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After completing this case study, the reader should be able to:

  • Identify and correct the precipitating factors associated with the development of hepatic encephalopathy in a cirrhotic patient.

  • Recommend appropriate nonpharmacologic and pharmacologic intervention for a cirrhotic patient who develops hepatic encephalopathy.

  • Design a plan for monitoring the efficacy and adverse effects of recommended treatments for hepatic encephalopathy.

  • Provide patient education for those receiving treatment for hepatic encephalopathy.


Chief Complaint (from Son)

“My mother says she is dizzy and has felt a little off over the past 2 days.”


Judy Sheddling is a 65-year-old woman who was brought to the ED by her son because of dizziness and confusion. The patient became increasingly confused over the past 2 days and on admission was alert to person only. The son states she is normally able to converse without difficulty but does require some assistance with ambulation. Over the past 2 days, she has had increasing difficulty with answering questions in conversations. He mentioned that his mother had forgotten to refill her prescription for rifaximin when she ran out a week ago. His mother had a scheduled endoscopy 2 days ago and did not take her lactulose the day prior to and the day of the test. She had also “retained a lot of water” and told her family that she was feeling bad.


  • ESLD secondary to NASH cirrhosis diagnosed 5 years ago; complicated by ascites

  • Grade 2 esophageal varices

  • Hypothyroidism

  • Colon cancer s/p resection (15 years ago)


Not obtainable at this time


Retired; lives with her husband; they have one son and two daughters


  • Constitutional: confused; weight gain

  • Eyes: no vision loss or pain

  • Ears, nose, mouth, throat: no hearing loss, nasal discharge, mouth or throat problems

  • Cardiovascular: no chest pains or palpitations

  • Respiratory: no shortness of breath, cough, or dyspnea on exertion

  • Gastrointestinal: (+) abdominal pain; no change in bowel habits, dysphagia, or odynophagia

  • Genitourinary: no dysuria or hematuria

  • Musculoskeletal: no joint pain or weakness

  • Neurologic: no weakness or headache

  • Psychiatric: no anxiety or depression

  • Endocrine: no diabetes; (+) thyroid disease

  • Hematologic: no enlarged lymph nodes


  • Folic acid 1 mg PO daily

  • Furosemide 40 mg PO daily

  • Lactulose 10 g/15 mL, one tablespoonful PO TID

  • Levothyroxine 100 mcg PO daily

  • Multivitamin one tablet PO daily

  • Pantoprazole 40 mg PO daily

  • Rifaximin 550 mg PO BID

  • Thiamine 100 mg PO daily



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