A 56-year-old man is brought to the emergency department due to worsening confusion. He has been forgetful and irritable for the past several days, and today, the patient's wife found him in bed, lethargic and disoriented. He has had no fever, headache, abdominal pain, or vomiting. The patient drinks a half to a full pint of vodka daily and was hospitalized previously for acute alcoholic pancreatitis. Temperature is 36.9 C (98.4 F), blood pressure is 116/68 mm Hg, and pulse is 84/min. The patient is somnolent but awakens to physical stimuli. He follows simple instructions but is not oriented to time or place. His speech is slurred. Lung fields are clear to auscultation and cardiac examination reveals normal heart sounds with no murmur. The abdomen is moderately distended with shifting dullness. The patient moves all extremities equally and has a flapping tremor of his outstretched, dorsiflexed hands. Deep tendon reflexes are 3+ diffusely. Laboratory results are as follows: Which of the following treatments will most likely improve this patient's mental status?

Question

A 56-year-old man is brought to the emergency department due to worsening confusion.  He has been forgetful and irritable for the past several days, and today, the patient's wife found him in bed, lethargic and disoriented.  He has had no fever, headache, abdominal pain, or vomiting.  The patient drinks a half to a full pint of vodka daily and was hospitalized previously for acute alcoholic pancreatitis.  Temperature is 36.9 C (98.4 F), blood pressure is 116/68 mm Hg, and pulse is 84/min.  The patient is somnolent but awakens to physical stimuli.  He follows simple instructions but is not oriented to time or place.  His speech is slurred.  Lung fields are clear to auscultation and cardiac examination reveals normal heart sounds with no murmur.  The abdomen is moderately distended with shifting dullness.  The patient moves all extremities equally and has a flapping tremor of his outstretched, dorsiflexed hands.  Deep tendon reflexes are 3+ diffusely.  Laboratory results are as follows:  Which of the following treatments will most likely improve this patient's mental status?

Quizplus · Accepted Answer

11ec25c8_d3f1_0e02_bc81_afc12613dd92_MD0003_00 This patient with likely cirrhosis (heavy alcohol use, ascites, thrombocytopenia) now has progressive confusion, slurred speech, and asterixis (flapping tremor with outstretched hands), which is suggestive of hepatic encephalopathy (HE). HE refers to impaired central nervous system function in patients with cirrhosis and is due in part to ammonia neurotoxicity from impaired liver function. Treatment involves identifying any underlying precipitant (eg, infection, sedative medications, gastrointestinal bleed) and lowering serum ammonia. Nonabsorbable disaccharides (eg, lactulose, lactitol) are preferred for lowering serum ammonia. Colonic bacteria metabolize lactulose to short-chain fatty acids (eg, lactic acid, acetic acid). This acidifies the colon to stimulate conversion of the absorbable ammonia to the nonabsorbable ammonium (an ammonia trap) and causes bowel movements (which facilitates fecal nitrogen excretion). The medication is titrated to produce 2 or 3 semiformed stools daily. (Choice A) Broad-spectrum antibiotics would be appropriate in a patient with a suspected or confirmed infection, which would generally present with fever, elevated leukocyte count, and other signs of infection (eg, tachycardia). (Choice B) Chlordiazepoxide is a long-acting benzodiazepine used to treat alcohol withdrawal, which would usually cause autonomic instability (eg, tachycardia, hypertension) along with mental status changes. (Choice C) Dantrolene is used in neuroleptic malignant syndrome and malignant hyperthermia. Patients with these conditions usually have severe muscle rigidity, fever, and tachycardia. (Choice D) Hypertonic saline is usually used in patients with hyponatremia and severe symptoms (eg, coma, seizure). A serum sodium level of 132 mg/dL is mild hyponatremia, which is not uncommon in patients with cirrhosis (hypervolemic hyponatremia) and would be an unlikely cause of this patient's symptoms. (Choice E) Thiamine is used to treat and prevent Wernicke encephalopathy, which may be seen in alcoholics due to poor dietary intake of thiamine. It presents as altered mental status, ataxia, and nystagmus, but asterixis is not generally present. (Choice G) A high-protein diet is generally not recommended in patients with cirrhosis as it can precipitate HE by causing increased serum ammonia levels. Educational objective: Treatment of hepatic encephalopathy involves identifying the underlying precipitant and lowering serum ammonia. Nonabsorbable disaccharides (eg, lactulose, lactitol) are preferred for lowering serum ammonia. 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)

A 56-Year-Old Man Is Brought to the Emergency Department Due