Assessment of minimal hepatic encephalopathy (with emphasis on computerized psychometric tests)

Probiotics are beneficial for liver cirrhosis: a systematic review and meta-analysis of randomized control trials

Introduction

Gut dysbiosis may play a pivotal role in the pathogenesis of cirrhosis and the severity of complications. Numerous studies have investigated the probiotics as treatments for cirrhosis. However, there is still a lack of definitive evidence confirming the beneficial effects of probiotics on cirrhosis.

Methods

Databases including PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for randomized controlled trials that compared the effects of probiotic intervention and control treatments, including placebo, no treatment, and active control, on cirrhosis, published from inception to February 2024. Outcomes included hepatic encephalopathy (HE) reversal, safety and tolerability of probiotics, liver function, quality of life, and other cirrhotic-related outcomes. A meta-analysis was conducted to synthesize evidence.

Results

Thirty studies were included. The quantitative synthesis results showed that compared with the control group, probiotics significantly reverse minimal hepatic encephalopathy (MHE) (risk ratio [RR] 1.54, 95% confidence interval [CI] 1.03 to 2.32) and improve HE (RR 1.94, 95% CI 1.24 to 3.06). Additionally, probiotics demonstrated higher safety and tolerability by causing a lower incidence of serious adverse events (RR 0.71, 95% CI 0.58 to 0.87). Probiotics could potentially improve liver function by reducing the Model for End-Stage Liver Disease (MELD) scores (standardized mean difference [SMD] -0.57, 95% CI -0.85 to -0.30), and displayed favorable changes in quality of life (SMD 0.51, 95% CI 0.27 to 0.75) and gut flora (SMD 1.67, 95% CI 1.28 to 2.06).

Conclusion

This systematic review and meta-analysis offers compelling evidence that probiotics are beneficial for cirrhosis by demonstrating reversal of HE, potential for liver function improvements, enhancements in quality of life, and regulation of gut dysbiosis. Furthermore, the apparent safety profile suggests that probiotics are a promising intervention for treating cirrhosis.

Clinical trial registration number

CRD42023478380.

Standardization of the psychometric hepatic encephalopathy score in a French population

The Psychometric Hepatic Encephalopathy Score (PHES) has previously been standardized in thirteen countries on three continents, confirming its status of gold standard test to detect minimal hepatic encephalopathy (MHE). In the meantime, performance has also been shown to vary with variables such as age, education, and barely sex. The present study aimed at standardizing the PHES in a French population. One hundred and ninety-six French healthy participants completed a French version of the paper-and-pencil PHES, involving five tests and six measures. Importantly, the balance was perfect between all levels of the three controlled factors, which were sex, age (seven decade-levels from 20–29 to 80–89 years), and education (two levels below or above 12 years of education). Raw measures were transformed to fit the normal distribution. ANOVAs on transformed variables showed no effect of sex, but an effect of age on all measures, and of education on five measures. Multiple or simple regressions were completed to build up normograms. Thorough analysis of variability within each test failed to find outliers that may bias the results. Comparison between French and seminal German data showed that they highly fitted though cultural and cognitive style specificities could be observed. This is the first study to standardize the PHES in a French population and to extensively explore the effects of sex, age and education using perfectly balanced samples. Subtle differences between countries of the same continent emphasize the need to build up normative data in each country to get accurate PHES in patients.

Auditory and visual P300 event-related potentials to detect minimal hepatic encephalopathy

INTRODUCTION

Diagnosis of Minimal hepatic encephalopathy (MHE) requires psychometric tests, although new methods are needed since sensitivity, specificity, and accuracy are low. The P300 event-related potential (ERP) is obtained by auditory and visual stimuli, although only the auditory P300 has been used to detect MHE. We aimed to compare the diagnostic features of auditory and visual P300 to detect MHE.

MATERIALS AND METHODS

Sixty patients with liver cirrhosis and thirty-five healthy controls completed the Psychometric Hepatic Encephalopathy Score (PHES), the critical flicker frequency (CFF), auditory, and visual P300. MHE was diagnosed if PHES and CFF scores were abnormal.

RESULTS

Fifty-three cirrhotic patients (age 54.5±8.6 years) completed all tests. Abnormal scores were: PHES (49.1%), CFF (67.9%). The proportion of MHE was 21.4%. The area under the receiver operating ROC curves (AUROC) for auditory P300 was better than visual P300 for distinguishing MHE from controls (AUROC 0.792 vs 0.725; p<0.005 for both; accuracy 73.8%vs 70.2%; sensitivity 72.2% both; specificity 74.2 vs 69.7, respectively. Among cirrhotic patients, only auditory P300 was useful to detect MHE, AUROC 0.723 p<0.05; 77.4% accuracy; 61.1% sensitivity; and 81.8% specificity.

