A 48-year-old cirrhotic patient (Child-Pugh B, ascites controlled on spironolactone 200 mg, MELD score 14) develops confusion, asterixis, and day-night reversal. Serum ammonia is 148 µg/dL. He experienced a GI bleed 3 days ago. Which precipitant and primary treatment principle applies here?
- A Precipitant: infection; Treatment: IV lactulose and neomycin combination
- B Precipitant: hyponatraemia; Treatment: 3% saline infusion to rapidly correct sodium
- C Precipitant: spontaneous bacterial peritonitis; Treatment: blood culture + ascitic tap + ceftriaxone
- D Precipitant: GI bleed; Treatment: lactulose to purge nitrogenous load from gut + rifaximin for chronic prevention ✓
Explanation
GI bleeding is the precipitant of hepatic encephalopathy here — blood in the gut is metabolised by colonic bacteria to ammonia. Initial management targets removal of the nitrogenous substrate: lactulose (laxative acidifying the colon, trapping NH4+, promoting evacuation) is the acute treatment, and rifaximin (non-absorbed gut antibiotic reducing urease-producing bacteria) is the standard of care for secondary prevention of HE (Bajaj NEJM 2010; rifaximin + lactulose showed superior outcomes). Rapid sodium correction with 3% saline risks central pontine myelinolysis. Neomycin is no longer recommended due to nephro/ototoxicity.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.