Original Article
Screening for minimal hepatic encephalopathy in asymptomatic drivers with liver cirrhosis

https://doi.org/10.1016/j.ajg.2011.04.002Get rights and content

Abstract

Background and study aims

Minimal hepatic encephalopathy (MHE) represents a part of the spectrum of hepatic encephalopathy (HE). It can have a far-reaching impact on quality and ability to function in daily life and may progress to overt HE. This study was designed to screen for MHE in drivers with liver cirrhosis in Mansoura, a city in the Nile delta in Egypt.

Patients and methods

A total of 174 consecutive drivers with positive serology for viral markers and cirrhosis were screened for MHE. Questionnaires and standard psychometric tests and well-informed consent were performed at the same setting. The diagnosis of MHE was made when one or both symbol digit test (SDT) and number connection test (NCT) appeared abnormal. Beck’s inventory and Mini Mental State Examination questionnaires were performed for those diagnosed as MHE. After overnight fasting, venous blood samples were taken for haematologic tests and routine liver function tests by conventional methods. Arterial ammonia was also measured.

Results

A total of 66 patients showed evidence for MHE out of 139 patients who fulfilled the inclusion criteria. No significant differences were present, apart from a significantly elevated arterial ammonia level (p-value <0.001) and a bad self-reported driving history (p < 0.05) in the MHE-positive group when compared with the MHE-negative group. Multivariate logistic regression revealed that advanced Child–Pugh grade (p < 0.001), hepatitis B virus (HBV)-related aetiology (p < 0.001) and smoking are significant risk factors for MHE. MHE is significantly commoner among Child–Pugh C patients (p < 0.05) when compared with the other Child–Pugh grades.

Conclusion

Our data revealed a high prevalence of MHE (47%) among Egyptian drivers with liver cirrhosis. It is hence recommended to include the driving history as well as regular pencil–paper standard psychometric testing in evaluating those at risk, especially in the outpatient setting, for early detection and proper management.

Introduction

Minimal hepatic encephalopathy (MHE) represents a part of the spectrum of hepatic encephalopathy (HE) in its mildest form [1]. The prevalence of MHE in liver disease has been reported to vary from 30% to 84%, depending on both the tests used and population studied [2]. Patients with MHE have no recognisable clinical symptoms of HE but have only mild cognitive and psychomotor deficits [1], [3]. Furthermore, MHE can have a far-reaching impact on quality of life, ability to function in daily life and progression to overt HE [1]. MHE has an impact on the ability to drive a car and may be a significant factor behind motor car accidents [4].

Many diagnostic techniques including psychometric tests, electroencephalogram and evoked potentials (EP) have been used to detect MHE. Among these tests, only psychometric tests can be easily done in epidemiological studies. The symbol digit test (SDT) and number connection test part A (NCT-A) were reported to have the advantages of simplicity and reliability [5], [6].

The objective of this study was to screen for MHE in drivers with liver cirrhosis from Mansoura, a city in the Nile delta in Egypt with a high prevalence of chronic liver disease.

Section snippets

Patients and methods

From the Hepatology Outpatient Clinic of Mansoura Specialized Medical Hospital a total of 174 consecutive drivers who were seropositive for viral markers and under consideration for antiviral therapy and proved to be cirrhotic were screened for MHE during the period from January 2009 to June 2010. Age range of patients was 23–57 years. The diagnosis of cirrhosis was based on clinical, biochemical and ultrasonographic or liver histological data. Exclusion criteria were overt HE (OHE) or a history

Results

The demographic characteristics of the participants are shown in Table 1; 35 patients did not fulfil the inclusion criteria and were excluded (recent alcohol intake (one patient), patient’s refusal (two patients), age above 60 years (seven patients) and refusal to perform liver biopsy (25 patients)).

A total of 66 patients showed evidence for MHE, while in 73 patients no evidence for MHE could be detected. The clinical and biochemical characteristics of the studied patients are demonstrated in

Discussion

Clinically, patients with MHE appear to be free of neuropsychiatric abnormalities; meanwhile, they exhibit specific, reversible, quantifiable neuropsychiatric and/or electroencephalographic abnormalities [7], [8].

Lack of symptoms, preservation of communication skills, overall intelligence and patient’s unawareness of his/her own disease, a phenomenon known as anosognosia, complicate the process of identifying patients with MHE at the clinical setting.

MHE is defined as the presence of at least

Conflicts of interest

The authors declared that there was no conflict of interest.

References (25)

  • P. Amodio et al.

    Clinical features and survival of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests

    Hepatology

    (1999)
  • H.O. Conn

    The hepatic encephalopathies

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