A 60-year-old man is brought to the emergency department due to progressive lethargy. The patient has a history of alcoholic cirrhosis and was recently seen in his primary care provider's office for increasing abdominal distension and leg swelling. His wife says that the swelling improved slightly after furosemide and spironolactone were started, but for the last 2 days he has been confused and irritable. The patient has slept most of the time and has not eaten. Temperature is 36.7 C (98 F), blood pressure is 96/50 mm Hg, and pulse is 96/min. On examination, the patient appears lethargic but is arousable. He is not very cooperative and at times is agitated. Mucous membranes are dry. His outstretched hands exhibit a flapping tremor. The abdomen is nontender and distended, and shifting dullness is present. Bilateral lower extremity pitting edema is present. Stool occult blood is negative. Laboratory results are as follows:
| Leukocytes | 8,000/mm3 |
| Platelets | 120,000/mm3 |
| Serum chemistry | |
| Sodium | 134 mEq/L |
| Potassium | 3.0 mEq/L |
| Bicarbonate | 30 mEq/L |
| Blood urea nitrogen | 28 mg/dL |
| Creatinine | 1.1 mg/dL |
| Glucose | 80 mg/dL |
Which of the following is the best initial treatment for this patient?
Hepatic encephalopathy | |
Precipitating factors |
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Clinical presentation |
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Treatment |
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GI = gastrointestinal; SBP = spontaneous bacterial peritonitis; TIPS = transjugular intrahepatic portosystemic shunt; UTI = urinary tract infection. | |
This patient with cirrhosis has lethargy, confusion, and asterixis (flapping tremor with outstretched hands) suggestive of hepatic encephalopathy (HE). HE refers to impaired central nervous system (CNS) function in patients with cirrhosis and is due in part to the neurotoxicity from ammonia (NH3) in the setting of impaired liver function.
In this patient, HE was likely triggered by the recent initiation of diuretic therapy. This, along with poor oral intake, led to low intravascular volume (hypotension, dry mucous membranes) with:
As a result, patients with HE and hypokalemia require prompt potassium repletion in addition to intravascular volume repletion. Disaccharides (eg, lactulose, lactitol) are also administered to lower NH3 levels.
(Choice A) Patients with cirrhosis tend to be malnourished; therefore, dietary protein restriction is generally not recommended. Protein-free diets can cause a negative nitrogen balance and increase mortality. Protein restriction is generally limited to patients who have required transjugular intrahepatic portosystemic shunting (TIPS).
(Choice B) Lorazepam can be used to treat alcohol withdrawal; however, this patient does not have typical manifestations of withdrawal (eg, tachycardia, hypertension, tremor).
(Choice C) Neomycin is a nonabsorbable antibiotic used to treat HE in patients unresponsive to lactulose and those unable to tolerate rifaximin.
(Choice E) TIPS is performed when a patient has ascites that does not respond to medical therapy (eg, diuretics) or has ongoing active or recurrent variceal bleeding even after appropriate treatment with upper endoscopy. TIPS is associated with HE in up to 35% of patients due to (NH3-rich) blood bypassing the liver.
Educational objective:
Patients with hepatic encephalopathy on diuretics can develop low intravascular volume despite having total volume overload, leading to a metabolic alkalosis with associated hypokalemia. Treatment includes volume resuscitation and repletion of hypokalemia in addition to serum ammonia-lowering medications (eg, lactulose).