H&P: 51-year-old female with Crohn’s disease, morbid obesity, and a BMI of 42 presents from home in a private vehicle with 4 days of fever, severe abdominal pain, diarrhea, and nausea and vomiting.

PMH: Hypertension, Crohn’s disease, and CKD Stage 3a with a baseline creatinine of 1.2

Home Medications: Stelera 90 mg SQ every 8 weeks (last dose 6 weeks ago), Prednisone 20 mg PO daily, Metoprolol 50 mg PO BID, and Lisinopril 20 mg PO daily

Vitals: B/P 99/56, HR 89, Temp 100.8, RR 18, Pulse ox 96% on room air

PE: Abdomen TTP, scant dark urine

Labs: Lactic Acid 4.2, WBC 18.5, Creatinine 1.5, CRP 105. Repeat lactic acid after fluid bolus 3.0 and 1.5.

CT: Abdomen revealing small-bowel wall thickening, mesenteric inflammatory stranding, and mesenteric adenopathy, partial small bowel obstruction. Impression: Crohn’s disease with partial obstruction

Consult: GI consulted, NGT placed, started IV prednisone to be tapered to PO once pain subsides and having bowel movements again.

Discharge Summary: Crohn’s flare with partial small bowel obstruction. Treated with NGT tube, IV prednisone, pain medication, 2 L normal saline bolus & normal saline continuous IV @ 75 ml/hr. Patient is tolerating PO intake and having normal bowel movements. Outpatient GI follow-up in 1 week.

Discharge Medication: Prednisone increased to 40 mg PO daily, resume home medications of Metoprolol 50 mg PO BID, and Lisinopril 20 mg PO daily, and normal Stelera injection in 10 days.

Question: Are there query opportunities based on the scenario stated above?

Discussion: The patient has exhibited the following risk factors and clinical indicators: 4 days of abdominal pain, diarrhea, and nausea & vomiting. Lactic Acid 4.2 with repeat lactic acid after fluid bolus 3.0 and 1.5. Crohn’s disease with partial small bowel obstruction and CKD stage 3a.

Diagnostic criteria for Lactic Acidosis:

Lactic acid > 4

Lactic Acid > 2 plus pH < 7.35

Lactic Acid > 2 plus Anion gap > 12

Treatment for Lactic Acidosis:

Normal saline IV fluid bolus 2,000 ml

Normal saline IV continuous rate 75 ml/hr

UASI Recommends: Query for Lactic Acidosis

Documentation without clarification:

Principal Diagnosis: K50.012 Crohn’s disease of small intestine with intestinal obstruction

Secondary Diagnosis: E66.01 Morbid obesity, Z68.41 BMI 40.0-44.9 adult

Working DRG: 386 Inflammatory bowel disease with CC

RW: 0.9898

GLMOS: 3.4

SOI/ROM: 1/1

Documentation with clarification:

Principal Diagnosis: K50.012 Crohn’s disease of small intestine with intestinal obstruction

Secondary Diagnosis: E66.01 Morbid obesity, Z68.41 BMI 40.0-44.9 adult, E87.20 Acidosis, unspecified

Working DRG: 386 Inflammatory bowel disease with CC

RW: 0.9898

GLMOS: 3.4

SOI/ROM: 2/2

CDI Educational Tips:

Acidosis is classified to code E87.20. Inclusion terms are lactic acidosis and metabolic acidosis.

E87.20 provides a CC as a secondary diagnosis.

The treatment of metabolic acidosis and alkalosis depends entirely on its cause. The underlying cause should also be treated.

Conditions often associated with acid/base imbalance include diarrhea, poisoning (metabolic acidosis), vomiting, dehydration (metabolic alkalosis), sepsis (elevated lactate), and COPD (respiratory acidosis).



An elevated lactate/lactic acid does not necessarily indicate lactic acidosis which requires elevated lactate in addition to acidosis (pH<7.35). Lactate levels < 2.0 are normal, and transient slight elevations are often not clinically significant. For example, a slightly elevated lactate of 2.2 on admission for which the lactate level is simply repeated.