My father had hepatic encephalopathy. What are its triggers?

Question

Hello doctor,

I am asking about my father, 62, who has liver cirrhosis and was recently diagnosed with overt hepatic encephalopathy. Over the last week, he has been confused, mixing up names, and staying awake all night. He has been on lactulose but skips doses due to diarrhea and stomach cramps.

The hospital mentioned adding Xifaxan, but we are unsure how necessary it is. Can you please guide us on:

How do we know if medicines are actually controlling the brain symptoms?
What warning signs mean this is getting dangerous fast?
Can diet, protein intake, or dehydration suddenly worsen his confusion even if medicines are taken?

Kindly suggest.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Your father’s confusion, name-mixing, and sleep reversal are typical signs of overt hepatic encephalopathy (HE) caused by toxin buildup, especially ammonia, due to cirrhosis.

Lactulose works by removing ammonia through stool. Diarrhea and cramps mean the dose may be too high, not that it should be stopped. The goal is two to three soft stools daily, not watery diarrhea. Dose adjustment solves most intolerance.

Rifaximin (Xifaxan) is strongly recommended after overt HE. It reduces ammonia-producing gut bacteria and, when combined with Lactulose, lowers recurrence risk by approximately 50 to 60 percent. It is safe and very effective for long-term prevention.

Below are a few noticeable signs that show the medication is working:

Improved alertness and orientation.
Normal sleep–wake cycle returning.
Clear speech and normal behavior.

Clinical improvement is more important than ammonia levels. Common triggers, even with medicine, include:

Dehydration.
Constipation or missed lactulose.
Infection.
GI (gastrointestinal) bleeding.
Excess intake of sedatives.
Severe protein restriction or muscle loss.

A few other danger signs that require urgent care are as follows:

Increasing drowsiness.
Not recognizing family.
Difficulty waking.
No bowel movement for more than 24 to 48 hours.
Fever or bleeding.

Strict adherence to lactulose and Rifaximin and avoiding triggers is essential to prevent recurrence.

I hope you find this helpful.

Thank you.