CONCLUSIONS

The auditory P300 sensitivity, specificity, and accuracy were similar to those of CFF. Our results showed that only auditory P300 is useful to differentiate patients with MHE. Although both modalities, auditory and visual, differentiated patients with cirrhosis from controls, we consider the visual P300 is not suitable for detecting MHE.

Liver transplant candidates have impaired quality of life across health domains as assessed by computerized testing

INTRODUCTION AND OBJECTIVES

Liver transplantation candidates are among the most comorbid patients awaiting lifesaving intervention. Health related quality of life (HRQOL) measured by instruments that incorporate dynamic computerized adaptive testing, could improve their assessment. We aimed to determine the feasibility of administration of the Patient-Reported Outcomes Measurement Information System (PROMIS-CAT) in liver transplant candidates.

MATERIALS AND METHODS

Liver transplantation candidates were prospectively enrolled following a review of their available medical history. Subjects were given a tablet computer (iPad) to access the pre-loaded PROMIS CAT.

RESULTS

109 candidates with mean age 55.6±8.6 years were enrolled in this pilot study. Mean MELD-Na score was 16.3±6.3; 92.6% had decompensated liver disease. Leading etiologies of cirrhosis included hepatitis C (34.8%), nonalcoholic steatohepatitis (25.7%) and alcohol (21.1%). Subjects with MELD-Na score>20 had the most significant impairment in HRQOL (anxiety/fear+5.9±2.7, p=0.0289, depression+5.1±2.5, p=0.0428, fatigue+4.3±2.6, p=0.0973) and physical impairment (-7.8±2.5, p=0.0022). Stage of cirrhosis and decompensated liver disease were predictive of impaired HRQOL but Child-Pugh Turcotte score was not. Hepatic encephalopathy was the strongest independent predictor of impaired HRQOL, with significant impairment across all domains of health.

CONCLUSIONS

Liver transplant candidates have significantly impaired HRQOL across multiple domains of health as measured by PROMIS-CAT. HRQOL impairment parallels disease severity. Future study is needed to determine how best HRQOL could be systematically included in liver transplantation listing policy, especially in those candidates with hepatic encephalopathy.

Neurobehavioral Effects of Organic Solvents Exposure Among Wood Furniture Makers in Ile-Ife, Osun State, Southwestern Nigeria

BACKGROUND

Furniture making industries are small scale businesses that commonly use organic solvents. There has been minimal focus on the health effects of this chemical hazard on the nervous system among furniture makers in Nigeria.

OBJECTIVES

The present study aimed to assess the association between organic solvents exposure and neurobehavioral status of furniture makers, using electronic technicians as a comparison group.

METHODS

A comparative cross-sectional study design was employed. A sample size of 108 was calculated for each group. A semi-structured interviewer-administered questionnaire was used to obtain data on the socio-demographic variables and use of personal protective equipment (PPE). A proforma was developed to collect neurobehavioral assessment data. A checklist was used to assess the furniture makers' workshops. Air was sampled from all of the workshops in both the study and comparison groups to determine the concentration of total volatile organic compounds (TVOCs).

RESULTS

The use of PPE was poor in both the study and comparison groups, with no significant difference between them (34.4% and 37.7% respectively). Total volatile organic compound and formaldehyde (HCHO) concentrations were significantly higher at the furniture makers' workshops compared with electronic technicians (p<0.001) for both chemicals. The 8-hour time-weighted average of TVOC was also higher in the furniture makers' workshops (4.4±0.6 mg/m3) compared with the control group (0.3±0.3 mg/m3). The neurobehavioral symptoms score was significantly higher among the study group relative to the comparison group (p<0.001). There was a significant difference in the outcome of the auditory verbal learning test, total recall (p=0.005), and delayed recall (p=0.003). There was no significant association between solvent exposure index and findings from the simple reaction time test.

CONCLUSIONS

Poor compliance with the use of PPE among furniture makers may increase their exposure to organic solvents. There were more neurobehavioral changes in the furniture makers with a higher exposure index. Measures are needed to educate artisans about workrelated chemical hazards and ensure compliance with basic occupational safety and hygiene standards.

PARTICIPANT CONSENT

Obtained.

ETHICS APPROVAL

Ethics approval was obtained from the Health Research and Ethics Committee of the Institute of Public Health, Obafemi Awolowo University (IPH/OAU/12/1049).

COMPETING INTERESTS

The authors declare no competing financial interests.

