Masson, H. Mardini, J. Rose, C.
Diagnosis of Minimal Hepatic Encephalopathy
Background: Since its introduction, transjugular intrahepatic portosystemic shunt TIPS has been extensively used for treatment of portal hypertension. Methods: Of patients referred for TIPS insertion, patients who survived the procedure by more than 4 weeks were available for assessment. Data collected at TIPS insertion was supplemented by case note analysis.
Psychometric testing was performed and health profile questionnaires administered on patients still attending. Results: Most patients had alcoholic liver disease However, patients with abnormal psychometry had significantly lower quality of life scores than those with normal psychometry.
Conclusions: Although, HE is relatively common after TIPS insertion, with careful selection of patients it is usually short-lived and easily managed.
In recent years, transjugular intrahepatic portosystemic stent-shunts TIPS have been increasingly used for the treatment of the complications of portal hypertension. Meta-analysis of randomized controlled trials confirms the superiority of TIPS over endoscopic treatments in prevention of variceal rebleeding but without any improvement in mortality. The diagnosis of HE typically relies on a clinical classification, 15 which is insufficiently sensitive to detect lesser degrees of impairment.Latest sunfly
Additionally, while the development of HE after TIPS insertion undoubtedly results in significant morbidity, the extent to which it affects quality of life and perceived health status has never been clarified. The other principal disadvantage of TIPS is the development of shunt dysfunction. Early clinical experience revealed that around half of TIPS patients would require shunt revision within the first year.
The actuarial rates of encephalopathy in the groups being treated with covered and uncovered prostheses were similar. TIPS was first used in Newcastle in and more than 50 procedures were undertaken prior to the time period covered by the study reported below.
In addition to presenting observational data regarding the development of clinically evident HE, we hypothesized that TIPS insertion would be associated with the development of minimal HE and that this would lead to a reduced quality of life.
To clarify this, we studied psychometric responses in those TIPS patients still attending, administered health questionnaires to measure quality of life and correlated the significance of this neuropsychiatric impairment with perceived health status.Hepatic encephalopathy HE is a serious complication of liver disease and portosystemic shunting that represents a continuum of neuropsychiatric changes and altered consciousness.
It is classified as overt hepatic encephalopathy OHE when clinically apparent or as covert hepatic encephalopathy CHE in its mildest form. Several diagnostic techniques ranging from simple clinical scales to sophisticated computerized tests exist yet diagnosis remains a challenge due to the time, cost and personnel involved.
Psychometric tests appear promising due to their high sensitivity and low cost but results are variable depending on age and education.Revolut login
The pros and cons of current diagnostic methods for overt and covert HE are reviewed along with strategy to CHE testing. Hepatic encephalopathy HE is a spectrum of neuropsychiatric abnormalities seen in patients with liver dysfunction and portal-systemic shunting diagnosed after exclusion of other known brain diseases 1. The Working Party at the 11th World Congress of Gastroenterology, Vienna, under the Organization Mondiale de Gastroentrologie proposed a multiaxial definition of HE that defined both the type of hepatic abnormality and the duration and characteristics of neurological manifestations in chronic liver disease.
Type A HE is due to acute liver failure, type B is attributable to portosystemic shunt or bypass, and type C is due to cirrhosis.
Type C HE can be further subclassified into episodic, persistent, and minimal 1. Based on clinical and neuropsychometric testing, HE can be categorized as overt or covert. HE that is clinically apparent is termed as overt hepatic encephalopathy OHE. HE that is mild without an obvious clinical profile and diagnosed only by specialized cognitive testing is termed as covert hepatic encephalopathy CHEpreviously known as minimal or subclinical hepatic encephalopathy.
Over the past decade, CHE has received growing interest due to its prognostic importance for the development of OHE 3. It has a characteristic cognitive profile that cannot be diagnosed clinically 14 — 6.
