Ammonia Amy — Cirrhosis & Hepatic Encephalopathy
Jaundice, ascites, asterixis — lactulose until 2–3 stools a day
Amy comes in yellow and swollen, answering yesterday's questions today. Her hands flap when she holds them out, and her husband says she has slept most of the week.
Amy's scarred liver cannot clear ammonia, so her brain pays the price. Jaundice, ascites, spider angiomas, easy bruising and a flapping tremor. Lactulose traps ammonia in the gut and pulls it out in stool; rifaximin kills the ammonia-producing bacteria. Confusion is the first sign that worsens, and bleeding is what kills.
Read Ammonia Amy's full story →The story arc
The setup
Twenty years of alcohol use leaves Amy with a small, scarred, nodular liver and a belly that fills faster than she can explain.
The turn
Her skin and eyes turn yellow, her urine is dark, her stools pale, and bruises appear where nobody touched her.
The crisis
She cannot name the month, her breath smells sweet and musty, and her outstretched hands flap. Ammonia is 118.
The save
Lactulose is titrated to two to three soft stools per day, rifaximin is added, protein is kept moderate rather than eliminated, and her mental status is checked every shift.
NCLEX study section — Cirrhosis & Hepatic Encephalopathy
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Gastrointestinal & Renal
Take this chapter into practice questions on the same topic.