TRC: Treatment of encephalopathy

Treatment of encephalopathy

Treatment is aimed at decreasing the intake and uptake of ammonia. The different opportunities are:

Lowering ammonia uptake by decreasing the protein intake via the diet. (less meat, cheese, etc.)
The laxative lactulose (see also osmotic laxatives) is broken down in the GI lumen to form lactic acid and acetic acid, thereby decreasing the pH in the colonic lumen. The hydrogen ions bind ammonia to form NH4+, which is not absorbed from the colonic lumen.
NH3 + H+ ↔ NH4+
Neomycin is an aminoglycoside antibiotic, which is not broken down and barely absorbed by the GI tract. Neomycin will eradicate the bacteria in the gastric lumen that break down proteins to produce ammonia.

What is the appropriate treatment algorithm for a patient with hepatic encephalopathy?

Extra info: D is ruled out since diuresis is never appropriate. A is ruled out since flumazenil has only limited efficacy. C is most appropriate since it begins with non-pharmacological therapy aimed at the cause of encephalopathy. B could be appropriate if non-pharmacological therapy has already been implemented, since the combination of lactulose and neomycin has been found to be more effective than either agent alone.

Option explanation:

lactulose, neomycin, flumazenil

lactulose, neomycin, lactulose + neomycin

dietary protein restriction, lactulose, neomycin

diuresis, dietary protein restriction, lactulose

Treatment of encephalopathy

Treatment of encephalopathy

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