CHE is known to be associated with deficits in driving skills 7 — 9reduction in quality of life 1011impairment of working capability 312 and, most importantly, predicting the subsequent onset of overt HE 13 — CHE is associated with poor prognosis and is an independent predictor of survival In recognition of the dangerous consequences of CHE, the name of the condition has recently been changed from minimal to covert, a position endorsed by the International Society for Hepatic Encephalopathy and Nitrogen Metabolism Articles were reviewed based on their relevance to the topic.
OHE is diagnosed clinically based on two types of symptoms: impaired mental status, as defined by the West Haven Criteria WHCand impaired neuromotor function The current standard for grading HE is based on clinical diagnosis, hence a thorough history and physical exam are imperative.
OHE can be further subdivided into episodic or persistent and precipitated or spontaneously occurring Overt HE remains a diagnosis of exclusion and other causes of altered mentation in cirrhotic patients should be investigated before considering this particular diagnosis. Since ammonia has been regarded as the key precipitating factor, plasma ammonia levels are used widely in patients with cirrhosis and altered mental status to diagnose HE 20 It represents a common conception that increased ammonia levels in a cirrhotic patient can confirm, or rule out, HE.
However, the degree of correlation between ammonia levels and the grading of HE continues to be controversial. Gundling et al evaluated in a prospective study in an emergency department setting whether elevated blood ammonia levels coincide with HE which was additionally established by the West Haven criteria and the critical flicker frequency, respectively and found that ammonia blood levels do not reliably detect HE.
Its use as sole indicator for HE in the Emergency Department may result in frequent misinterpretations The well-known West Haven criteria Conn score is based upon impairment in consciousness, intellectual function, and behavior 1. It classifies HE into five grades of severity. Grade 0 represents patients without detectable changes in personality or behavior, grade I includes patients with trivial lack of awareness, shortened attention span, and altered sleep and mood, and grades II—IV represent overt HE and coma.
To avoid missing the lower grades of HE, the presence of HE should be evaluated by using the mini mental status exam MMSE that examines memory and attention in a systematic manner. The performance of each indicator was compared across grades and sites HESA is simple, time efficient and sensitive to subtle brain changes like the WHC but offers a more objective approach, which should yield greater reliability across the spectrum of HE. However the length of HESA makes it difficult to apply in clinical practice.
These questions have been used in two recent randomized clinical trials Simon-Talero et al and Rockey et al 28 The Modified-orientation log is an 8-question adaptation of the orientation developed by Novack et al 30 in traumatic brain injury and extends it to hepatic encephalopathy.
Its questions are heavily weighted towards disorientation to time, which is the earliest form of disorientation in OHE.Additionally, the efficacy of rifaximin and lactulose for reversal of MHE was evaluated.
Methods: A total of eligible cirrhotic patients underwent testing for MHE. The patients with MHE were randomized to three groups for treatment with either lactulose, rifaximin, or placebo.Vst beat slicer
Treatment outcomes were measured at the end of 3 months. An area under the curve value of 0. Reversal of MHE was seen in Rifaximin showed better tolerability compared to lactulose. Rifaximin is as efficacious as lactulose in the treatment of MHE and better tolerated. Hepatic encephalopathy HE consists of a spectrum of neuropsychiatric abnormalities that are seen in patients with liver dysfunction and after exclusion of other known neurological diseases.
Psychometric hepatic encephalopathy score for diagnosis of minimal hepatic encephalopathy in China
MHE includes a specific spectrum of cognitive deficits, which mostly involve the domains of response inhibition, executive function, attention and vigilance. These psychometric tests specifically assess the above-mentioned cognitive domains.
As such, the PHES can be used to assess a number of parameters, like motor speed, motor accuracy, concentration, attention, visual perception, visual-spatial orientation, visual construction and memory.
These are related to most of the neuropsychological impairments in MHE. There is also a computer-based test known as the Inhibitory Control Test ICTwhich was constructed for the evaluation of attention and response inhibition.
It has been used previously to characterize traumatic brain injury, attention deficit disorder, and schizophrenia. It is an established fact that the clinical manifestations of HE in each stage can be reversed when managed by adequate therapeutic management. As mentioned above, MHE is currently underdiagnosed in patients with liver cirrhosis. MHE carries a high potential for progression to overt HE. Meanwhile, the current management of MHE is directed at reduction of ammonia production from the gastrointestinal tract.
