Q; 47 year old male with history of cirrhosis is admitted to ICU with exacerbation of hepatic encephalopathy. Attempts to insert naso-gastric tube to administer lactulose is unsuccessful and caused nasal bleeding due to hepatic coagulopathy. What is your other option?



Answer: Lactulose can be administered by enema.

Lactulose is a disaccharide. It acidifies the colon as it degrades. Acidification of colon causes migration of ammonia from the blood into the colon, where ammonium (NH3) get converted  to  ammonium ion (NH4) +. The trapped ammonium ion then get excreted in stool. Usual dose is to mix 300 mL of lactulose solution in 700 mL of water or saline. Solution is then administered via enema for about 30 minutes retention. Patients with high degree of coma may not be very co-operative. Also, soiling of bed, skin infection and 'mess' it creates for nursing staff, makes enema an undesirable option. Overall objective is to improve hepatic encephalopathy up to the point where patient can tolerate insertion of NGT or PO intake.


Reference: 

Raza M A, Bhatti R S, Akram J. Effect of rectal lactulose administration with oral therapy on time to recovery from hepatic encephalopathy: A randomized study. Annals of Saudi Medicine. 2004; 24(5): 374-377.