lactulose / Generic mfg. - LARVOL DELTA

Non-Cirrhotic Hyperammonemic Encephalopathy in a Critically Ill Patient (ACG 2026) - "Case Description/ A 36-year-old female with a history of gastric bypass who presented with leg ulcers and oral mucosal lesions was found to have TEN likely from allopurinol use for gout...Data points indicate concurrent interventions: no intervention (gray X), lactulose alone (blue circles), continuous renal replacement therapy (CRRT, red squares), and L-carnitine with CRRT (purple triangles)...Ammonia levels declined to within normal range (10â28 µmol/L, green shaded area) by day 29 following CRRT discontinuation. Error bars represent same-day repeated measurements."

Clinical • Autoimmune Hepatitis • Cardiovascular • CNS Disorders • Fibrosis • Gout • Hepatology • Immunology • Infectious Disease • Inflammation • Inflammatory Arthritis • Metabolic Disorders • Nephrology • Portal Hypertension • Renal Disease • Septic Shock • Steven-Johnson Syndrome

Non-Cirrhotic Confusion: Portosystemic Encephalopathy in Hereditary Hemorrhagic Telangiectasia (ACG 2026) - "Her mental status improved significantly with lactulose and rifaximin therapy. Liver transplantation remains the only definitive cure for hepatic HHT and should be considered in patients with refractory complications. This case demonstrates a rare presentation of hepatic HHT and emphasizes the need to consider portosystemic encephalopathy in patients with altered mental status despite preserved liver function."

Cardiovascular • CNS Disorders • Congestive Heart Failure • Gastroenterology • Gastrointestinal Disorder • Heart Failure • Hematological Disorders • Hepatic Encephalopathy • Hepatology

A Hidden Culprit: Refractory Hepatic Encephalopathy Secondary to a Large Spontaneous Splenorenal Shunt (ACG 2026) - "He required oral and rectal lactulose along with rifaximin to remain alert; omission of a single dose prompted reintubation. (B) Intra-obliteration image with BRTO device in the shunt. (C) Post-obliteration image showing absence of contrast within the shunt."

Cardiovascular • CNS Disorders • Fibrosis • Hematological Disorders • Hepatic Encephalopathy • Hepatology • Immunology • Portal Hypertension

Gastric Bypass-Associated Hyperammonemia: A Severe Early Presentation Requiring Hemodialysis and Surgical Reversal (ACG 2026) - "She was treated with lactulose, rifaximin, protein restriction, thiamine, zinc, and L-carnitine with persistent severe hyperammonemia. Ammonia levels should be measured early in post-bariatric patients with unexplained encephalopathy. Medically refractory cases warrant rapid escalation beyond gut-directed therapy."

Bariatric surgery • CNS Disorders • Epilepsy • Fibrosis • Genetic Disorders • Hepatology • Immunology • Inflammation • Metabolic Disorders • Renal Disease • Respiratory Diseases

Immune Checkpoint InhibitorâInduced Severe Hypothyroidism Mimicking Hepatic Encephalopathy (ACG 2026) - "Case Description/ A 64-year-old man with cirrhosis from metabolic dysfunction and alcohol-related liver disease and multifocal unresectable HCC on tremelimumab-durvalumab presented with one week of progressive confusion, disorientation, and hypoactivity...The patient demonstrated marked improvement in mental status while continuing lactulose and rifaximin...Individualized approaches, including IV levothyroxine when enteral absorption is unreliable, may be critical to recovery. Generative AI was used in the development and editing of this abstract."

Checkpoint inhibition • CNS Disorders • Endocrine Cancer • Endocrine Disorders • Fibrosis • Hepatic Encephalopathy • Hepatocellular Cancer • Hepatology • Immunology • Liver Cirrhosis • Metabolic Disorders • Oncology • Solid Tumor

Not Just IBS: A Large Ileocecal Valve Tubulovillous Adenoma Presenting as Chronic Bloating and Hematochezia (ACG 2026) - "demonstrated that in patients with IBS, lactulose hydrogen breath testing (LHBT) may detect oro-caecal transit rather than small intestinal bacterial overgrowth in patients with IBS...Because younger patients are often considered low risk for advanced colorectal pathology, diagnosis may be delayed when symptoms overlap with functional disorders2,3. Figure: Figure 1: Cecal polyp obstructing terminal ileum Figure: Figure 2: Terminal ileum post resection of cecal polyp"