This can be achieved by administration of lactulose, a non-absorbable disaccharide. MHE can also be managed with non-absorbable antibiotic rifaximin. Randomized controlled studies and a meta-analysis 17 have compared probiotics, prebiotics and a symbiotic with lactulose in the treatment of MHE. These studies have shown that in MHE reversal, lactulose is equally or more effective than the pre-pro-synbiotics.
It has a tolerability profile and good safety. The study was conducted in a gastroenterology tertiary care center in Mumbai, India, from May to March We also compared the efficacy of rifaximin and lactulose in the reversal of MHE. The study was approved by the Institutional Ethics Committee.
Written informed consent was obtained from each participant before their enrollment. Patient selection Fig. The diagnosis of cirrhosis was based on clinical history, serologic testing, radiologic imaging and liver histology, when available.
All the patients were either hospitalized or attending the Outpatient Clinic of Gastroenterology. Exclusion criteria were: 1 history of recent alcohol intake or substance abuse in the last 12 weeks; 2 history of recent gastrointestinal tract bleeding; 3 serious infections and use of drugs affecting psychometric performance, like antidepressants and sedatives in the last 4 weeks; 4 previous transjugular intrahepatic portosystemic shunt or shunt surgery; 5 significant comorbid illness e.
Among the 70 patients who were excluded, a history of overt HE was present in 10, history of recent alcohol consumption in 15, recent variceal bleed in 15, acute kidney injury in 15, and hepatocellular carcinoma in 5. Out of total recruited patients, 30 were hospitalized, 22 of which had MHE The reasons for hospitalization included new-onset ascites, alcoholic hepatitis, and refractory ascites.
The PHES is calculated from the results of these five tests. The clinical significance of the PHES score has been previously evaluated in a large number of healthy volunteers, in addition to patients with liver cirrhosis with MHE.Correspondence Address : Dr.
Aim: To construct normal values for the tests of the psychometric hepatic encephalopathy score PHES and evaluate the prevalence of minimal hepatic encephalopathy MHE among Turkish patients with liver cirrhosis. Materials and Methods: One hundred and eighty-five healthy subjects and sixty patients with liver cirrhosis without overt hepatic encephalopathy were included in the study.
The variables that affected the results of the test were included in the multiple linear regression models and formulas were constructed to predict the expected results for each tests. Therefore, 19 of the 60 cirrhotic patients were diagnosed with MHE Future multicenter national studies are needed to validate widely applicable norms. The prognostic significance of subclinical hepatic encephalopathy. Am J Gastroenterol ; Poordad FF, Review article: The burden of hepatic encephalopathy.
Aliment Pharmacol Ther ;Suppl Different biochemical correlates for different neuropsychiatric abnormalities in patients with cirrhosis.Goldmund audio
Hepatology ; Inhibitory control test for the diagnosis of minimal hepatic encephalopathy. Gastroenterology ;e1. J Hepatol ; Nat Clin Pract Gastroenterol Hepatol ; Detection of minimal hepatic encephalopathy: Normalization and optimization of the psychometric hepatic encephalopathy score.
A neuropsychological and quantified EEG study. Normality tables in the Spanish population for psychometric tests used in the diagnosis of minimal hepatic encephalopathy.
Med Clin Barc ; Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver. Dig Dis Sci ; Psychometric hepatic encephalopathy score for the detection of minimal hepatic encephalopathy in Korean patients with liver cirrhosis.
J Gastroenterol Hepatol ; World J Gastroenterol ; Development of a clinical hepatic encephalopathy staging scale. Aliment Pharmacol Ther ; Clin Liver Dis ; Schomerus H, Hamster W, Neuropsychological aspects of portal-systemic encephalopathy.
