Q: What are the few clues (pieces of puzzle) to diagnose D-Lactic Acidosis?

Answer: 

This unique form of lactic acidosis can occur in patients with jejunoileal bypasses, small bowel resections, or other forms of short-bowel syndrome. Bacteria are responsible for metabolizing glucose and carbohydrate to D-lactic acid, which is then systemically absorbed. D-lactate is only slowly metabolized by human subjects. Clues to the diagnosis are

• history of a short bowel or any other cause of malabsorption, 
• acidosis with a broad anion gap that cannot be explained,
• neurologic symptoms (Encephalopathy),
• normal lactate level,
• negative Acetest,
• ingestion of large amounts of carbohydrate,
• diminished colonic motility, allowing time for nutrients in the colon to undergo bacterial fermentation

Treatment consists of fluid resuscitation, restriction of simple sugars, NaHCO3 administration as necessary, and the judicious use of antibiotics (such as metronidazole). The latter requires some caution, because antibiotics can precipitate the syndrome by permitting overgrowth of lactobacilli.