A 68-year-old woman with cirrhosis receiving enteral nutrition due to recent gastrointestinal surgery and worsening hepatic encephalopathy. Which of the following should be tried first?

• A. Lactulose and rifaximin therapy
• B. Decrease protein provision to 0.6 g/kg/d
• C. Formula enriched with branched-chain amino acids
• D. Medium-chain triglyceride adding to tube feeding

Answer: (A)

When hepatic encephalopathy is present in cirrhosis, the priority is to reduce ammonia production and absorption in the gut. Lactulose does this by lowering colonic pH, which converts ammonia (NH3) to ammonium (NH4+), a form that is trapped and excreted, and it also acts as a laxative to shorten gut transit time. The goal with lactulose is typically to achieve 2–3 soft stools per day, which corresponds to better ammonia clearance.

If HE persists or recurs after optimizing lactulose therapy, adding rifaximin is beneficial. Rifaximin is a nonabsorbable antibiotic that decreases the gut bacteria responsible for producing ammonia, providing additional control of encephalopathy.

Avoid reducing protein intake as a first step. Maintaining adequate protein is important for nutrition, and current practice does not support heavy protein restriction to manage HE. Branched-chain amino acid–enriched formulas or medium-chain triglyceride–containing formulas aren’t first-line strategies for initial HE management; they may be considered in specific situations but do not address the underlying ammonia problem as effectively as lactulose (and rifaximin) does.