A 59-year-old man with a history of alcoholic cirrhosis is brought to the hospital by his wife for a progressive confusion for the past two hours. He has also an abdominal distension and yellowing of the eyes. His wife report two episodes of bloody emesis in the morning .He is admitted to the hospital and the appropriate treatment is initiated. Neurologic examination shows normal, reactive pupils and a flapping tremor when the wrists are extended. Which of the following is most likely contributing to this patient's altered mental status?

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Eductional Objective: Hepatic encephalopathy is caused by the accumulation of toxic metabolites (predominantly ammonia) in the systemic circulation due to liver failure.   Hepatic encephalopathy is frequently precipitated by a stressor (eg, gastrointestinal bleeding, infection) that increases blood ammonia levels.

A 59-Year-Old Man with a History of Alcoholic Cirrhosis Is