Minimal Hepatic Encephalopathy in Indians: Psychometric Hepatic Encephalopathy Score and Inhibitory Control Test for Diagnosis and Rifaximin or Lactulose for Its Reversal

Abstract

Background and Aims: Psychometric hepatic encephalopathy score (PHES) is used widely for diagnosis of minimal hepatic encephalopathy (MHE). This prospective study aimed to determine the utility of the inhibitory control test (ICT) for the diagnosis of MHE. Additionally, the efficacy of rifaximin and lactulose for reversal of MHE was evaluated. Methods: A total of 180 eligible cirrhotic patients underwent testing for MHE. When PHES was # −5 and ICT lures were $ 14, MHE was diagnosed. The 108 patients with MHE were randomized to three groups for treatment with either lactulose, rifaximin, or placebo. Treatment outcomes were measured at the end of 3 months. Results: The 108 patients with MHE diagnosed by PHES and/or ICT accounted for 60%. The diagnosis of MHE was made by both ICT and PHES positivity in 56 patients, by abnormal ICT and normal PHES in 37 patients, and by abnormal PHES and normal ICT in 15 patients. For diagnosis of MHE, ICT had sensitivity of 78.87%, specificity of 66.06% with 60.22% positive predictive value and 82.76% negative predictive value. An area under the curve value of 0.724 (95% CI: 0.653-0.788) was obtained for diagnosis of MHE. Reversal of MHE was seen in 71.42%, 70.27% and 11.11% of patients in the rifaximin, lactulose and placebo arms (p < 0.001). Rifaximin showed better tolerability compared to lactulose. Conclusions: For the diagnosis of MHE, ICT is a simple tool but has lower sensitivity and better specificity than PHES. Rifaximin is as efficacious as lactulose in the treatment of MHE and better tolerated.

Clinical efficiency of inhibitory control test for the diagnosis of minimal hepatic encephalopathy: A systematic review with meta‐analysis

“…After duplicates were removed, a total of 48 studies were identified in the present study, of which 36 were excluded from the analysis according to the inclusion and exclusion criteria; the remaining 12 studies 6,9–19 were included in the systematic review (Figure 2). The characteristics of these 12 studies are presented in Table 1.…”

“…The characteristics of these 12 studies are presented in Table 1. Three 6,10,19 of 12 studies were published before 2010, and nine studies 9,11–18 were published after 2010. All 12 studies 6,9–19 enrolled patients with different etiologies of liver cirrhosis, including viral hepatitis, alcohol hepatitis, autoimmune hepatitis, nonalcoholic steatohepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and cryptogenic cirrhosis.…”

“…Three 6,10,19 of 12 studies were published before 2010, and nine studies 9,11–18 were published after 2010. All 12 studies 6,9–19 enrolled patients with different etiologies of liver cirrhosis, including viral hepatitis, alcohol hepatitis, autoimmune hepatitis, nonalcoholic steatohepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and cryptogenic cirrhosis. Eight studies 9,11–13,15–18 used PHES as their reference test, whereas the other four studies 6,10,14,19 used SPT as the reference test.…”

“…In recent decades, the ICT has been applied for MHE diagnosis in the United States, Germany, Italy, Poland, and India (Table 1). 6,9–19 Several studies indicated that the ICT is a rapid and convenient method for MHE diagnosis in patients with liver cirrhosis; however, its efficiency is influenced by educational level and cultural differences 9,10,13,15,18 . Therefore, in this study, the clinical evidence concerning the ICT application was systematically summarized, and subsequently, a meta‐analysis was undertaken to evaluate its efficiency for MHE diagnosis.…”

Novel computerized psychometric tests as primary screening tools for the diagnosis of minimal hepatic encephalopathy

“…The ICT has been used to screen MHE in the United States, Germany, Italy, and India (Table 1 )[ 6 , 8 - 11 , 23 , 24 ]. In the United States, with a cut-off value of ≥ 5 lures/person, Bajaj et al[ 6 ] found that the ICT had a 90% sensitivity and specificity for screening MHE, and the area under the receiver operator characteristic (AUROC) was 0.902 when using the standard paper-and-pencil psychometric tests (SPT) as the reference standard.…”