A 48-year-old man with alcoholic cirrhosis is brought to the emergency department due to 2 days of progressive drowsiness and lethargy. Several months ago, the patient had similar symptoms that improved after treatment with lactulose. He has had no nausea, vomiting, hematemesis, or melena. The patient was diagnosed with cirrhosis a year ago and required endoscopic ligation of esophageal varices at that time. Current medications include furosemide, spironolactone, and lactulose. The patient has been abstinent from alcohol for the past year, takes his medications regularly, and does not use tobacco or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, and pulse is 86/min. He is somnolent but wakes up to voice and follows instructions. Physical examination reveals mild scleral icterus, dry mucous membranes, and several spider angiomas on the upper chest. The lungs are clear to auscultation, and heart sounds are normal with no murmur. The abdomen is distended with shifting dullness, and there are dilated veins around the umbilicus. No abdominal tenderness is present. Rectal examination reveals negative occult blood stool. A flapping tremor of both hands is present, but there are no other focal neurologic deficits. Laboratory results are as follows: Which of the following is the next best step in management of this patient?

Question

A 48-year-old man with alcoholic cirrhosis is brought to the emergency department due to 2 days of progressive drowsiness and lethargy.  Several months ago, the patient had similar symptoms that improved after treatment with lactulose.  He has had no nausea, vomiting, hematemesis, or melena.  The patient was diagnosed with cirrhosis a year ago and required endoscopic ligation of esophageal varices at that time.  Current medications include furosemide, spironolactone, and lactulose.  The patient has been abstinent from alcohol for the past year, takes his medications regularly, and does not use tobacco or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, and pulse is 86/min.  He is somnolent but wakes up to voice and follows instructions.  Physical examination reveals mild scleral icterus, dry mucous membranes, and several spider angiomas on the upper chest.  The lungs are clear to auscultation, and heart sounds are normal with no murmur.  The abdomen is distended with shifting dullness, and there are dilated veins around the umbilicus.  No abdominal tenderness is present.  Rectal examination reveals negative occult blood stool.  A flapping tremor of both hands is present, but there are no other focal neurologic deficits.  Laboratory results are as follows:  Which of the following is the next best step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf3c_8e6e_8f63_ff8ac99ae7d2_MD0005_00 This patient with cirrhosis has altered mental status, elevated ammonia, and asterixis (flapping tremor with outstretched hands), suggesting hepatic encephalopathy (HE). HE is a spectrum of neurocognitive and motor abnormalities that primarily occurs in patients with hepatic disease. Although multifactorial in origin, most cases are due to elevated ammonia levels from a precipitating event. This patient's HE was likely precipitated by the use of diuretics for volume overload (ascites), which resulted in: Hypovolemia (dry mucous membranes, high urea nitrogen) - one of the most common precipitants of HE Hypokalemia - facilitates conversion of ammonium to ammonia Metabolic alkalosis - decreases urinary loss of ammonia He should be treated with volume and electrolyte repletion and a temporary cessation of diuretics. (Choice A) Infection is a common cause of HE in patients with hepatic disease. However, this patient has a normal leukocyte count, no fever, and no abdominal pain. Hypovolemia and electrolyte abnormalities are more likely to be the precipitants of this patient's HE. (Choice C) Lactulose is an important part of the treatment for HE, and this patient who already takes lactulose may require transient additional dosing until symptoms improve. However, the first step in treating HE is to treat the underlying precipitating cause; addressing the electrolyte and volume disturbance takes priority. (Choice D) Upper gastrointestinal bleeding is a common instigator of HE and can often be diagnosed by nasogastric lavage. However, this patient has no occult blood in his stool, no melena, and a relatively preserved hemoglobin level, making a gastrointestinal bleed less likely. (Choice E) Rifaximin is sometimes substituted for lactulose in patients whose condition does not improve within 48 hours of treatment. This patient requires correction of his electrolyte and volume abnormalities; substituting rifaximin for lactulose is not required at this time. Educational objective: Hepatic encephalopathy (HE) is usually triggered by elevated ammonia levels due to an underlying precipitating event. A common trigger of HE is excessive diuresis, which reduces intravascular volume and results in hypokalemia and metabolic alkalosis. Treatment includes volume and electrolyte repletion and using medications (eg, lactulose) to reduce ammonia levels. References: Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. (http://www.ncbi.nlm.nih.gov/pubmed/25042402) Current concepts in the pathophysiology and management of hepatic encephalopathy. (http://www.ncbi.nlm.nih.gov/pubmed/21857820)

A 48-Year-Old Man with Alcoholic Cirrhosis Is Brought to the Emergency