Review Question - QID 107354

This patient’s clinical presentation is consistent with hepatic encephalopathy (HE) given her recent TIPS procedure, agitation, and confusion. The most appropriate treatment for this condition is lactulose.

HE involves reversible neurological impairment due to liver dysfunction. HE is associated with increased blood ammonia concentration. Patients with TIPS are at higher risk of developing HE due to blood being redirected away from the liver, which leads to higher circulating blood ammonia levels. HE treatment is aimed at increasing ammonia excretion and reducing ammonia production. Patients should first have any electrolyte abnormalities repleted, in particular, hypokalemia as hypokalemia by itself can exacerbate this condition. Appropriate subsequent treatment can involve rifaximin or lactulose which decrease gut absorption of ammonia.

Incorrect Answers:
Answer 1: Ciprofloxacin may be prescribed in patients with cirrhosis for spontaneous bacterial peritonitis prophylaxis or to treat infectious diarrhea.

Answer 3: Nadolol may be prescribed in patients with cirrhosis and low grade varices that have not bled but are at risk for hemorrhage. This will prevent the incidence of rebleeding.

Answer 3: Protein-restricted diet is not recommended in HE since it may result in malnutrition and predispose to infection.

Answer 5: Rifampin is not indicated in the treatment of hepatic encephalopathy; however, rifaximin is (an antibiotic that destroys gut flora).

Bullet Summary:
Lactulose and rifaximin are appropriate treatments for hepatic encephalopathy.