From the Guidelines
Hepatic encephalopathy (HE) is typically assessed using a combination of clinical examination, neuropsychological testing, and neurophysiological investigations.
Methods of Assessment
- Clinical examination: The West-Haven classification is the most frequently used clinical classification of HE, which includes assessing signs such as asterixis, psychomotor slowing, sleep–wake inversion, temporospatial disorientation, and impaired consciousness 1.
- Neuropsychological testing: This is the reference examination for the diagnosis of covert HE, and includes tests such as the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and PSE-Syndrom-Test, which measure multiple domains of cognitive function 1.
- Neurophysiological investigations: These include techniques such as cognitive-evoked potentials (EPs), electroencephalogram (EEG), visual EPs, and somatosensory EPs (SEPs), which provide a functional assessment of the nervous system and can be used to quantify cognitive impairment due to HE 1.
Specific Tests
- Animal naming test: This is a recommended test for investigating covert HE, as it is a simple and effective way to assess cognitive function 1.
- Psychometric tests: These include tests of attention, executive function, psychomotor abilities, and speed of information processing, which are commonly used to diagnose minimal hepatic encephalopathy (MHE) 1.
Importance of Assessment
- Early detection: Early detection of HE is crucial, as it can significantly impact patient outcomes and quality of life 1.
- Monitoring: Regular monitoring of HE is necessary to assess the effectiveness of treatment and to detect any changes in cognitive function 1.
From the Research
Assessment Methods for Neurological Symptoms in Hepatic Encephalopathy
The assessment of neurological symptoms in hepatic encephalopathy (HE) involves various methods, including:
- Neuropsychological test batteries and neurophysiological tests to evaluate cognitive function in outpatients and establish the diagnosis of minimal HE 2
- Psychometric tests, such as:
- Portosystemic hepatic encephalopathy test
- Continuous reaction time test
- Stroop EncephalApp
- Animal naming test
- Critical flicker frequency test
- Inhibitory control test 3
- Clinical examination and clinical decision, using West Haven criteria to assess the severity of neurological dysfunction in overt HE 4
- Imaging of the brain and portal-systemic circulation with magnetic resonance imaging (MRI) in difficult cases 2
- Electrophysiological evaluation to reveal alterations in attention, working memory, psychomotor speed, and visuospatial ability in minimal HE 4
Diagnostic Approaches
Diagnostic approaches for HE include:
- Excluding other causes of neurological symptoms
- Using psychometric tests to detect minimal HE
- Clinical examination and West Haven criteria to diagnose overt HE
- Imaging techniques, such as MRI, to aid in diagnosis and identify pathophysiologic mechanisms 5
Treatment and Management
Treatment and management of HE involve:
- Identification and correction of precipitating factors
- Empirical ammonia-lowering treatment with Rifaximin and Lactulose
- Secondary prophylaxis with Rifaximin and Lactulose
- Treatment of minimal HE on a case-by-case basis 4
- Novel treatment strategies, including fecal transplantation, TIPS revision, and closure of eventual splenorenal shunts 6