Metab Brain Dis ; A prospective, quantified electroencephalography study. Liver Int ; Value of the critical flicker frequency in patients with minimal hepatic encephalopathy.AIM: To construct normal values for the tests of the psychometric hepatic encephalopathy score PHES and to evaluate its usefulness in the diagnosis of minimal hepatic encephalopathy MHE among Chinese individuals with cirrhosis.
Cirrhotic subjects with overt HE were excluded by the West-Haven criteria and a detailed neurological examination. Age and education years were confirmed to be predictors of all five tests. In total, 53 patients with liver cirrhosis completed the PHES. Of the patients with liver cirrhosis, 24 MHE was diagnosed in 26 patients Core tip: The psychometric hepatic encephalopathy score PHES has been standardized in several countries, but requires further validation in China.
The authors aimed to evaluate the usefulness of PHES for the diagnosis of minimal hepatic encephalopathy MHE among Chinese patients with liver cirrhosis. In China, the results of the five neuropsychological tests of PHES were influenced by age and educational status. In total, Number connection test-A and digit symbol test are simple and useful tools that can be used for the diagnosis of MHE in China.
Minimal hepatic encephalopathy MHE is a highly prevalent asymptomatic disturbance in patients with liver cirrhosis. MHE is associated with impaired health-related quality of life and driving capability and can predict the development of overt hepatic encephalopathy OHE [ 1 - 4 ]. The psychometric hepatic encephalopathy score PHES is internationally recommended as the gold standard for the diagnosis of MHE[ 89 ].
PHES can be used to assess motor speed, motor accuracy, concentration, attention, visual perception, visual-spatial orientation, visual construction and memory[ 10 ], which are related to most of neuropsychological impairments in MHE. However, in China further validation is needed. Healthy volunteers: The healthy volunteers that were recruited for the control group included people who visited the Health Promotion Center at the First Affiliated Hospital of Anhui Medical University in Hefei, China, for routine health examinations, and through word-of-mouth referrals.
Liver cirrhosis group: Consecutive inpatients from the Department of Gastroenterology and Hepatology were recruited. The diagnosis of liver cirrhosis was based on a combination of physical examination, laboratory tests, medical imaging and endoscopic evidence or on liver histology, if available. All the subjects, both healthy volunteers and patients with liver cirrhosis, were required to have a fair knowledge of numbers and the Chinese alphabet.
The research protocol was approved by the ethics committee of the hospital in accordance with the ethical guidelines of the Declaration of Helsinki. Written informed consent to participate was obtained from each subject. All the five tests of PHES were administered to all the enrolled subjects in the same sequence.
The tests were conducted on a one-to-one basis in a quiet room with sufficient light. A specially trained medical doctor assisted the enrolled subjects in finishing these tests. As some of our enrolled subjects were not familiar with the English alphabet, we replaced the alphabet in NCT-B with the Chinese alphabet in the same order[ 12 ].
Accordingly, a higher result of DST equals better performance, and lower results on the other tests equal better performance. Formulas were constructed to predict the expected results of the five neuropsychological tests. These values were then used as references to which the results from the patients with liver cirrhosis were compared. On the day of neuropsychological testing, venous blood was taken for routine liver function tests, hematologic parameters and venous ammonia concentration.
Venous ammonia was measured within 30 min after blood sampling. Statistical analyses were performed using the statistical package for the social science SPSS version Non-parametric tests were applied if homogeneity of variance assumptions were not met.Enter your email address and we'll send you a link to reset your password.
The West Haven Criteria allow providers to classify severity of encephalopathy, communicate clearly about a patient's level of consciousness, and trend changes in their mental status. Please fill out required fields. This is an unprecedented time. It is the dedication of healthcare workers that will lead us through this crisis. Thank you for everything you do.
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Useful Tests for Hepatic Encephalopathy in Clinical Practice
Subcategory of 'Diagnosis' designed to be very sensitive Rule Out. Disease is diagnosed: prognosticate to guide treatment Prognosis. Numerical inputs and outputs Formula. Med treatment and more Treatment. Suggested protocols Algorithm. Disease Select Specialty Select Chief Complaint Select Organ System Select Log In. Email Address.
