Management of hepatic encephalopathy commonly includes which agent?

• A. Rifaximin
• B. Neomycin
• C. Lactulose
• D. Metronidazole

Answer: (D)

Managing hepatic encephalopathy centers on lowering the amount of ammonia that gut bacteria produce and absorb, then enhancing its removal. One way to reduce intestinal ammonia is to alter the gut flora with antibiotics. Metronidazole is an antibiotic that targets anaerobic bacteria in the gut, which are major producers of ammonia. By dampening these bacteria, metronidazole helps decrease the ammonia load entering the bloodstream and crossing to the brain, which can improve encephalopathy symptoms. In many treatment patterns, antibiotics are used alongside lactulose (which acidifies the gut and traps ammonia) to achieve faster and more effective control of encephalopathy. While lactulose and rifaximin are now common cornerstone therapies, metronidazole remains a recognized option, particularly when first-line measures aren’t suitable or as an adjunct.