Question

A 68 year old woman with a history of cirrhosis is receiving enteral nutrition due to recent gastrointestinal surgery. She has worsening hepatic encephalopathy. Which of the following should be tried first?

1: Decrease in protein provision to 0.6 g/kg/d
2: Formula high in medium chain triglyceride content
3: Formula enriched with branched-chain amino acids
4: Lactulose and rifaximin therapy

Answer 1

The initial treatment for hepatic encephalopathy in a patient with cirrhosis receiving enteral nutrition should be lactulose and rifaximin therapy. This approach is aimed at rapidly reducing ammonia levels in the blood. Adjustments to protein intake and specialized formulas may be considered later in the treatment process.

Step-by-step explanation:

The 68-year-old woman with cirrhosis suffering from hepatic encephalopathy (HE) should be treated first with lactulose and rifaximin therapy. This combination of therapies is usually considered the initial management for HE. Lactulose helps reduce the absorption of ammonia from the gut, and rifaximin is an antibiotic that alters the gut microbiota to reduce ammonia production. While altering protein intake or using specialized formulas can be part of managing HE, the priority in treatment is to reduce ammonia levels promptly through the use of these medications.

A decrease in protein provision is typically considered after initiating lactulose and rifaximin if HE symptoms persist or recur despite treatment. Formulas high in medium-chain triglycerides or enriched with branched-chain amino acids may be beneficial in some cases but are not the first line of treatment. It's important to monitor and tailor nutrition in patients with HE carefully, as too little protein can also exacerbate malnutrition, further complicating the condition.