Acute Careniche
A 46-year-old man who drinks a bottle of spirits most days has vomited for three days and eaten nothing; he stopped drinking two days ago. He is alert, with epigastric tenderness and deep sighing respiration. Venous glucose 4.1 mmol/L, sodium 136 mmol/L, chloride 96 mmol/L, bicarbonate 11 mmol/L [22-32], creatinine 78 micromol/L, lactate 1.8 mmol/L [less than 2.0], beta-hydroxybutyrate 5.2 mmol/L [less than 0.6]. Measured and calculated osmolalities agree. Which one of the following explains his acidosis?