Minimal Hepatic Encephalopathy

Abstract

Minimal hepatic encephalopathy (MHE) is the earliest form of hepatic encephalopathy and can affect up to 80% of cirrhotic patients. By definition, it has no obvious clinical manifestation and is characterized by neurocognitive impairment in attention, vigilance and integrative function. Although often not considered to be clinically relevant and, therefore, not diagnosed or treated, MHE has been shown to affect daily functioning, quality of life, driving and overall mortality. The diagnosis of MHE has traditionally been achieved through neuropsychological examination, psychometric tests or the newer critical flicker frequency test. A new smartphone application (EncephalApp Stroop Test) may serve to function as a screening tool for patients requiring further testing. In addition to physician reporting and driving restrictions, medical treatment for MHE includes non-absorbable disaccharides (eg, lactulose), probiotics or rifaximin. Liver transplantation may not result in reversal of the cognitive deficits associated with MHE.

Palliative Care for Patients with End-Stage Liver Disease

“…Minimal HE, the earliest stage of HE, occurs in up to 80 % of cirrhotics. It manifests with significant impairment in attention, psychomotor speed, visuospatial perception, response inhibition, and delayed information processing [91,92]. The presence of HE, even at the subclinical level, complicates significantly the patient's quality of life and their medical management [91,93,94].…”

Legal Responsibilities of Physicians When They Diagnose Hepatic Encephalopathy

“…1,2 The diagnosis of CHE requires sensitive neuropsychological cognitive testing. However, no agreement exists among experts about which standardized screening tools should be used to diagnose CHE.…”

“…4 Studies using a variety of such tests have concluded that the prevalence of CHE in cirrhotic patients ranges from 30% to 80%. 2 Numerous studies indicate that cirrhotic patients with CHE may have significantly reduced fitness to operate motor vehicles or safely perform in occupations requiring concentration, dexterity, and normal reaction times for safe performance. 2,5 Patients with OHE have demonstrable impairments of driving skills (discussed later).…”

“…2 Numerous studies indicate that cirrhotic patients with CHE may have significantly reduced fitness to operate motor vehicles or safely perform in occupations requiring concentration, dexterity, and normal reaction times for safe performance. 2,5 Patients with OHE have demonstrable impairments of driving skills (discussed later). Successful medical therapy alleviates the cognitive and neurologic symptoms of OHE, returning treated patients with OHE to a cognitive state of CHE.…”

PET and MR imaging of neuroinflammation in hepatic encephalopathy

“…The diagnosis of MHE is based on a battery of psychometric tests (Ciecko-Michalska et al 2012;Weissenborn 2013). The psychometric hepatic encephalopathy score (PHES) (Kircheis et al 2014) and Stroop smart phone application (Stinton and Jayakumar 2013) have been proposed to screen MHE. The diagnostic accuracy of psychometric tests is limited (Kircheis et al 2014).…”