A 58-year-old man is brought to the emergency department by his wife due to worsening confusion and lethargy over the past 24 hours. The patient has a history of alcohol-induced cirrhosis and portal hypertension. He has not had any recent fever, falls, or changes in his medications. Vital signs are within normal limits. On physical examination, he is disoriented to time and place. Scleral icterus is present. When asked to hold his arms outstretched with wrists extended, a sudden, brief downward flapping of the hands is observed. Laboratory studies show a normal leukocyte count, an elevated serum ammonia level, and normal serum electrolytes. Which of the following is the most appropriate next step in management?
- AAdministration of intravenous haloperidol
- BAdministration of intravenous broad-spectrum antibiotics
- Administration of oral lactuloseCevap
- DEmergent hemodialysis
- ETransjugular intrahepatic portosystemic shunt placement
Cevap
Administration of oral lactulose
The correct answer is the administration of oral lactulose. This patient's presentation of confusion, lethargy, and asterixis in the setting of known cirrhosis is classic for hepatic encephalopathy. Hepatic encephalopathy is driven by the accumulation of neurotoxins, primarily ammonia, which the impaired liver is unable to effectively metabolize into urea. Lactulose is a non-absorbable synthetic sugar. In the colon, it is broken down by colonic bacteria into short-chain fatty acids, which lowers the colonic pH. This acidic environment converts absorbable ammonia (NH3) into non-absorbable ammonium (NH4+), trapping it in the colon so it can be safely excreted in the stool. This mechanism effectively lowers systemic ammonia levels and rapidly improves the encephalopathy.
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Anahtar Kavram
Hepatic encephalopathy is a common complication of cirrhosis presenting with altered mental status and asterixis; first-line treatment is oral lactulose to safely reduce systemic ammonia levels.