What is the management for a patient with cirrhosis and elevated ammonia levels, presenting with intestinal obstruction or ileus?

Management of Cirrhotic Patient with Elevated Ammonia and Intestinal Fluid/Air-Fluid Levels

In this patient with cirrhosis, elevated ammonia (132), and CT findings suggesting ileus or obstruction, you should use polyethylene glycol (PEG) or lactulose enema rather than oral lactulose, while simultaneously investigating and treating precipitating factors including infection, GI bleeding, and the cause of the ileus. 1

Immediate Management Priorities

Address the Ileus/Obstruction First

• Hold oral lactulose in the setting of ileus as oral administration may worsen abdominal distention and carries aspiration risk 1
• Consider polyethylene glycol as the preferred alternative when patients are at risk of ileus/abdominal distention, as specifically recommended by the 2024 AASLD guidance 1
• Lactulose enema (300 mL lactulose in 700 mL water for total 1 L) can be administered if PEG is unavailable, ensuring the solution is retained for at least 30 minutes 1

Treat Hepatic Encephalopathy Empirically

• Start empiric HE therapy immediately while investigating precipitating factors, as the ammonia level of 132 μmol/L is elevated and correlates with HE severity 1
• The goal is 2-3 soft bowel movements daily once the ileus resolves 1, 2, 3
• Monitor electrolytes closely to prevent dehydration and hypernatremia, which are common complications of aggressive lactulose therapy 1, 3

Investigate and Treat Precipitating Factors

Most Common Precipitants to Rule Out

The CT findings of fluid-filled bowel with air-fluid levels suggest possible:

Infection (most critical to address):

• Start empiric antibiotics immediately in critically ill patients at high risk of infection 1
• Obtain complete blood count with differential, C-reactive protein, blood cultures, urinalysis with culture, and consider diagnostic paracentesis if ascites present 1

GI Bleeding:

• Check complete blood count, perform digital rectal examination, and stool blood test 1
• The intestinal fluid on CT could represent blood 1
• Endoscopy should be performed urgently if bleeding is suspected 1

Constipation/Ileus:

• The CT findings confirm this as a precipitant 1
• Determine if medication-related (opioids, benzodiazepines) or from other causes 1

Electrolyte disorders and AKI:

• Check serum electrolytes, BUN, creatinine, and assess volume status 1
• Dehydration from diuretics or paracentesis is a common precipitant 1

Specific Treatment Algorithm

If Patient Can Take Oral Medications (Once Ileus Resolves):

1. Lactulose 30-45 mL every 1-2 hours until achieving 2 bowel movements, then titrate to maintain 2-3 soft stools daily 1, 2, 3
2. Consider adding rifaximin 550 mg twice daily for recurrent HE prevention, though its role in acute ACLF/critically ill patients requires further study 1, 2

If Patient Cannot Take Oral Medications or Has Persistent Ileus:

1. Polyethylene glycol is preferred per 2024 AASLD guidance for patients at risk of ileus 1
2. Lactulose enema (300 mL lactulose + 700 mL water) 3-4 times daily, retained for 30+ minutes 1
3. Nasogastric tube administration only if safe (avoid if recent variceal banding) 1

For Severe or Refractory Cases:

• Intravenous L-Ornithine L-Aspartate (LOLA) 30 g/day can be added to lactulose, leading to lower HE grade within 1-4 days 2, 4
• Consider ICU admission if patient develops Grade 3-4 HE (West Haven criteria) or Glasgow Coma Scale <8 1

Critical Pitfalls to Avoid

Do not over-rely on ammonia levels for management decisions:

• Ammonia levels are variable and do not guide lactulose dosing 1, 5
• However, this elevated level (132 μmol/L) does correlate with mortality risk and organ dysfunction 6
• A low ammonia level would suggest looking for alternative causes of altered mental status 1

Avoid oral lactulose in ileus:

• This is explicitly contraindicated and may worsen the clinical picture 1
• The 2024 AASLD guidance specifically addresses this scenario with PEG recommendation 1

Monitor for lactulose complications:

• Overuse causes dehydration, hypernatremia, aspiration risk, and severe perianal irritation 3
• Paradoxically, excessive lactulose can precipitate HE 3

Additional Considerations

• Assess volume status and cardiac function as baseline in all critically ill cirrhotic patients 1
• Brain imaging is NOT routinely indicated unless this is the first episode, there are focal neurological signs, seizures, or inadequate response to therapy 1
• The ileus itself may be a manifestation of severe HE or sepsis, so treating the underlying HE and infection may resolve the bowel dysmotility 1