Gastrointestinal and Hepatic — Cirrhosis complications

A 56-year-old man with cirrhosis secondary to chronic hepatitis C infection is brought to hospital by his wife because of worsening confusion over the past two days. He was alert and functioning normally three days ago, but since last night he has been disoriented to time and place, with periods of somnolence alternating with agitation. He has known ascites managed with diuretics and has not had a bowel movement in four days. On examination he is afebrile, blood pressure 118/76 mmHg, heart rate 92 beats per minute. He is oriented to person only and has a flapping tremor of the outstretched hands when asked to hold them extended (asterixis). The abdomen is mildly distended with shifting dullness but no tenderness or rebound. There is no nuchal rigidity or focal neurologic deficit. Laboratory investigations show an elevated serum ammonia level, a mildly elevated white blood cell count, and normal renal function. Diagnostic paracentesis, urinalysis, and chest X-ray show no evidence of infection, and rectal examination shows no evidence of gastrointestinal bleeding.