Continuing Medical Education Questions: March 2026

Article Title: ACG Clinical Guideline: Hepatic Encephalopathy LEARNING OBJECTIVE After this activity, the participant will be able to apply evidence-based principles to identify, evaluate, and manage hepatic encephalopathy (HE) in patients with cirrhosis. CASE 1 A 67-year-old woman with history of hepatitis C-related cirrhosis is brought into the hospital by her husband with 2 days of worsening confusion and agitation. She has no prior history of hepatic encephalopathy. Vital signs are notable for a temperature of 37.7 °C, heart rate of 96 bpm and blood pressure of 112/72 mm Hg. Labs are notable for sodium 133 mEq/L, glucose 105 mg/dL, creatinine 0.9 mg/dL, aspartate aminotransferase 72 U/L, alanine aminotransferase 48 U/L, alkaline phosphatase 120 U/L, bilirubin 0.8 mg/dL, ammonia 64 µmol/L (normal 11–32 μmol/L). Neurologic exam shows no focal deficits. QUESTION 1 What is the most appropriate next step in management? Start lactulose and discharge home directly from emergency room Repeat ammonia level to confirm diagnosis of HE Start rifaximin monotherapy Initiate urgent work up for etiologies of altered mental status CASE 2 A 57-year-old man with cryptogenic cirrhosis has been hospitalized 4 times in the past 12 months for HE. He stopped driving after his first admission to the hospital. Review of his medical records shows that there has been no CT or MRI of his brain in the past 2 years; there are also notes of multiple missed appointments, social work documentation reporting lack of family or friend support, and the patient also states he has difficulty in filling prescriptions due to cost. QUESTION 2 Which factor was added as a fifth axis to the management of HE framework and is likely contributing to this patients' recurrent admissions? Medication adherence Neuroimaging Social infrastructure Serum ammonia level QUESTION 3 A 47-year-old man with covert hepatic encephalopathy (CHE) is started on lactulose. After a 6-week trial, he returns to clinic and reports improved concentration, ability to sleep better at night, and fewer falls. What is the primary proven benefit of treating CHE? Improved quality of life and daily function Reduced mortality Slow the progression of cirrhosis Improvement in liver function tests and ammonia level