Testing for minimal hepatic encephalopathy in the United States: An AASLD survey

We read with interest the recent article by Kale et al. describing the MR imaging of patients with cirrhosis with minimal hepatic encephalopathy (MHE) who were diagnosed using a battery of neuro-psychometric tests.1 MHE is a neurocognitive complication of cirrhosis which is associated with poor quality of life, increased rate of progression to overt hepatic encephalopathy (OHE) and driving skill impairment.2-6 MHE detection is not possible by clinical examination but can only be performed using neuropsychometric/neurophysiological techniques, as in the paper by Kale et al.1, 7-9 We set out to determine the diagnostic approaches of U.S.-based members of AASLD toward MHE systematically to identify potential barriers to routine testing. An anonymous questionnaire querying the practice profile, personal opinions regarding MHE diagnostic strategies, frequency of diagnosis, reasons for testing/not testing for MHE, measures that would increase their testing for MHE and treatment for MHE, was e-mailed to 246 AASLD members. One hundred thirty-seven replies were received, of which 98 (72%) were in academic programs, 33 (24%) in private practice, and 6 (4%) were trainees. The majority of respondents believed that MHE was a problem and agreed that it should be tested for. However, only a minority was able to test for it >50% of the time and 52 (38%) respondents never tested for it (Table 1). The reasons for testing or not testing for MHE are displayed in the table. The majority who tested for MHE tested all cirrhotics (56%), the rest restricted testing to those driving (18%), operating machinery (15%), working full-time (9%), and not actively drinking (8%). Of the respondents, 85% believed that simple and rapid tests for MHE diagnosis which can be administered by clinic personnel would increase the likelihood of testing for MHE; other factors that would increase their likelihood for MHE testing are displayed in the table. In addition, 85% believed that MHE, once diagnosed, should be treated. Lactulose was the preferred agent for 78%, rifaximin 18%, zinc 8%, and the rest believed other treatments would be effective. In conclusion, although the majority of AASLD respondents believe that MHE is a significant problem which should be tested for, only a minority are able to test for it routinely. Barriers to routine MHE testing include added time, resource and personnel requirements and lack of standardized tests in the United States population. Simple and rapid tests for diagnosis of MHE would likely increase the probability of testing for MHE in the future. Jasmohan Singh Bajaj*, Ashkan Etemadian*, Muhammad Hafeezullah*, Kia Saeian*, * Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI.