Question

A 45-year-old man is admitted to the medical floor of a hospital with increasing jaundice, swollen legs, and episodes of disorientation for the last several weeks. His abdomen is distended and he looks ill. According to the family, he is an alcoholic and has recently been diagnosed with cirrhosis of liver. On examination, he has a temperature of 99 F, BP 100/72 mm Hg, and his pulse is 86/minute. Sclerae are icteric, and he has 2+ pitting pedal edema. Lungs are clear, and heart sounds are normal. Abdomen is distended with moderate ascites, caput medusae, and no tenderness. Liver and spleen are not palpable. He is awake but drowsy and oriented to person and place but not to time. He does have a fine tremor in his hands. Labs show WBC 8000/uL, platelets 100,000/uL, Hb 12g%, AST 76 U/L, ALT 56 U/L, AP 62 U/L, and ammonia is 124 mg/dL.

At this time which of the following is most important to avoid full decompensation into hepatic encephalopathy?

1. Increase dietary protein
2. Prevent constipation
3. Sedate the patient to avoid injury from disorientation
4. Start IV antibiotics empirically anticipating infection
5. Add thiamine and folic acid for nutritional support

Answer 1

The most important intervention to avoid decompensation into hepatic encephalopathy in this patient is to start IV antibiotics anticipating infection.

Step-by-step explanation:

The most important intervention to prevent full decompensation into hepatic encephalopathy in this patient with cirrhosis of the liver is to start IV antibiotics empirically anticipating infection. In patients with cirrhosis, infections are a common trigger for hepatic encephalopathy. The elevated ammonia level in this patient also suggests that hepatic encephalopathy is imminent.

Increasing dietary protein may worsen hepatic encephalopathy as protein breakdown in the gut produces ammonia, which is metabolized in the liver. Preventing constipation is important to avoid the buildup of toxins in the gut, but it is not the most critical intervention in this case.

Sedating the patient to avoid injury from disorientation is not recommended as it may mask the symptoms of hepatic encephalopathy and delay diagnosis and treatment. Thiamine and folic acid supplementation for nutritional support is important in patients with alcohol-related liver disease, but it is not the most immediate priority in this patient.