Anorexia • Colorectal Cancer • Gastroenterology • Gastrointestinal Disorder • Solid Tumor

Bleeding Through the Belly Button: Umbilical Variceal Hemorrhage as the Initial Presentation of Portal Hypertension (ACG 2026) - "He remained hemodynamically stable and was started on octreotide and ceftriaxone...Lactulose was started following the procedure for hepatic encephalopathy prophylaxis...Figure: Sagittal CT abdomen and pelvis demonstrating paraumbilical varices within an umbilical hernia sac (arrow), consistent with ectopic umbilical varices in the setting of portal hypertension. Figure: Axial CT abdomen and pelvis demonstrating recanalized paraumbilical veins with varices extending into the umbilical hernia sac, consistent with ectopic umbilical varices related to portal hypertension."

Cardiovascular • CNS Disorders • Fibrosis • Gastroenterology • Hematological Disorders • Hepatic Encephalopathy • Hepatology • Immunology • Portal Hypertension

Manganese-Associated Parkinsonism Mimicking Hepatic Encephalopathy in a Patient With Transjugular Intrahepatic Portosystemic Shunt (ACG 2026) - "He was adherent to lactulose with 2 to 3 bowel movements daily and rifaximin. Recognition of manganese associated neurotoxicity can prevent unnecessary escalation of HE directed therapy and guide appropriate management. Figure: Axial T1 weighted FLAIR MRI demonstrating symmetric bilateral T1 hyperintensity within the globus pallidus (arrows), consistent with manganese deposition in the basal ganglia."

Clinical • CNS Disorders • Fibrosis • Hepatic Encephalopathy • Hepatology • Immunology • Liver Cirrhosis • Movement Disorders • Parkinson's Disease

Acute Liver Failure in the Setting of Acute Hepatitis B and Concomitant Ashwagandha Use (ACG 2026) - "Tenofovir was initiated for acute hepatitis B with high viral load, while lactulose, rifaximin, and vitamin K were administered for hepatic encephalopathy and coagulopathy. Despite receiving aggressive supportive care, the patient rapidly deteriorated, emphasizing the need for timely intervention and early consideration for DDLT in similar cases. Figure: Laboratory Trends throughout Hospitalization"

Acute Kidney Injury • CNS Disorders • Hematological Disorders • Hepatic Encephalopathy • Hepatitis B • Hepatitis C • Hepatology • Human Immunodeficiency Virus • Hypoglycemia • Immunology • Infectious Disease • Inflammation • Liver Failure • Musculoskeletal Pain • Nephrology • Renal Disease • Respiratory Diseases

Fulminant Thyrotoxicosis-induced Cholestatic Liver Failure: Navigating Thyroid Management Amid Hepatotoxic Risk (ACG 2026) - "The patient was treated with methimazole, propranolol, corticosteroids, lactulose, rifaximin, antimicrobials, and hemodialysis...Management includes hemodynamic stabilization, beta-blockade, corticosteroids, and careful antithyroid selection, with methimazole preferred over propylthiouracil in significant liver dysfunction...Figure: Figure 2. Long-axis ultrasound of the right hepatic lobe showing gallbladder wall thickening and sludge without biliary ductal dilation, consistent with cholestatic changes."

Acute Kidney Injury • Atrial Fibrillation • Autoimmune Hepatitis • Cardiovascular • CNS Disorders • Endocrine Disorders • Hematological Disorders • Hepatology • Immunology • Infectious Disease • Inflammation • Liver Failure • Nephrology • Renal Disease • Respiratory Diseases • Thrombocytopenia

An Unusual Case of Noncirrhotic Portal Hypertension Secondary to Focal Nodular Hyperplasia and Congenital Hepatic Fibrosis With Diffuse Mesenteric Thrombosis (ACG 2026) - "He is then hospitalized and diagnosed with hepatic encephalopathy with symptoms of confusion, forgetfulness, irritability, and brain fog, which are being managed with lactulose treatment...Nodular hyperplasia may contribute to the development of NCPH due to the disruption of blood flow, requiring continuous monitoring through imaging and biopsy. Overall, this case emphasizes the diagnostic and management complexity of NCPH complicated by portal and SMV thrombosis and congenital hepatic fibrosis."