Password Show. Or create a new account it's free. Forgot Password? Sign In Required. To save favorites, you must log in. Creating an account is free, easy, and takes about 60 seconds. Log In Create Account. The principal investigators of the study request that you use the official version of the modified score here.
Log in to create a list of your favorite calculators! Log in. Defines criteria for the stages of hepatic encephalopathy.Minimal hepatic encephalopathy MHE is a major neuropsychiatric complication of liver cirrhosis and portosystemic shunting. Although MHE produces a spectrum of cognitive impairments in the domains of short-term attention, working memory, and executive function, it generally does not present with obvious clinical manifestation on conventional assessments.
Paper-and-pencil psychometric tests, such as the psychometric hepatic encephalopathy score and the repeatable battery for the assessment of neuropsychological status, are recommended to diagnose MHE. However, these tests are neither rapid nor convenient to use in practice.
To facilitate repeated testing in clinic and follow-up, computer-aided psychometric tests, such as the scan test, Cognitive Drug Research assessment battery, inhibitory control test, EncephalApp Stroop App, and critical flicker frequency, have been used to screen for MHE among patients with liver cirrhosis.
The aim of this review was to describe the progression from the utility of paper-and-pencil to computer-aided psychometric tests for MHE screening in clinical practice. HE is classified as either overt or covert based on the severity of its clinical manifestations 1. Patients with overt HE OHE present varying degrees of neuropsychiatric symptoms, such as asterixis, dyspraxia, stupor, and even coma. However, MHE is regarded as the preclinical stage of OHE and includes a spectrum of cognitive deficits in attention span, psychomotor speed, and working memory 2.
Although the early diagnosis of MHE is critical for subsequent treatment and follow-up, the diagnosis of MHE is complicated by the lack of standard and reliable diagnostic tests that are suitable for clinical practice 8. The psychometric hepatic encephalopathy score PHES and repeatable battery for the assessment of neuropsychological status RBANS are the two most extensively used paper-and-pencil psychometric tests for MHE diagnosis Table 1 610 — While the PHES and RBANS have been validated in clinical studies, they often require a significant amount of time to administer and, therefore, cannot be rapidly and conveniently performed to diagnose MHE in clinical practice A survey by the AASLD indicated that although most hepatologists believe that MHE should be diagnosed based on test results, only a small number of patients with cirrhosis are, in fact, routinely tested for MHE Therefore, simple and rapid tests that can be administered by medical personnel would increase the frequency of MHE testing during both initial clinical assessment and follow-up.
Several recent studies have indicated that psychometric tests can be computerized for simplification and administered in the clinic within a few minutes 521 — The instructions for psychometric testing do not differ between paper-and-pencil tests and computer-aided tests, and testing results are reviewed by medical professionals to reach achieve a substantial conclusion.
A preferable strategy for MHE diagnosis is to initially screen patients with cirrhosis who may exhibit MHE using rapid, convenient and highly sensitive computer-aided psychometric tests and then conduct the PHES for further validation In this review, we summarize the advances from paper-and-pencil to computer-aided psychometric tests for MHE screening.Try free
Among different paper-and-pencil psychometric tests, the PHES is currently recommended internationally as the gold standard for the diagnosis of MHE 125 It evaluates motor speed, motor accuracy, concentration, attention, visual perception, visual construction, and memory, which are related to most of the neuropsychological impairments of MHE It has been validated internationally in Germany, Italy, Spain, India, Korea and China, and local population-based normative values have been established to reduce the bias induced by cultural differences Table 3 611 — 1328 It has been proven to be of diagnostic as well as prognostic use.
It can predict both occurrence of OHE and survival in patients with MHE, as well as identify patients with cirrhosis who are at risk of falling within 1 year after the testing 142830 Univariate analysis has identified significant age and education effects on PHES scores These effects, however, are controlled to a certain extent by the large normative data set obtained from healthy volunteers, minimizing the chance for error.Hepatic Encephalopathy – Q&A with Dr. Yapp
In addition, some of the subtests showed significant learning effects, which are balanced in the composite score of the whole battery.
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