 Enteric production of ammonia can be decreased by non-absorbable disaccharides such as lactulose or lactitol and non-absorbable antibiotics such as rifaximin. Lactuloselactitol pass through the small bowel undigested. In the colon, bacteria degrade lactulose to various organic acids e.g. lactic acid, acetic acid with subsequent lowering of colonic pH. The mode of ammonia lowering may involve bacteriostatic effects, cathartic effects, or enhancement of conversion of ammonia to ammonium with excess hydrogen ion. Presumably ammonium is then excreted into the feces and eliminated 9, 10. Lactulose remains the main stay of therapy of overt HE, despite the paucity and inconsistency of clinical trials demonstrating its efficacy 11. The dosage should be adjusted to accomplish two to three soft bowel movements each day. Lactulose can be given through a nasogastric tube or through retention enemas. The usual dose is 30-120 ml each day in divided doses. Stool pH should be below six. Side effects include bloating and flatulence. Severe diarrhea with dehydration and hyperglycemia and acidosis occurs if the dosage is too high. 