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SSRI-associated hyponatremia — ABIM Board MCQ

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ModeratePsychiatry relevant to IMSSRI-associated hyponatremiaABIM Board

A 58-year-old with decompensated cirrhosis develops disorientation and asterixis after constipation and an upper gastrointestinal bleed. CT shows no acute intracranial lesion, glucose is normal and there is no sedative exposure. What is the best initial management?

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Correct answer: C — Give lactulose titrated to regular soft stools while identifying and correcting precipitants

The best answer is “Give lactulose titrated to regular soft stools while identifying and correcting precipitants”. This is episodic overt hepatic encephalopathy. Lactulose is first-line treatment, titrated to regular soft bowel movements, while constipation, gastrointestinal bleeding, infection, electrolyte disturbance and other precipitants are corrected. Ammonia concentration does not determine whether to treat, complete protein withdrawal is harmful, rifaximin is commonly added for recurrence, and benzodiazepines can worsen cerebral dysfunction.

Reference: AASLD/EASL Hepatic Encephalopathy Practice Guideline: https://pubmed.ncbi.nlm.nih.gov/25042402/