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HE Treatment — RACP Adult Medicine MCQ

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EasyGastroenterologyHE TreatmentRACP Adult Medicine

A 55-year-old woman with alcoholic cirrhosis presents with acute confusion. She has asterixis and fetor hepaticus. Her medications include spironolactone, furosemide, and lactulose. She recently had an upper GI bleed treated with EVL. Ammonia is 165 μmol/L. She has missed her lactulose for 3 days due to vomiting. What is the most appropriate treatment?

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Correct answer: D — Lactulose (oral or NG) titrated to 2-3 soft stools/day plus rifaximin

Hepatic encephalopathy precipitated by GI bleed (large protein load) + lactulose non-adherence. Treatment: (1) Lactulose (oral/NG or rectal) titrated to 2-3 soft stools/day (first-line), (2) Rifaximin 550 mg BD (prevents recurrence — RFHE trial showed 58% reduction in recurrent HE), (3) Identify and treat precipitants (GI bleed, infection, constipation, electrolytes, medications). Do NOT restrict protein — adequate nutrition (1.2-1.5 g/kg/day protein) is essential.

Reference: GESA – 2024 – HE; EASL 2024; RFHE Trial