ROSH Gastrointestinal Practice Exam

In a patient with chronic kidney disease and liver cirrhosis presenting with confusion, what is the indicated management?

1. Head CT and lumbar puncture

2. Lactulose

3. Neomycin

4. Protein-restricted diet

The correct answer is: Lactulose

The management of confusion in a patient with chronic kidney disease and liver cirrhosis is most appropriately addressed with lactulose because it serves as an effective treatment for hepatic encephalopathy. This condition is commonly seen in patients with liver cirrhosis, where the liver is unable to adequately filter toxins from the blood, leading to the accumulation of substances such as ammonia that can affect brain function and cause confusion or altered mental status. Lactulose works by drawing ammonia from the blood into the gut, where it can be eliminated through the stool. It also acidifies the contents of the colon, converting ammonia to ammonium, which is less readily absorbed into the bloodstream. This results in lower levels of ammonia and subsequently helps alleviate the symptoms of confusion associated with hepatic encephalopathy. While a protein-restricted diet may be considered in some cases of liver disease to reduce ammonia production from protein metabolism, it is not an immediate management strategy for acute confusion. Head CT and lumbar puncture are more suited for evaluating intracranial pathology like infection or hemorrhage, which are not the primary concerns in this context. Neomycin, an antibiotic that reduces ammonia-producing gut bacteria, has largely fallen out of favor due to its side effects and the availability of safer