Subclinical neuropsychiatric abnormalities are present in ≈40% of patients.

Covert or minimal hepatic encephalopathy (C/MHE) has been associated with falls, motor vehicle accidents, and worsened liver-related outcomes from cirrhosis, but diagnosis requires specialized testing and frequently is missed. In this systematic review of 101 studies, researchers pooled data from 16,000 patients with cirrhosis to estimate the prevalence of C/MHE and identify patient charac- teristics associated with excess risk. In all studies, C/MHE was diagnosed using neuropsychological tests: the psychometric hepatic encephalopathy score (PHES) — a composite of five separate psycho- metric tests — was used most commonly and typically is regarded as the gold standard.

Key findings were as follows:

• The prevalence of C/MHE increased with worsening liver disease: 29%, 46%, and 62% for Child-Pugh class A, B, and C,
• C/MHE was most common in patients with cirrhosis due to alcohol (46%) or viral hepatitis (41%) and least common in patients with cirrhosis due to metabolic dysfunction–associated steatotic liver disease (35%) or autoimmune liver disease (27%).
• Laboratory markers of cirrhosis severity (i.e., elevated serum ammonia, bilirubin, and international normalized ratio [INR], and low serum albumin, hemoglobin, and platelets) were associated with C/MHE, but none are highly accurate predictors.

COMMENT

C/MHE surely is underdiagnosed among patients with cirrhosis and apparently normal mental status and neurological exams. Many comprehensive and abbreviated diagnostic tools for C/MHE have been evaluated; some are sufficiently brief to perform in routine primary care, but brief tools tend to have suboptimal sensitivity, specificity, or both (NEJM JW Gastroenterol Nov 2014 and Clin Gastroenterol Hepatol 2014; 12:1384). Given the high prevalence of C/MHE, an empirical trial of treatment for hepatic encephalopathy in patients with cirrhosis and subtle or subacute cognitive changes might be prudent.

— Rahul B. Ganatra, MD, MPH

Dr. Ganatra is Instructor in Medicine at Harvard Medical School and Director of Continuing Medical Education for the Medical Service, VA Boston Healthcare System, Boston.

Lv X-H et al. Prevalence and characteristics of covert/minimal hepatic encephalopathy in patients with liver cirrhosis: A systematic review and meta-analysis. Am J Gastroenterol 2024 Apr; 119:690. (https://doi.org/10.14309/ajg.0000000000002563)

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