Skip to Main Content

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services ( for more information.


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

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

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

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

  • Provide patient education for those receiving treatment for HE.


Chief Complaint (From Son)

“My mother says she is dizzy and has felt a little off over the last couple of days.”


Charlene McInerney 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 lactulose when she ran out 1 week ago. His mother had a scheduled endoscopy 2 days ago and did not take any of her medications 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


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

No history of alcohol use


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


No known allergies


Confusion with no loss of consciousness reported. Abdominal pain reported. No change in bowel habits, dysphagia, or odynophagia. Weight gain noted per son.

Physical Examination



Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.