Subclinical Hepatic Encephalopathy in Cirrhotic Patients: Prevalence and Relationship to Liver Function

Abstract

Neuropsychological tests were administered to 22 alcoholic cirrhotic patients, 20 nonalcoholic cirrhotic patients and 42 control subjects matched for age and educational background. Liver function estimated by Pugh score was identical in alcoholic and nonalcoholic cirrhotics. Thirty-two cirrhotic patients (76%) failed one or more psycho logical test. Performance was worse in cirrhotics than in controls in all but one test: the degree of neurological impairment was similar in alcoholics and nonalcoholics and correlation with the severity of Liver dysfunction was only marginal. A combination of the five more sensitive tests was able to identify 31 of 32 cirrhotic patients with subclinical encephalopathy; this ‘mini battery’ of tests can be performed within 10 mins. Suhclinical hepatic encephalopathy is frequent in cirrhotic patients and can adversely affect their psychosocial behaviour.

Critical flicker frequency for quantification of low-grade hepatic encephalopathy

“…Because of its prognostic and socioeconomic relevance, 2,7-10,20-24 interest has focused on subclinical HE, which describes a poorly defined syndrome found in the grey zone between normality and manifest HE. Although neuropsychologic tests can be used for diagnosis of SHE, their value in clinical routine is limited because of methodologic problems, age, training, and education effects, [6][7][8][9][10][12][13][14][15][16][17]35,36 as well as because of a lack of standardization. In addition, no single psychometric test can pick up SHE reliably, and because of the diversity of symptoms, test batteries have to be used.…”

“…5 However, a significant proportion of cirrhotic patients, who appear normal on clinical examination, exhibit various quantifiable neuropsychologic deficits and this condition has been termed subclinical hepatic encephalopathy (SHE). [6][7][8][9][10] Whereas detection of overt HE (grade I-IV) is made clinically and does not provide a major diagnostic challenge, diagnosis of SHE is prob-lematic. Psychometric and electrophysiologic tests are currently used for detection of SHE.…”

“…Electrophysiologic tests such as visual-evoked, somatosensory-evoked, or brain stem auditory-evoked potentials suffer from methodologic problems, require sophisticated equipment and analysis, and exhibit a lower sensitivity than psychometric tests. 7,[12][13][14] Psychometric bedside tests, such as the number-connection test, are frequently used, but more refined psychometric test combinations or computerized psychometry 6,10,15 are required to pick up the various neuropsychiatric deficits. However, interpretation of psychometric test results is hampered by training effects, proband education, the need for age-matched controls, and by the fact that a standardized definition of SHE by means of psychometric tests is still missing.…”

“…These uncertainties may explain the wide range of SHE prevalence of 20% to 80% reported for cirrhotic patients. 6,7,9,[15][16][17][18] Although the borderline between normality and pathology is difficult to assess and controversy exists whether an abnormal psychometric test result reflects true disease, 19 the subtle motor and cognitive deficits in SHE patients are of sociomedical and prognostic relevance and may impair daily life. 2,[7][8][9][10][20][21][22] Indeed, some, 9,23 but not all, 24 investigators suggested that a high proportion of SHE patients are unfit to drive a car, with improvement in response to therapy.…”

Quantitative T1 Mapping of Hepatic Encephalopathy Using Magnetic Resonance Imaging

“…[7][8][9][10][11][12][13][14][15]27 In particular, because of its prognostic and socioeconomic relevance, interest largely has focused on the ill-defined syndrome of SHE that lies between normality and manifest HE. 1,[5][6][7][28][29][30] MRI has been used to acquire T 1 -weighted images of the brains of a cohort of HE patients and the so-called pallidal index has been used to determine levels of MR signal hyperintensity and attempts have been made to correlate these changes with grade of HE. [8][9][10][11][12][13][14][15] It has been shown that, compared with healthy control subjects, patients with subclinical or manifest HE had hyperintensity in occipital white matter and all basal ganglia tissues except the thalamus.…”