How do I manage worsening OHE in my 58-year-old father?

Question

Hello doctor,

I am writing about my father, 58, who has alcohol-related cirrhosis and was diagnosed with overt hepatic encephalopathy last year. Over the past few days, he has been very confused, mixing up names of family members and struggling to button his shirt. His hands shake with that flapping movement doctors mentioned before.

He is on lactulose but often skips doses because of frequent loose motions. The hepatologist added Xifaxan (Rifaximin) recently, but we are unsure how fast it should start working. Yesterday, he seemed more drowsy and almost fell while walking to the bathroom.

His ammonia levels were high in the last report.

Could this mean the OHE is worsening despite medication?
Should we bring him to the hospital immediately or adjust doses at home?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

Thank you so much for sharing your concern with me.

Your father’s symptoms strongly suggest worsening hepatic encephalopathy, a complication of liver cirrhosis in which toxins (especially ammonia) affect brain function. Confusion, difficulty with simple tasks (like buttoning clothes), drowsiness, and the characteristic flapping tremor (asterixis) are typical signs.

However, the omission of Lactulose medication can cause an immediate deterioration due to the fact that the drug aids in removing ammonia via the stool. It is important to aim for two to three soft stools a day, not diarrhea.

Rifaximin works by reducing ammonia-producing gut bacteria. It usually begins helping within several days, but it is mainly an add-on therapy, not a replacement for lactulose.

Because your father is becoming more confused and drowsy and has nearly fallen, this could indicate progression of encephalopathy or a triggering problem such as infection, dehydration, constipation, gastrointestinal bleeding, electrolyte imbalance, or medication changes.

The problem needs to be assessed immediately in the hospital, instead of altering medication dosage at home. Doctors can order blood tests, checks for infections, electrolyte balance, and proper hydration. The dosage of Lactulose may be altered.

In the meantime, ensure he takes lactulose regularly, stays hydrated, and avoids sedative medications. However, given the recent worsening mental status, prompt medical evaluation today is strongly recommended to prevent further complications.

I hope it helps with your query.

Thank you.