Stroop Test Validation to Screen for Minimal Hepatic Encephalopathy in Pediatric Extrahepatic Portal Venous Obstruction

OBJECTIVES

Minimal hepatic encephalopathy (MHE) has been reported in children with extrahepatic portal vein obstruction (EHPVO). MHE assessment is restricted to research situations as neuropsychiatric tests are time-intensive. Computerized Stroop Test (CST) has been used in cirrhotic adults for MHE screening. The study aims to assess MHE frequency in young Indian children with EHPVO and validate CST for MHE screening in pediatric EHPVO.

METHODS

Thirty-seven children with EHPVO between 7 and 12 years of age and 37 age- and sex-matched controls were enrolled. Fasting plasma ammonia was measured. MHE was diagnosed by Revised Amsterdamse Kinder Intelligentie Test. The performance of a Tamil language version of CST in MHE screening was assessed.

RESULTS

MHE was diagnosed in 18.9% (7/37) of EHPVO (EHPVO-MHE). Plasma ammonia levels were higher in EHPVO-MHE compared to EHPVO without MHE (EHPVO-No-MHE) but abnormal plasma ammonia levels are unsuitable for MHE screening. CST was administered in 35 EHPVO and 37 controls. EHPVO-MHE, compared to EHPVO-No-MHE, had longer "on time," "off time," "(on+off) time," and "(on-off) time." For MHE diagnosis, specificity and sensitivity of "(on+off) time" were 100% and 89.6% for a cutoff of >180.4 seconds (area under receiver operating characteristic = 0.97).

CONCLUSIONS

In the absence of other risk factors for neurological insult or patent surgical shunts, MHE frequency in young Indian children with EHPVO, determined by Revised Amsterdamse Kinder Intelligentie Test, was lesser than in earlier studies. CST is suitable for MHE screening in clinical practice to select patients for neuropsychiatric evaluation.

Combining arterial-spin labeling with functional magnetic resonance imaging measurement for characterizing patients with minimal hepatic encephalopathy

AIM

Our objective is to explore key changes in brain functions in relation to minimal hepatic encephalopathy (MHE). We incorporated both resting-state functional magnetic resonance imaging (fMRI) and arterial spin labeling (ASL) to enhance the detection of MHE.

METHODS

We undertook fMRI scanning for 56 MHE patients and 66 healthy controls. Region functional connectivity was carried out to assess the connectivity status between pairs of regions among 90 brain regions. Additionally, blood flow (BF) status was measured by ASL for all subjects. Spearman's correlation test was implemented to identify any correlation among z-values, results from number connection test type A, and digit symbol tests. Finally, the receiver operating characteristic curve was generated for assessing the accuracy of BF in MHE diagnosis.

RESULTS

The corresponding functional connectivity was significantly different between MHE and control groups in 15 regions. For MHE patients, BF showed an increasing pattern in regions of interest. Blood flood in the putamen was positively correlated with number connection test type A neuropsychological performance, whereas it was negatively correlated with the digit symbol test. Blood flood in the right putamen showed the highest value of area under the curve with a sensitivity of 85.7% and specificity of 89.4%.

CONCLUSION

Connectivity impairment resulting from ganglia-thalamo-cortical circuits may play important roles in mediating the development of MHE patients. An increase in the BF, particularly in the right putamen, may be considered as evidence for the presence of MHE.

Diagnosis of minimal hepatic encephalopathy in a tertiary care center from eastern Romania: validation of the psychometric hepatic encephalopathy score (PHES)

The psychometric hepatic encephalopathy score (PHES) is frequently used as a "gold standard" for the diagnosis of minimal hepatic encephalopathy (MHE). In Romania, there are currently no widely available tests for the detection of MHE. In this study we aimed to standardize the PHES in a healthy Romanian population and to estimate the prevalence of MHE in a group of Romanian patients with liver cirrhosis. A total of 260 healthy volunteers and 106 patients with liver cirrhosis were included in the study. The five neuropsychological tests comprising the PHES were administered to all enroled subjects. Blood samples for routine tests and serum ammonia were collected. In the healthy volunteer group age and education years were found to be predictors of all tests and gender only in two tests: digit symbol test and serial dotting test. The PHES of the healthy volunteer group was 0,43 ± 1,37 and the cut-off between normal and pathological values was set at -3 points. In the liver cirrhosis group the mean PHES was -2,44 ± 3,41, significantly lower than in the control group (p = 0,001). The estimated prevalence of MHE was 34,7 % (37 patients). In patients with cirrhosis there was a significant correlation between PHES and the severity of the liver disease according to Child-Pugh classification (r = 0,529, p = 0,001) and MELD score (r = -0,525, p = 0,001). According to our results, accurate Romanian PHES norms for the diagnosis of MHE have been developed. MHE was diagnosed in a significant proportion of Romanian patients with liver cirrhosis.

