whom we ship. During that research, I gained a new appreciation for just how fiendishly complex DKA really is.


High Blood Sugar


The "official" DKA range starts at 250 mg/dL in terms of blood sugar, but that also has to be accompanied by a pH shift. It gets pretty complicated pretty quickly, and medical DKA can't actually be determined with home gear, 'cause we have no way to test arterial blood gases at home (mixed blessing). So short answer: It really depends, and Your Diabetes May Vary.

Once DKA sets in, weird things begin to happen in how cells absorb or discharge fluids. The kidneys freak out. The liver goes whacko. Sodium levels plummet. Bicarbonate drops. The three ketones (acetone, beta-hydroxybutyrate, and acetoacetate) shift the pH of the blood. Lungs respond by shifting their normal breathing patterns to rapid shallow breaths. Electrolytes and hormones of every flavor spiral out of control: Some dropping, others increasing. Fluid loss is epic. A typical DKA drains a gallon-and-a-half of fluid from the body!

In short, it's a metabolic train wreck.

Stats tell us DKA accounts for 14% of all hospital admissions of PWDs, and 16% of diabetes-related fatalities. For those of you with a morbid fascination for such things, it's actually cerebral edema, triggered by rapid intracellular fluid shifts that can happen as the medical team struggles to restore the fluid balance, that's the number one cause of death in DKA.

The second leading cause of death is hypokalemia, a severe shortage of potassium. Potassium levels can tank (or in medical terminology "drop precipitously") once insulin is added to treat the hyperglycemia. So what? Well, potassium is an electrolyte whose day job is regulating the nerve and muscle cells in the heart. Right. Potassium is in the driver's seat when it comes to keeping your heart beating. You can see how, if the levels got too low it could be... uh, bad for you.

OK, enough scary crap.

To start my search for the cause of DKA rocky stomach, I opened up my copy of Dr. Steven Edelman's diabetes treatment bible. Yeah, he's the same guy who runs the "Take Control Of Your Diabetes" traveling circus (i.e. interactive conference series), and his book is a treasure trove of clinical data. Nevertheless, in my (slightly out of date version) Dr. E says: "The gastrointestinal symptoms probably are related to the ketosis and/or the acidosis."

So that's not particularly helpful.

Next I turned to the Joslin Deskbook, which is not one of those books you snuggle up with at night for a good read. It flatly says the cause is unknown.

Sot that's not particularly helpful, either.

Next stop, the Internet, where one widely quoted theory is that as ketones pass into the urine they carry both sodium and potassium salts with them, and that this supposedly triggers the nausea, although by what mechanism, is not stated. From other sources I could see that nausea is a common symptom of low sodium. So could that be it? The ketones steal the sodium and that triggers the nausea? Although I found this theory widely published as a fact, the source was never credited. And then I noticed that the wording in many locations was identical, suggesting a single un-credited source. After much digging, I finally tracked the original quote to Dr. Ahmad Al-Mubaslat, an endo at a private practice in Kansas City, MO.

Still not satisfied, I tried some out-side-the-box consideration of my own. Thinking about the huge fluid loss in DKA, I checked dehydration symptoms but found that nausea isn't one of them. So that wasn't it.

Then I saw that the primary ketone, beta-hydroxybutyrate, considered by many to be thDKA Tshirte smoking gun for nausea, commonly described as a "strong organic acid." I know it's in the blood and in the urine during DKA, but is it also in the stomach itself? Could acid in the stomach be the cause? I couldn't find anything more about that, so I'm probably barking up the wrong tree.

But it may be that the opposite is true. Rather than acid in the stomach, the buffers to our own stomach acids could be affected. Remember that one of the things that plummets during DKA are levels of bicarbonate. Well, bicarb is secreted by the stomach, where it's a building block of the mucus that protects the stomach lining from it's own digestive acids. So it could be that DKA wipes out our endogenous Tums.

But guesswork by an amateur sleuth is no substitute for fact, so I gave up and wrote to Yale Diabetes Center's Dr. Silvio Inzucchi, who is both brilliant and patient when it comes to off-the-wall-questions from reporters. His response was, "I was taught that the ketones (like beta-hydroxybutyrate) and the acidosis lead to intestinal paralysis (or severe slowing) and this leads to the nausea." Then he goes on to say, "Not sure what the proof for that is."

I think the proof may be in the pudding. This was the first thing from a credible, reliable source that simply made sense to me. It would also help explain why some of us are more likely to suffer DKA nausea and vomiting than others. The longer we've have diabetes, and/or the worse our control might have been during that time period, the more likely it is that we might have a touch of gastroparesis. Nothing like a little neuropathy of the intestines to set us up for acidosis-induced intestinal paralysis!

So no one knows for sure, but I'll put my money on Dr. Inzucchi.



This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.


Disclaimer: Content created by the Diabetes Mine team. For more details click here.


This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.