My mom, 62, has NASH-related cirrhosis. Why is she disoriented?

Question

Hello doctor,

My mother, 62, with NASH-related cirrhosis, has started acting disoriented since last night. She called me by the wrong name and tried to leave home at midnight, saying she had office work, though she retired years ago. She is on Xifaxan (Rifaximin) and lactulose for previous overt hepatic encephalopathy episodes.

She missed one Rifaximin dose yesterday and also had constipation for two days. Could that alone trigger such confusion? There is no fever, but her speech sounds slurred, and she seems very sleepy today.

I am unsure if this is grade 1 or something more serious. Should we get ammonia levels checked urgently or bring her straight to the emergency?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

Thank you so much for sharing your concern with me.

Your mother’s symptoms are very concerning for recurrent hepatic encephalopathy in the setting of liver cirrhosis due to NASH (nonalcoholic steatohepatitis). Confusion, misnaming family members, abnormal sleep behaviour, dysarthria, and somnolence suggest progression to moderate (grade 2 to 3) encephalopathy, which should be assessed urgently.Yes. Hepatic encephalopathy can occur from constipation alone.

When stool is left in the colon, toxins such as ammonia build up. Missing a single dose of Rifaximin is less likely to cause a major episode by itself, but combined with constipation, it can contribute. Other triggers such as dehydration, infection, electrolyte imbalance, or gastrointestinal bleeding must also be ruled out. In this situation, do not wait only for ammonia testing at home. Ammonia levels do not always correlate perfectly with symptoms, and clinical status is more important. Because she is disoriented, sleepy, and speaking abnormally, she should be taken to the emergency department immediately for evaluation.

Doctors will usually check blood tests, electrolytes, kidney function, infection markers, and adjust lactulose dosing to achieve two to three soft bowel movements daily. Rapid reversal of symptoms is often seen with early treatment. Make sure she maintains lactulose, remains hydrated, and avoids sedatives until assessed. Given her current mental status, urgent hospital assessment today is strongly recommended.

I hope this helps you.

Thank you.