Clinical • Cardiovascular • CNS Disorders • Fibrosis • Gastroenterology • Gastrointestinal Disorder • Hematological Disorders • Hepatic Encephalopathy • Hepatology • Immunology • Liver Cirrhosis • Portal Hypertension • Thrombocytopenia • Thrombosis

Proton Pump Inhibitor Use and Risk of Spontaneous Bacterial Peritonitis, Hepatic Encephalopathy, and Mortality in Decompensated Cirrhosis: A Dose-Response Analysis Using an Active Comparator Design (ACG 2026) - "Whether PPI dose and duration independently predict complications in decompensated cirrhosis when compared to histamine-2 receptor antagonists (H2RAs) while controlling for rifaximin, lactulose, and beta-blocker use remains underexplored in a large multi-institutional cohort. 6,214 matched pairs; mean age 59.3±11.2y, 61.4% male, MELD-Na 18.7±6.4. PPI users had higher SBP (14.8% vs 9.6%; HR 1.58, 95% CI 1.34â1.87; p365d; p-trend< 0.001)."

CNS Disorders • Fibrosis • Hepatic Encephalopathy • Hepatology • Immunology • Infectious Disease • Metabolic Dysfunction-Associated Steatotic Liver Disease

Distinct Breath Gas Patterns Reveal Clues to Treatment Response in Real-World Clinical Data (ACG 2026) - "Introduction: SIBO and IMO are commonly assessed using lactulose hydrogen-methane (H 2 -CH 4 ) breath testing (LBT), with a positive LBT typically prompting antimicrobial therapy... Four distinct clusters were identified (Fig. 1): cluster 1 (n=1,745), low levels for both gases with a minor, late rise for both gases; cluster 2 (n=1,999), H 2 -dominant, featuring early significant rise in H2 and later rise in CH 4 ; cluster 3 (n=586), CH 4 -dominant cluster, early and significant rise in CH4 with low H2 levels; cluster 4 (n=723), high levels in both gases, with a notable late rise in CH 4 . There was a significant relationship between cluster membership and proportion responding to therapy (Ï2 (1,4) = 11.93, p = 0.0076), with cluster 4 having the highest response rate (56.1% improvement, 95% CI [45.4%, 68.2%], Fig."

Clinical data • Real-world • Real-world evidence

HydrogenâMethane Breath Test Findings in Parkinsonâs Disease: Distinct Patterns of IMO and SIBO (ACG 2026) - " We retrospectively reviewed 107 consecutive PD patients who underwent glucose/lactulose hydrogen breath test... Among 105 analyzed patients, the median age was 75 [70â80] years, 50.5% were women, and 86.7% had chronic constipation. Mean MDS-UPDRS motor score was 23.5 + 13.8, consistent with mild-to-moderate motor severity. 26 (24.8%) patients were tested 15 [10â40] months before PD diagnosis, and 77 (73.3%) were tested 53 [16â86] months after PD diagnosis."

CNS Disorders • Constipation • Gastroenterology • Gastrointestinal Disorder • Movement Disorders • Parkinson's Disease

Results of Lactulose Breath Testing Amongst Different DGBI Diagnoses (ACG 2026) - "SIBO and IMO positivity rates trended higher in DGBI patients (SIBO: 43.37%; IMO: 51.20%) compared with non-DGBI controls (SIBO: 35.56%; IMO: 40.00%), although these differences were not statistically significant (SIBO: P = 0.346; IMO: P = 0.182) (Tables 1 and 2). Consistent with our hypothesis, the IBS-D subgroup demonstrated a notable increase in SIBO positivity (60.00%) relative to the non-DGBI group, approaching statistical significance (P = 0.103). In contrast, a lower SIBO positivity rate was noted in IBS-C patients (25.00%) compared to the non-DGBI group (P=0.544)."

CNS Disorders • Constipation • Gastroenterology • Gastrointestinal Disorder

From Pristanic Pathway to Portal Hypertension: A Case of Alpha-methylacyl-CoA Racemase Deficiency in an Adult Causing Cirrhosis and Altered Mental Status (ACG 2026) - "The clinical presentation was atypical for HE, with a subacute progressive neurologic syndrome evolving over ~10 months without improvement on lactulose...Recognition of AMACR deficiency has important therapeutic implications, including initiation of low pristanic acid diet and avoidance of agents which could cause mitochondrial toxicity such as valproic acid. Screening for liver fibrosis and cancer should be considered in these patients since AMACR deficient patients are at risk for hepatocellular carcinoma and liver sarcoma."

