Subclinical hepatic encephalopathy (SHE) is assumed to have a negative effect on patients' daily functioning; therefore, treatment is recommended. However, no studies have been performed that document the clinical relevance of SHE. We performed a study in which the prevalence of SHE was determined in 179 outpatients with cirrhosis using two psychometric tests (Number Connection Test Part A [NCT-A] and the Digit Symbol Test [DGT]) and automated analysis of the electroencephalogram (EEG). SHE was defined by the presence of at least one abnormal psychometric test and/or abnormal slowing of the EEG. The influence of cirrhosis and SHE on patients' daily functioning was assessed using the Sickness Impact Profile (SIP) questionnaire. The distribution of SIP scores of the patients with cirrhosis differed from the reference scores of the general population. Patients with cirrhosis and SHE (n ‫؍‬ 48) reported significantly more impairment in all 12 scales of the SIP, in the psychosocial subscore, the physical subscore, as well as in the total SIP score, compared with cirrhotic patients without SHE (n ‫؍‬ 131). Multivariate analysis taking into account severity of liver disease (Child-Pugh score), presence of varices, and alcoholic etiology, showed that SHE independently was related to a diminished total SIP score. The reproducibility of the SIP was high when the test was repeated after a 3-month period. We conclude that SHE implies impaired daily functioning and warrants attempts at treatment. (HEPATOLOGY 1998;28:45-49.)Clinical manifestations of hepatic encephalopathy include a decreased intellectual function, personality disorders, an altered level of consciousness, and neuromuscular dysfunction. 1 In addition to clinical manifest hepatic encephalopathy, 2 a subclinical stage has been described, which cannot be detected through global clinical examination, but requires specific neuropsychological and neurophysiological examination. [3][4][5][6][7][8][9][10][11][12] The prevalence of subclinical hepatic encephalopathy (SHE) is estimated to vary from 30% to 84% according to recent studies using appropriate methods. [12][13][14][15][16] This variation in reported prevalence depends on the kind (psychometric or electrophysiological) and number of tests used, and the population (etiology and severity of the liver disease) tested. 17

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Hepatic encephalopathy (HE) is a serious complication of Neuropsychological tests used for the assessment of advanced liver disease and refers to neuropsychiatric abnorsubclinical hepatic encephalopathy (SHE) may overdimalities (such as disorders of personality, altered levels of agnose SHE because scores are usually not corrected for consciousness, impairment of intellectual function), and neuage. The aim of this study was to estimate the prevalence romuscular dysfunction (asterixis) because of liver insuffiof SHE using two easy administrable psychometric tests ciency. defects, yet have a normal mental and neurological status on One hundred and thirty-seven consecutive patients global clinical examination. [3][4][5][6][7][8][9][10][11][12][13] The prevalence of this subclin-(mean age 49 years, range 17-77) with cirrhosis without ical hepatic encephalopathy (SHE) has been reported to vary any clinical signs of encephalopathy, were screened for from 30% 13 to 84%, 11 depending on the tests and population SHE. In addition, the Child-Pugh score and the arterial used. blood ammonia were determined. Patients with concur-The neuropsychological defects found in SHE may have a rent use of alcohol, benzodiazepines or anti-epileptics negative effect on patients' daily life. 6,14 In addition, these were excluded.defects are considered to be a preclinical stage of clinical Fifty percent of the patients had an abnormal NCT manifest HE. 4,9,15 In view of the reported high incidence of according to the standard recommended procedure, in SHE in patients with cirrhosis and its possible impact on contrast only 7% of the patients had an abnormal NCT daily life, routine assessment of early stages of HE is recomwhen scores corrected for age were used. Combining the mended, 4,6,9,16 as this syndrome may be fully reversible with results of the spectral EEG and the psychometric tests treatment. 4,[17][18][19][20] However, the extensive neuropsychological corrected for age yielded a higher prevalence of SHE test batteries used in most studies (up to 21 different psycho-(23%) than when each test method was used alone (17% metric tests! 9 ), are not suitable for a fast routine screening vs. 10% abnormal, respectively). Severity of liver disease in an outpatient clinic. Conn 21 suggested to use the Number correlated with the presence of SHE, because the preva-Connection Test (NCT) as a sole psychometric test for quantilence of abnormal tests increased from 14% in Child-fying HE. Other investigators 4,9,12,13,22 have proposed to use a Pugh grade A to 45% in Child-Pugh grade B or C. Age combination of two to three psychometric tests as a diagnostic above 40 years and an elevated blood ammonia level screen for SHE. As neuropsychological performance is known were significant determinants related to an abnormal to be influenced by age, 23,24 education, 24 and repetitive test-EEG. We conclude that the NCT uncorrected for age ing, 21 several investigators have used neurophysiological markedly overdiagnoses SHE and, therefore, should not tools suc...

The prognostic significance of subclinical hepatic encephalopathy appears limited.

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