A 59-year-old man with alcohol-related cirrhosis was admitted 2 days ago for an upper GI bleed. Today his family says he's "not making sense." He's drowsy but arousable to voice, following one-step commands slowly. When you ask him to hold his arms out, his wrists show a coarse, irregular flap. He is mildly jaundiced, his abdomen is distended, and his stool this morning was melena. Labs: ammonia 110 mcg/dL, Na+ 129 mEq/L, platelets 78,000/µL, INR 1.8.
His mental status is worsening and there's a new finding on exam. What does it mean, and what do you do first?
His confusion, the flapping tremor (asterixis), and an ammonia of 110 point to worsening hepatic encephalopathy. Lactulose is the direct treatment: it traps ammonia in the gut and clears it out. He's drowsy but arousable and following commands, so he can protect his airway and take it safely by mouth. A more obtunded patient would need it rectally or via NG tube instead.
Asterixis, the "liver flap," happens because rising ammonia disrupts the brain's motor control centers, causing brief lapses in sustained muscle tone. Assess it by having the client extend both arms, dorsiflex the wrists, and hold, watch for involuntary flapping. It's a bedside sign worth trending, not just noting once.
"The lactulose is causing diarrhea, hold it." Soft, frequent stools (2 to 3 a day) are the therapeutic effect, that's how ammonia leaves the body. Only the provider adjusts the dose if stools become excessive; you don't simply stop it.
keep asking why