A 45-year-old man with a history of alcohol use disorder is admitted for severe weakness and generalized malaise. Laboratory investigations reveal: S…

This patient has hypokalemic metabolic alkalosis with urinary chloride > 20 mEq/L. Causes of chloride-resistant metabolic alkalosis (urinary chloride > 20 mEq/L) include current diuretic use, Bartter syndrome, Gitelman syndrome, and Liddle syndrome. Since this is an adult with acute findings and a history of alcohol abuse (often associated with covert behaviors or diuretic use), surreptitious diuretic abuse or active diuretic use is the most common cause. Bartter and Gitelman are congenital tubulopathies usually presenting with hypomagnesemia and hypocalciuria (Gitelman) or hypercalciuria (Bartter), and vomiting presents with low urinary chloride (< 10 mEq/L).