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Cirrhosis encephalopathy — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Cirrhosis encephalopathyUSMLE Step 3

A man with cirrhosis has a second overt hepatic-encephalopathy recurrence despite adherence to lactulose titrated to two to three soft stools daily. Infection, bleeding, constipation, and sedatives have been excluded. Which long-term change is most appropriate?

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Correct answer: C — Add rifaximin 550 mg twice daily while continuing titrated lactulose

The best answer is “Add rifaximin 550 mg twice daily while continuing titrated lactulose”. Rifaximin is effective add-on therapy to lactulose for prevention of recurrent overt hepatic encephalopathy, with the strongest trial evidence in patients with repeated episodes. Long-term protein elimination worsens nutrition, and sedatives may precipitate encephalopathy. Continuing both agents targets recurrence while preserving the established benefit of lactulose.

Reference: AASLD Practice Guideline: Hepatic Encephalopathy in Chronic Liver Disease: https://www.aasld.org/sites/default/files/2022-07/Hepatic%20Encephalopathy%20in%20Chronic%20Liver%20Disease%202014.pdf