Rifaximin vs. lactulose in treatment of minimal hepatic encephalopathy

BACKGROUND & AIMS

Lactulose and rifaximin have already been shown to improve both cognitive functions and health related quality of life (HRQOL) in MHE patients. We aimed to compare the efficacy of rifaximin with lactulose in reversal of MHE and improvement in HRQOL in cirrhotic patients with MHE.

METHOD

This prospective, randomized, open label, non-inferiority trial, was conducted at the Gastroenterology department of a tertiary care institute in Northern India. MHE was diagnosed if any two of the five neuro-psychometric (NP) tests were positive. HRQOL was assessed using the sickness impact profile (SIP) questionnaire (John Hopkins University, USA).

RESULTS

Of 527 cirrhotics screened, 351 were found eligible and tested for MHE. A total of 112 (31.9%) patients were found to have MHE and then randomized into two groups group A (lactulose; 30-120 ml/day) and B (Tablet. rifaximin; 400 mg thrice a day). Based on the intention-to-treat population, the proportion of patients with MHE reversal at 3 months was 73.7% (42/57) in the rifaximin arm and 69.1% (38/55) in the lactulose arm [4.6% difference (90% CI -9.3% to 18.4%)]. However, non-inferiority of rifaximin over lactulose could not be established as the pre-specified non-inferiority margin (-5%) lies within the two-sided 90% confidence interval of the difference. HRQOL was significantly improved in both groups (P = 0.20). However, the proportion of patients with flatulence (P = 0.004) and diarrhoea (P = 0.0002) was significantly higher in patients who took lactulose.

CONCLUSION

Non-inferiority of rifaximin over lactulose for MHE reversal was not established.

Contemporary Understanding and Management of Overt and Covert Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a major complication of liver disease that leads to significant morbidity and mortality. Caring for hospitalized patients with HE is becoming more complex, and the economic burden of HE continues to rise. Defining and diagnosing HE, particularly covert HE (CHE), remain challenging. In this article, we review new tools and those currently under development for the diagnosis of CHE and the latest advances in the acute and long-term management of overt HE (OHE) and CHE. In particular, we review the latest data on the use of lactulose and rifaximin for treatment of OHE and summarize the data on adjunctive agents such as sodium benzoate and probiotics.

Covert Hepatic Encephalopathy: Who Should Be Tested and Treated?

Covert hepatic encephalopathy is a common problem in cirrhosis, affecting up to 80% of patients. It is defined as test-dependent brain dysfunction with clinical consequences in the setting of cirrhosis in patients who are not disoriented. Because it is not apparent clinically, and diagnostic testing has not been standardized, the issue has often been ignored in clinical practice. Yet, the clinical consequences are notable, including impaired quality of life, diminished work productivity, and poor driving skills.

Progress in diagnosis of minimal hepatic encephalopathy

Minimal hepatic encephalopathy (MHE) is defined as HE without symptoms on clinical/neurological examination, but with deficits in some cognitive areas that can only be measured by neuropsychometric testing. MHE is associated with reduced quality of working, driving, memory, and cognitive function, and is a risk factor for the development of overt HE. Compared with non-MHE patients, MHE patients have a high mortality rate, so positive screening and intervention in patients with MHE are needed to improve the quality of life in patients with cirrhosis and reduce traffic accidents and the social burden of medical care. The current approach to the diagnosis of MHE includes mental scales (paper pencil test, computer test, or the combination of the two), electrophysiological examination, and imaging examination. Diagnosis of MHE is still a challenge now, and it is needed to establish a better clinical diagnosis standard to improve the diagnostic level.

Minimal hepatic encephalopathy in children with liver cirrhosis: diffusion-weighted MR imaging and proton MR spectroscopy of the brain

INTRODUCTION

The aim of this work was to detect minimal hepatic encephalopathy (minHE) in children with diffusion-weighted MR imaging (DWI) and proton magnetic resonance spectroscopy (1H-MRS) of the brain.

METHODS

Prospective study conducted upon 30 consecutive children (age range 6-16 years, 21 boys and 9 girls) with liver cirrhosis and 15 age- and sex-matched healthy control children. Patients with minHE (n = 17) and with no minHE (n = 13) groups and control group underwent DWI, 1H-MRS, and neuropsychological tests (NPTs). The glutamate or glutamine (Glx), myoinositol (mI), choline (Cho), and creatine (Cr) at the right ganglionic region were determined at 1H-MRS. The apparent diffusion coefficient (ADC) value and metabolic ratios of Glx/Cr, mI/Cr, and Cho/Cr were calculated.

