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GI Bleeding Precipitating HE — RACP Adult Medicine MCQ

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EasyGastroenterologyGI Bleeding Precipitating HERACP Adult Medicine

A 60-year-old man with known cirrhosis (Child-Pugh C) on lactulose and rifaximin presents with worsening confusion (Grade 3 HE). He has melaena on rectal examination. Hb has dropped from 120 to 75 g/L. Ammonia is 185 μmol/L. What is the most likely precipitant of hepatic encephalopathy?

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Correct answer: C — GI bleeding

GI bleeding is one of the most common and important precipitants of HE. Blood in the GI tract provides a large protein load that is metabolised to ammonia by gut bacteria. The nitrogen load from 500 mL of blood is equivalent to ~100 g of protein. Management: treat the GI bleed (endoscopy, octreotide), lactulose (target 2-3 soft stools/day), and rifaximin.

Reference: GESA – 2024 – Hepatic Encephalopathy; EASL 2024