Clinical • Ataxia • Cardiovascular • CNS Disorders • Developmental Disorders • Epilepsy • Fibrosis • Hepatic Encephalopathy • Hepatocellular Cancer • Hepatology • Immunology • Liver Cirrhosis • Liver Failure • Mental Retardation • Metabolic Disorders • Metabolic Dysfunction-Associated Steatotic Liver Disease • Movement Disorders • Portal Hypertension • Sarcoma • Solid Tumor

New-Onset Decompensated Cirrhosis Secondary to Congestive Hepatopathy Complicated by Spontaneous Bacterial Peritonitis: A Case Report (ACG 2026) - "Management and Outcome: The patient received ceftriaxone IV albumin and therapeutic paracenteses...Diuresis with furosemide and spironolactone sodium restriction lactulose and carvedilol were initiated...High SAAG with high ascitic protein strongly suggests congestive hepatopathy and should prompt cardiac evaluation and optimization. Recognition of this entity may prevent delayed diagnosis and guide appropriate multidisciplinary management."

Case report • Clinical • Cardiomyopathy • Cardiovascular • Chronic Kidney Disease • Chronic Obstructive Pulmonary Disease • Congestive Heart Failure • Fibrosis • Heart Failure • Hepatology • Hypertension • Immunology • Infectious Disease • Liver Cirrhosis • Liver Failure • Respiratory Diseases

Ectopic Portosystemic Collateralization Presenting as Uterine and Parametrial Varices in MetALD (ACG 2026) - "Management focused on alcohol cessation, lactulose therapy and outpatient hepatology follow-up...This case highlights an unusual manifestation of portal hypertension and underscores the importance of recognizing atypical collateral pathways on imaging, especially when gastroesophageal varices are not readily apparent. Figure: CT abdomen and pelvis from September 2025 demonstrating hepatosplenomegaly with portosystemic collateralization, including dilation of the parametrial plexus and right gonadal vein, consistent with rare ectopic pelvic varices in portal hypertension."

Cardiovascular • Fibrosis • Gastroenterology • Gastrointestinal Disorder • Hematological Disorders • Hepatology • Immunology • Liver Failure • Metabolic Disorders • Portal Hypertension • Thrombocytopenia

The Hepatitis That Wouldn't Go Away: Autoimmune Hepatitis Unmasked After Amoxicillin-Clavulanate Exposure (ACG 2026) - "He additionally developed hepatic encephalopathy requiring lactulose. Prednisone was restarted, and azathioprine therapy was planned...While the patient initially responded to corticosteroids, relapse after steroid withdrawal, subsequent ANA positivity, and the need for ongoing immunosuppression favored unmasking or triggering of underlying AIH rather than a self-limited autoimmune-like drug reaction. Early recognition and long-term follow-up are essential, as disease recurrence may warrant maintenance immunosuppressive therapy."

Autoimmune Hepatitis • Cardiovascular • CNS Disorders • Diabetes • Fibrosis • Hepatic Encephalopathy • Hepatology • Hypertension • Immunology • Infectious Disease • Inflammation • Liver Failure • Metabolic Disorders • Respiratory Diseases

Recurrent Hyperammonemic Encephalopathy Status Post Ureterosigmoidostomy (ACG 2026) - "Urine-stool cultures repeatedly grew E. coli , and episodes consistently resolved with lactulose and rifaximin...Episodes continued despite arginine and sodium phenylbutyrate supplementation...USO, a method of urinary diversion post cystectomy, is thought to cause extrahepatic encephalopathy via colonic exposure to urine and increased delivery of ammonia to the portal drainage system. Our case illustrates this rarely described anatomic cause of hyperammonemia, the morbidity that results, and definitive management by elimination of urinary-colonic contact."

CNS Disorders • Dyslipidemia • Fibrosis • Genetic Disorders • Hepatic Encephalopathy • Hepatology • Immunology • Obesity

Comparative Outcomes of Proton Pump Inhibitors and H2 Receptor Antagonists in Cirrhosis: A Propensity-Matched Cohort Study (ACG 2026) - "One-to-one propensity score matching was performed for age, sex, race, socioeconomic status, tobacco and alcohol use, comorbidities, cirrhosis etiology, prior decompensating events, MELD score, and concomitant medications (lactulose, rifaximin, furosemide, and spironolactone). Propensity matching yielded two well-balanced cohorts of 8,922 patients each. Over 5-year follow-up, overall patients on PPIs had a high risk of SBP than patients on H2RAs (HR: 1.760; 95% CI: 1.135 - 2.729), however there was no difference in the risk of HE, CDI, osteoporosis/fragility fractures between the 2 groups (Table 1). On sub analysis of the 2 most commonly prescribed PPIs, omeprazole and pantoprazole, there was a higher risk of HE and CDI in omeprazole users than patients on H2RAs, while there was a higher risk for HE in patients on pantoprazole than H2RAs (Tables 2 and 3)."

