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, calling family members by wrong names, abnormal sleep behavior, slurred speech, and excessive sleepiness suggest progression beyond mild (grade 1) encephalopathy, possibly toward grade two to three, which requires urgent evaluation.

Yes, constipation alone can trigger hepatic encephalopathy, because toxins like ammonia accumulate when stool is retained. 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. Early treatment often reverses symptoms quickly.

Until she is evaluated, ensure she continues lactulose, stays hydrated, and avoids sedatives, but given her current mental status, urgent hospital assessment today is strongly recommended.

I hope this helps you.

Thank you.