A 58-year-old man with cirrhosis due to alcohol-associated liver disease is brought to the emergency department because of progressive confusion over the past 2 days. Family members report increasing sleepiness and difficulty completing routine tasks. His medications include furosemide and spironolactone. Temperature is 36.8°C (98.2°F), blood pressure is 110/68 mm Hg, pulse is 84/min, and respiratory rate is 16/min. Physical examination reveals disorientation, scleral icterus, ascites, and asterixis. Laboratory studies demonstrate an elevated serum ammonia level.
Which of the following is the most appropriate initial treatment?
The correct answer is:
A: Lactulose.
This patient has hepatic encephalopathy, a neuropsychiatric complication of advanced liver disease caused by accumulation of ammonia and other toxins. Lactulose reduces intestinal ammonia absorption by acidifying the colonic lumen and trapping ammonia as ammonium. It is first-line therapy and often produces significant clinical improvement.
Answer choice B: Oral iron supplementation, is incorrect.
Iron therapy may be appropriate for iron deficiency anemia but does not address the underlying cause of hepatic encephalopathy.
Answer choice C: Prednisone, is incorrect.
Students may associate corticosteroids with severe alcoholic hepatitis. However, this patient’s primary problem is encephalopathy due to cirrhosis and ammonia accumulation.
Answer choice D: Propranolol, is incorrect.
Nonselective beta-blockers reduce the risk of variceal bleeding in portal hypertension but do not improve mental status in hepatic encephalopathy.
Answer choice E: Spironolactone dose escalation, is incorrect.
Spironolactone is useful for managing ascites, which this patient has, but it does not treat the neurologic manifestations of hepatic encephalopathy.
Key Learning Point
Hepatic encephalopathy presents with altered mental status and asterixis in patients with advanced liver disease and is treated initially with lactulose.
