Hepatic Encephalopathy — RACP Adult Medicine MCQ

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EasyGastroenterology & HepatologyHepatic EncephalopathyRACP Adult Medicine

A 55-year-old man with NASH cirrhosis presents with confusion, asterixis, and fetor hepaticus. His ammonia level is 120 µmol/L. He has no evidence of GI bleeding or infection. What is the first-line treatment for hepatic encephalopathy?

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Correct answer: E — Oral lactulose

Lactulose is first-line treatment for both acute and chronic hepatic encephalopathy. The dose is titrated to achieve 2–3 soft stools per day. It works by reducing ammonia absorption through acidification of colonic contents and osmotic laxation. Rifaximin is added as secondary prophylaxis after a second episode. Protein restriction is NOT recommended and may worsen sarcopenia.

Reference: eTG – 2025 – Gastrointestinal; EASL – 2022 – Hepatic Encephalopathy Guidelines