Covert Hepatic Encephalopathy: “Minimal” Changes Cause a Major Screening Problem

Abstract

Introduction: Covert hepatic encephalopathy (CHE) is seen in up to 80% of cirrhotic patients and significantly impacts quality of life and daily function of cirrhotic patients. Because of the lack of clinically detectable changes in verbal skills or motor function, the diagnosis of CHE is difficult and typically requires specialized testing to discern the subtle changes in cognition. Recently a four-question Sickness Impact Profile Score for CHE (SIP CHE Score) was found useful to detect CHE in the clinic. The goal of this study was to evaluate our group's practice of screening for CHE. Methods: Single-center retrospective chart review of patients followed in general gastroenterology and hepatology clinics at an academic medical center. Patient charts were reviewed including nursing and physician visits to ascertain if screening for CHE had occurred. Results: A total of 49 patients (61% male) charts were reviewed. Cirrhosis was diagnosed by liver biopsy in 60%, and by imaging or clinical criteria in 40%. Child-Pugh A, B, and C classes were 69%, 29%, and 2% respectively. 57% had HCV as the etiology of cirrhosis. Of the 49 patients 18% (9/49) carried a diagnosis of overt hepatic encephalopathy. Of the remaining patients, 15% (6/40) were diagnosed with CHE and treatment initiated. Of the remaining 34 patients only 11% (3/34) received any directed questioning for minimal changes consistent with CHE and none of the cohort received any specialized neurocognitive testing. Conclusion: The majority of cirrhotic patients are not screened for CHE. A standardized screening tool, such as the recently validated four-question Sickness Impact Profile Score for CHE (SIP CHE Score), should be incorporated in the routine evaluation of patients with cirrhosis.