Clinical and Pathophysiological Characteristics of Cirrhotic Patients with Grade 1 and Minimal Hepatic Encephalopathy

Abstract

Background and AimsEASL/AASLD hepatic encephalopathy (HE) guidelines proposed the alternative use of the term ‘Covert HE’ combining minimal HE (mHE) and Grade 1 HE into a single entity. However, longitudinal data to indicate that these are indeed a single entity are lacking. The aims of this study were to determine whether the occurrence of complications of cirrhosis requiring hospital admission and mortality were similar in these sub-groups of patients.MethodsClinically-stable cirrhotic patients (n = 106) with no previous history of ‘Overt HE’ were included over a 2-year period and classified as having no HE (n = 23), mHE (n = 39) or Grade 1 HE (n = 44). Standard biochemistry, venous ammonia, bacterial DNA and neutrophil function were measured at inclusion and the patients were followed for a mean of 230±95 days.ResultsPatients with Grade 1 HE had significantly more complications requiring hospitalisation (infection 9/18/34%; HE 4/8/18%; other 13/10/11%; P = 0.02) and significantly greater mortality (4/5/20%; P = 0.04) compared to patients with no HE or mHE respectively. Patients with mHE and grade 1 HE had similar ammonia levels, but higher than the no HE group (P<0.001). MELD score was similar between groups but Grade 1 HE patients had increased frequency of bacterial translocation (P = 0.06) and neutrophil spontaneous respiratory burst (P = 0.02) compared to patients with mHE.ConclusionsThe results of this study show for the first time that ‘Covert HE’ is a heterogeneous entity with significantly greater hospitalisations and mortality in the Grade 1 HE patients compared with mHE. Further prospective longer-term studies are required before EASL/AASLD guidance is fully implemented.

Minimal hepatic encephalopathy identifies patients at risk of faster cirrhosis progression

“…CFF). The main problem is represented by patients with low‐grade HE, which even has made to look for modifications of PHES or different cut‐offs for CFF . To date, neuropsychological and neurophysiological tests to detect MHE have focused mainly on predicting overt HE, which is the instinctive next step.…”

Letter: stepwise diagnosis in covert hepatic encephalopathy – critical flicker frequency and MELD‐score as a first‐step approach. Replication and pitfalls

“…We agree with Dr Zacharias et al that minimal hepatic encephalopathy (MHE) and hepatic encephalopathy grade 1 may be distinct entities among patients with CHE as has been suggested by other authors. 5,6 Unfortunately, our database does not allow us to analyze whether the variables that we identified and the stepwise strategy work differently in patients with MHE and hepatic encephalopathy Grade 1. Nevertheless, and in the same sense, the grades of hepatic encephalopathy according to West Haven classification among overt hepatic encephalopathy according to ISHEN are also different.…”

The advantage of calling things by the same name

“…However, distinguishing between overt and covert hepatic encephalopathy is also relevant for clinical management because treatment for patients with covert hepatic encephalopathy is currently not recommended . Detractors of distinguishing covert and overt hepatic encephalopathy base their arguments on clinical and even pathophysiological differences between patients who have hepatic encephalopathy grade 1 and those with MHE . Indeed, in the joint American Association for the Study of Liver Diseases (AASLD)/European Association for the Study of the Liver (EASL) guidelines, the informativeness and clinical value of the use of the term covert hepatic encephalopathy was identified as an area of uncertainty .…”

“…The design of the study does not offer insight as to why these decisions were taken, whether it is simply due to lack of knowledge of the guidelines or other reasons. Although nowadays there is little discussion regarding the negative aspects of using a low‐protein diet, the measurement of ammonia can still be considered to rule out hepatic encephalopathy in patients who have more than 1 possible cause of altered neurological status . This underlines the need to increase the efforts to promote diffusion of the AASLD/EASL guidelines to physicians from other specialties who manage these patients.…”