RESULTS

There was elevated ADC value and Glx/Cr and decreased mI/CI and Ch/Cr in patients with minHE compared to no minHE and control group. There was significant difference between minHE, no minHE, and control group in the ADC value (P = 0.001 for all groups), GLx/Cr (P = 0.001 for all groups), mI/Cr (P = 0.004, 0.001, and 0.001, respectively), Ch/Cr (P = 0.001 for all groups), and full-scale IQ of NPT (P = 0.001, 0.001, and 0.143, respectively). The NPT of minHE had negative correlation with ADC value (r = -0.872, P = 0.001) and GLx/Cr (r = -0.812, P = 0.001) and positive correlation with mI/Cr (r = 0.732, P = 0.001).

CONCLUSION

DWI and 1H-MRS are imaging modalities that can detect minHE in children with liver cirrhosis and correlate well with parameters of NPT.

Can computerized brain training games be used to identify early cognitive impairment in cirrhosis?

OBJECTIVES

We evaluated whether commercially available, computerized "brain-training" games can be used to identify subtle cognitive impairments in patients with cirrhosis.

METHODS

We compared patients with cirrhosis who did not have overt encephalopathy (n=31), patients with pre-cirrhotic chronic liver disease (n=28), and normal controls without liver disease (n=16) with respect to their scores on the number connection test-A (NCT-A), the Inhibitory Control Test (ICT), and five, short (∼2.5 min), brain-training games that were administered on an Apple iPad and tested different cognitive domains.

RESULTS

Patients with cirrhosis had similar scores to patients with pre-cirrhotic liver disease and slightly worse scores than normal controls in the NCT-A and the ICT, although these differences were not statistically significant. In contrast, patients with cirrhosis had significantly worse scores than patients with pre-cirrhotic liver disease and even more so than normal controls in all five of the brain-training games. After adjustment for age and educational attainment, these differences remained significant for two of the tests, "Color Match" which is a version of the Stroop test and measures selective attention, and "Memory Matrix", which measures visuospatial memory. The area under the receiver operating characteristic curve discriminating cirrhosis from pre-cirrhotic liver disease was 0.56 (95% confidence interval (CI) 0.41-0.72) for the ICT and 0.58 (95% CI 0.43-0.73) for the NCT-A, indicating no discrimination, while it was 0.75 (95% CI 0.63-0.87) for "Color Match" and 0.77 (95% CI 0.64-0.90) for "Memory Matrix", indicating good discrimination.

CONCLUSIONS

Short, brain-training games administered on an iPad can be used as psychometric tests to detect subtle cognitive impairments in patients with cirrhosis without overt encephalopathy that could not be detected by the NCT-A or the ICT.

Psychometric hepatic encephalopathy score for diagnosis of minimal hepatic encephalopathy in China

AIM: To construct normal values for the tests of the psychometric hepatic encephalopathy score (PHES) and to evaluate its usefulness in the diagnosis of minimal hepatic encephalopathy (MHE) among Chinese individuals with cirrhosis.

METHODS: The five tests of PHES, number connection test-A (NCT-A), number connection test-B, serial dotting test, line tracing test and digit symbol test (DST), were administered to all enrolled subjects in a quiet room with sufficient light. Cirrhotic subjects with overt HE were excluded by the West-Haven criteria and a detailed neurological examination. Based on the nomograms of healthy volunteers, the patients were classified as having MHE when their PHES was less than -4.

RESULTS: In total, 146 healthy volunteers completed all the PHES tests. Age and education years were confirmed to be predictors of all five tests. In total, 53 patients with liver cirrhosis completed the PHES. Of the patients with liver cirrhosis, 24 (45.3%), 22(41.5%) and 7(13.2%) had Child-Pugh grades A, B and C, respectively. MHE was diagnosed in 26 patients (49.1%). Compared with compensated cirrhotic patients (Child A), decompensated cirrhotic patients (Child B and C) had a higher proportion of MHE (65.5% vs 29.2%). No differences in age and education years were found between the MHE and non-MHE groups. NCT-A and DST were able to diagnose MHE with a sensitivity of 76.9% and a specificity of 96.3% (AUC = 0.866, K = 0.735).

CONCLUSION: The proportion of MHE is associated with liver function. NCT-A and DST are simple tools that can be used for the diagnosis of MHE in China.