How to manage my depression along with cirrhosis?

Question

Hello doctor,

I am a 47-year-old female, and I have cirrhosis due to autoimmune hepatitis. I have been hospitalized three times in the past year for overt hepatic encephalopathy, and each time the trigger seems to be a urinary tract infection or constipation. My hepatologist has already placed me on Lactulose and Rifaximin. My latest tests show that my albumin is 2.6 g/dL, my bilirubin is 4.1 mg/dL, and my Child Pugh score is Class C.

My nephrologist is now involved because my creatinine has started increasing and is currently 1.6. He is concerned about the possibility of hepatorenal syndrome developing. The overt hepatic encephalopathy episodes come on very quickly. The last time, I went from feeling completely fine to not recognizing my daughter within a few hours. My husband had to leave his job to stay home and care for me, which is putting a significant financial strain on our family.

A neurologist was consulted during my last hospital admission because I had some tremors, and they confirmed the presence of asterixis. I am currently taking Mycophenolate for autoimmune hepatitis, and my hepatologist is unsure whether the dose needs adjustment given my current liver function.

My psychiatrist, who has been treating my depression for many years, is concerned that my low mood between the episodes of overt hepatic encephalopathy is becoming more difficult to treat. I would appreciate guidance on how to prevent these episodes from recurring and whether the TIPS procedure is still an option for me, given my MELD score of 19.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Your situation is complex and understandably stressful. Recurrent hepatic encephalopathy (HE) is common in advanced liver cirrhosis (LC), especially when liver function is reduced, as suggested by a Child Pugh (CP) class C score and a model for end-stage liver disease (MELD) score of around 19. In this condition, the damaged liver cannot adequately clear toxins such as ammonia, which then affect brain function and lead to confusion, tremors, and the asterixis your neurologist observed.

You are already on the standard preventive therapy with Lactulose and Rifaximin. Lactulose should usually be adjusted to maintain two to three soft stools daily, which helps eliminate ammonia from the body. Missing doses or developing constipation can quickly trigger hepatic encephalopathy episodes. As you noted, infections, especially urinary tract infections (UTIs), are also common triggers and should be treated promptly.

Other preventive measures include maintaining good hydration, avoiding sedative medications when possible, correcting electrolyte imbalances, and ensuring adequate nutrition with moderate protein intake rather than strict protein restriction. Family members should watch for early warning signs such as sleep reversal, irritability, slowed thinking, or subtle confusion so treatment can be intensified early if symptoms begin.

Your rising creatinine raises concern for hepatorenal syndrome (HRS), which requires close monitoring by both hepatology and nephrology teams. Regarding transjugular intrahepatic portosystemic shunt (TIPS), it is generally used for complications such as refractory ascites or variceal bleeding. However, it can sometimes worsen hepatic encephalopathy, so careful patient selection is essential. In patients with advanced disease and recurrent encephalopathy, evaluation for liver transplantation (LT) is often an important discussion.

Given the frequent hospitalizations and the impact on your family life, close follow-up with your hepatology team and early treatment of infections are crucial. With coordinated care involving hepatology, nephrology, and mental health support, many patients achieve better control of hepatic encephalopathy (HE) while planning the next steps in long-term management.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.