Subclinical hepatic encephalopathy impairs daily functioning

Abstract

Subclinical hepatic encephalopathy (SHE) is assumed to have a negative effect on patients' daily functioning; therefore, treatment is recommended. However, no studies have been performed that document the clinical relevance of SHE. We performed a study in which the prevalence of SHE was determined in 179 outpatients with cirrhosis using two psychometric tests (Number Connection Test Part A [NCT-A] and the Digit Symbol Test [DGT]) and automated analysis of the electroencephalogram (EEG). SHE was defined by the presence of at least one abnormal psychometric test and/or abnormal slowing of the EEG. The influence of cirrhosis and SHE on patients' daily functioning was assessed using the Sickness Impact Profile (SIP) questionnaire. The distribution of SIP scores of the patients with cirrhosis differed from the reference scores of the general population. Patients with cirrhosis and SHE (n ‫؍‬ 48) reported significantly more impairment in all 12 scales of the SIP, in the psychosocial subscore, the physical subscore, as well as in the total SIP score, compared with cirrhotic patients without SHE (n ‫؍‬ 131). Multivariate analysis taking into account severity of liver disease (Child-Pugh score), presence of varices, and alcoholic etiology, showed that SHE independently was related to a diminished total SIP score. The reproducibility of the SIP was high when the test was repeated after a 3-month period. We conclude that SHE implies impaired daily functioning and warrants attempts at treatment. (HEPATOLOGY 1998;28:45-49.)Clinical manifestations of hepatic encephalopathy include a decreased intellectual function, personality disorders, an altered level of consciousness, and neuromuscular dysfunction. 1 In addition to clinical manifest hepatic encephalopathy, 2 a subclinical stage has been described, which cannot be detected through global clinical examination, but requires specific neuropsychological and neurophysiological examination. [3][4][5][6][7][8][9][10][11][12] The prevalence of subclinical hepatic encephalopathy (SHE) is estimated to vary from 30% to 84% according to recent studies using appropriate methods. [12][13][14][15][16] This variation in reported prevalence depends on the kind (psychometric or electrophysiological) and number of tests used, and the population (etiology and severity of the liver disease) tested. 17

Minimal Hepatic Encephalopathy Impairs Quality of Life

“…40 It is measured by using general health scales like Nottingham Health Profile (NHP), the Sickness Impact Profile (SIP), SF -36 16,[41][42][43] and disease specific scales like Chronic Liver Disease Questionnaire (CLDQ), NIDDK-QA and the Liver Disease Quality of Life Instrument. [44][45][46][47] MHE adversely affects HRQOL as shown by various studies.…”

“…[44][45][46][47] MHE adversely affects HRQOL as shown by various studies. 11,41,43,[48][49][50] Complex activities which require attention or information processing and psychomotor skills are mainly affected, such as driving a car or planning a trip. Basic functions of day to day self-care like personal hygiene, dressing and shopping are preserved.…”

“…Significant impairment is seen in social interaction, alertness, emotional behavior, sleep, work, home management, and recreation and pastimes. 11,43,47 In a study using SF-36 and NHP, Marchesini et al 42 had shown that etiology and duration of cirrhosis had no effect on HRQOL and minor symptoms like pruritus and muscle cramps had significant negative impact on HRQOL. In decompensated cirrhotics, MHE impairs domains of activity, emotional function and global scoring on CLDQ.…”

Management of Covert Hepatic Encephalopathy

“…64,65 Studies have consistently shown that patients with MHE have a diminished quality of life, cognitive function, daily function, and driving impairment. [3][4][5][6][7][8][9][10] While it was once thought that cognitive impairment with CHE or OHE was reversible, data from studies evaluating medical treatment or liver transplantation suggest that the associated cognitive changes may not be totally reversible. [66][67][68] Moreover, it has been demonstrated that even after therapy and improvement to normal mental status, a single episode of OHE may continue to have residual negative effects on cognitive function.…”

“…2 Prior terminology included "sub-clinical", "latent", and "minimal" appear to trivialize the condition. There is abundant evidence in the literature that MHE has a profound impact on quality of life, daily functioning, driving ability, [3][4][5][6][7][8][9][10] and nearly half of all patients with MHE may be unfit to maintain employment. 9 Based on the current ISHEN guidelines, 11 patients with MHE and Grade I encephalopathy by WestHaven Criteria were re-classified as having covert hepatic encephalopathy (CHE).…”