Minimal Hepatic Encephalopathy Is Associated with Motor Vehicle Crashes

Bajaj, Jasmohan S.; Saeian, Kia; Schubert, Christine M.; Hafeezullah, Muhammad; Franco, José; Varma, Rajesh; Gibson, Douglas P.; Hoffmann, Raymond G.; Stravitz, R. Todd; Heuman, Douglas M.; Sterling, Richard K.; Shiffman, Mitchell L.; Topaz, Allyne; Boyett, Sherry; Bell, Debulon E.; Sanyal, Arun J.

doi:10.1002/hep.23128

Cited by 286 publications

(249 citation statements)

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“…64,65 Studies have consistently shown that patients with MHE have a diminished quality of life, cognitive function, daily function, and driving impairment. [3][4][5][6][7][8][9][10] While it was once thought that cognitive impairment with CHE or OHE was reversible, data from studies evaluating medical treatment or liver transplantation suggest that the associated cognitive changes may not be totally reversible. [66][67][68] Moreover, it has been demonstrated that even after therapy and improvement to normal mental status, a single episode of OHE may continue to have residual negative effects on cognitive function.…”

Section: Management Guidelines For Covert Hepatic Encephalopathymentioning

confidence: 99%

“…Over the last decade, there is compelling evidence that MHE has a negative impact on quality of life and patient well being. [3][4][5][6][7][8][9][10] However, the natural history of CHE and the effect of treatment on the overall prognosis of CHE requires further long-term studies.…”

Section: Management Guidelines For Covert Hepatic Encephalopathymentioning

confidence: 99%

“…2 Prior terminology included "sub-clinical", "latent", and "minimal" appear to trivialize the condition. There is abundant evidence in the literature that MHE has a profound impact on quality of life, daily functioning, driving ability, [3][4][5][6][7][8][9][10] and nearly half of all patients with MHE may be unfit to maintain employment. 9 Based on the current ISHEN guidelines, 11 patients with MHE and Grade I encephalopathy by WestHaven Criteria were re-classified as having covert hepatic encephalopathy (CHE).…”

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confidence: 99%

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Management of Covert Hepatic Encephalopathy

Waghray

Mullen

2015

Journal of Clinical and Experimental Hepatology

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Hepatic encephalopathy is a reversible progressive neuropsychiatric disorder that encompasses a wide clinical spectrum. Covert hepatic encephalopathy is defined as patients with minimal hepatic encephalopathy and Grade I encephalopathy by West-Haven Criteria. Terminology such as "sub-clinical", "latent", and "minimal" appear to trivialize the disease and have been replaced by the term covert. The lack of clinical signs means that covert hepatic encephalopathy is rarely recognized or treated outside of clinical trials with options for therapy based on patients with episodic hepatic encephalopathy. This review discusses the current available options for therapy in covert hepatic encephalopathy and focuses on non-absorbable disacharides (lactulose or lactitol), antibiotics (rifaximin), probiotics/synbiotics and L-ornithine-L-aspartate. ( J CLIN EXP HEPATOL 2015;5:S75-S81)

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Section: Management Guidelines For Covert Hepatic Encephalopathymentioning

confidence: 99%

Section: Management Guidelines For Covert Hepatic Encephalopathymentioning

confidence: 99%

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confidence: 99%

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Management of Covert Hepatic Encephalopathy

Waghray

Mullen

2015

Journal of Clinical and Experimental Hepatology

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“…4 After measuring cognition with a brief psychometric test battery, and the inhibitory control test (ICT), the drivers were assigned to either the MHE cohort or the non-MHE cohort. Collision and violation data were collected by self-report and from the Department of Transportation for the year before and the year after the psychometric testing.…”

mentioning

confidence: 99%

“…ICT appeared to be more sensitive than the standard psychometric battery in the diagnosis of MHE. 4 Similar criteria were used as in a prior report for the case definition of MHE: Ͼ2 standard deviations for any two of the four psychometric tests or Ͼ 5 lures on the ICT. 5 Yet, the psychometric battery was slightly different in this study than in their prior work.…”

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confidence: 99%

Minimal Hepatic Encephalopathy and Driving† ‡

Dubinsky

Stein

2009

Hepatology

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O perating a motor vehicle is an overlearned motor task involving aspects of divided attention and visual perception (surveillance of roadway, traffic, and regulatory and informational signage), and time-on-task, accomplished by multiple limb-coordinated motions. Driving is a privilege granted by the government based on age (reflecting driver maturity), minimal performance standards (corrected vision, passing a written and a performance test under low workload conditions), and restricted based on bad experience (moving violations and collisions). Society tolerates the increased risk of the immature driver, because the only way their driving skills improve and the risk of collisions decrease is with practice. A trained driving examiner makes the licensing decision for the immature driver on behalf of the State. Society, through the legislative process, has restricted driving for certain conditions or driving violations. For example, States have progressively tightened the permissible level of breath alcohol concentration of drivers to a uniform 0.08 mg/dL. Through the same mechanism, some jurisdictions have increased the frequency of testing of older drivers and required physician reporting of potentially impaired drivers.Physicians are not trained to determine fitness-todrive. Thus, when called upon by a patient or their family to answer the question "can they drive?" the physician has no basis on which to base a decision. Previously, we addressed this question for drivers with dementia, through a systematic literature review. 1 This evidence-based medicine practice parameter reported that there was an increased risk of collisions for drivers with a clinical dementia rating scale score of 0.5 (possible Alzheimer's disease) and 1 (probable Alzheimer's disease) compared to nondemented drivers. The clinical dementia rating is a complex rating scale, based on a structured interview, encompassing many domains, and not easily adaptable to a brief clinical encounter. Of the many psychometric tests used in the studies of driving in people with dementia, only Trails A (as part of a regression analysis including age, sex, and driving history) and the Sternberg Test (a triarchic memory test) were partially predictive of future crash risk. 2,3 Thus far, no simple psychometric test has been found to have a threshold level robust enough to reliably divide drivers into high or low risk for future crashes. This is because driving is a complex task involving many cognitive domains, and collisions are rare events that involve both capable and impaired drivers.Bajaj and colleagues present an interesting report of motor vehicle crashes in drivers with cirrhosis, with and without minimal hepatic encephalopathy (MHE) over a 2-year period. 4 After measuring cognition with a brief psychometric test battery, and the inhibitory control test (ICT), the drivers were assigned to either the MHE cohort or the non-MHE cohort. Collision and violation data were collected by self-report and from the Department of Transportation for the year befor...

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Diagnosis and Management of Cirrhosis and Its Complications

Tapper

Parikh

2023

JAMA

104

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ImportanceCirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people.ObservationsThe most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men.Conclusions and RelevanceApproximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.

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Minimal Hepatic Encephalopathy Is Associated with Motor Vehicle Crashes

Cited by 286 publications

References 28 publications

Management of Covert Hepatic Encephalopathy

Management of Covert Hepatic Encephalopathy

Minimal Hepatic Encephalopathy and Driving† ‡

Diagnosis and Management of Cirrhosis and Its Complications

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