Biliary Cancer • Cholangiocarcinoma • CNS Disorders • Fibrosis • Gastroenterology • Hepatic Encephalopathy • Hepatocellular Cancer • Hepatology • Immunology • Infectious Disease • Liver Failure • Musculoskeletal Diseases • Osteoporosis • Solid Tumor

Quality of Lactulose Instructions for Hepatic Encephalopathy Among Veterans With Cirrhosis (ACG 2026) - "Among 201 Veterans with cirrhosis reviewed, 27 were prescribed lactulose for HE. Only 3/27 patients (11%) had adequate instructions including both a bowel movement goal and titration guidance. A bowel movement goal was documented for 26/27 patients (96%), while titration guidance was present for 3/27 patients (11%)."

CNS Disorders • Constipation • Fibrosis • Gastroenterology • Gastrointestinal Disorder • Hepatic Encephalopathy • Hepatology • Immunology

Adjunctive Use of Vibrating Capsule for Refractory Constipation in Autosomal Dominant Polycystic Kidney Disease With Severe Organomegaly (ACG 2026) - "He had failed or inadequately responded to lactulose, polyethylene glycol, magnesium citrate, bisacodyl, senna, mineral oil, enemas, suppositories, lubiprostone, prucalopride, fiber, linaclotide alone, plecanatide alone, and pelvic floor physical therapy. Figure: Figure 1b. Sagittal T2-weighted MRI demonstrates renomegaly along with stool-filled colon."

Autism Spectrum Disorder • Autosomal Dominant Polycystic Kidney Disease • Chronic Kidney Disease • CNS Disorders • Constipation • Gastroenterology • Gastrointestinal Disorder • Genetic Disorders • Muscular Dystrophy • Myotonic Dystrophy • Nephrology • Pancreatic Cancer • Polycystic Kidney Disease • Renal Disease

The Contemporary "Balloon Man" Phenotype: A Giant Fecaloma in a Patient on Chronic Antipsychotics (ACG 2026) - "Psychiatry transitioned him from clozapine and olanzapine to haloperidol without breakthrough psychosis. He was discharged on prucalopride, polyethylene glycol, bisacodyl, and lactulose...Figure: Fig 2. Prior flexible sigmoidoscopy showing 2-3 cm clean-based rectosigmoid ulcers, consistent with chronic stercoral pressure injury from recurrent fecal loading."

Clinical • Acute Kidney Injury • CNS Disorders • Constipation • Endocrine Disorders • Gastroenterology • Gastrointestinal Disorder • Immunology • Mental Retardation • Nephrology • Renal Disease • Schizophrenia

The Hidden Cost of Containment: Rectal Tube-Induced Hemorrhage (ACG 2026) - "Introduction: Indwelling fecal management systems (FMS) are routinely utilized in the intensive care unit (ICU) to manage severe fecal incontinence, protect skin integrity, and monitor stool output-particularly during lactulose titration for hepatic encephalopathy...In Case 3, a 63yo male with cirrhosis (MELD 13) on ticagrelor bled on day 8 (Hgb nadir 5.2 g/dL) from a large, pressure-induced rectal ulcer; he received 16 units of packed red blood cells and achieved hemostasis after device removal. In Case 4, a non-cirrhotic comparator with a high INR on warfarin bled on day 12 (Hgb nadir 7.6 g/dL) from a superficial fissure; hemostasis was achieved conservatively...The extreme severity is underscored by a 50% mortality rate in our case series where standard interventions, such as anoscopy and direct suture control, failed once arterial erosion occurred in decompensated liver disease. Extreme caution must be exercised when considering indwelling balloon devices in advanced..."

Cardiovascular • CNS Disorders • Fibrosis • Gastrointestinal Disorder • Hematological Disorders • Hepatic Encephalopathy • Hepatology • Immunology • Mood Disorders • Portal Hypertension