Abstract
Background: 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. However, numerous studies have shown that, although the neurological symptoms are slight, affected patients are markedly impaired in their quality of life and ability to work. Various treatment modalities that have been shown to reverse MHE include lactulose/lactitol, probiotics/synbiotics, L-carnitine but rifaximin has shown a general trend toward better efficacy and better tolerability in patients with overt hepatic encephalopathy (OHE). Objective: Our objective is to assess the diagnostic role of minimental state examination (MMSE), electroencephalography (EEG) and visual evoked potential (VEP) in detection of MHE and to evaluate the efficacy of rifaximin in improving EEG and VEP in patients with MHE. Patients and Methods: Sixty cirrhotic patients were enrolled in the study depending on clinical evidence of stigmata of chronic liver disease, laboratory investigations including liver function tests, ultrasonographic features of liver cirrhosis and with no evidence of overt hepatic encephalopathy. Diagnois of MHE was made depending on minimental state examination (MMSE) and neurophysiological tools including EEG and VEP. A control group of sixty healthy volunteers with age and sex matched were included. The patient group received Rifaximin 550 mg twice daily for 8 weeks then follow up EEG and VEP studies were done. Results: MHE was detected in 36.7%, 48.3%, 51.7% of our series based on MMSE, EEG and VEP respectively. Child Pouph A, B, C was found in 51.7%, 35%, 13.3% respectively. Rifaximin was well tolerated. At the end of treatment, EEG and VEP studies were done which showed signficant changes between pre and post treatment results (P value = 0.03, 0.001, Conclusion: MMSE as well as EEG and VEP were reasonable diagnostic tools for early detection of MHE particularly in countries with low level of education. Rifaximin significantly improves both EEG and VEP in cirrhotic patients with MHE.
Highlights
Minimal hepatic encephalopathy Minimal hepatic Encephalopathy (MHE) diagnosed by minimental state examination (MMSE) MHE diagnosed by EEG MHE diagnosed by visual evoked potential (VEP)
In our study we diagnosed MHE in 60 cirrhotic patients without overt encephalopathy by using combination of minimental state examination, EEG and VEP P100 event-related potential and this is close to the results of recent reports by Mina et al [29]
We found that MHE was present in 36% - 51% which is close to the esults of previous studies that reported that the prevalence of MHE is high in patients with cirrhosis of liver and varies between 30% and 84% [3]
Summary
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 [1].MHE has a high frequency among patients with liver cirrhosis (22% - 74%) and occurs in patients with portosystemic shunt [2] but the true frequency of patients with MHE is unknown, because MHE often remains undiagnosed due to the lack of evident symptoms and standardized clinical criteria and diagnosis rest mainly on careful patient history and physical examination, normal mental status examination, demonstration of abnormalities in cognition and/or neurophysiological function, and exclusion of concomitant neurological disorders [3] [4].numerous studies have shown that, the neurological symptoms are slight, affected patients are markedly impaired in their quality of life and ability to work [5]. Various treatment modalities that have been shown to reverse MHE include lactulose/lactitol, probiotics/synbiotics, L-carnitine, branched-chain amino acids [7]. Compared with lactulose or neomycin, rifaximin has shown a general trend toward better efficacy and better tolerability in patients with OHE [8]. 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. Various treatment modalities that have been shown to reverse MHE include lactulose/lactitol, probiotics/synbiotics, L-carnitine but rifaximin has shown a general trend toward better efficacy and better tolerability in patients with overt hepatic encephalopathy (OHE). Diagnois of MHE was made depending on minimental state examination (MMSE) and neurophysiological tools including EEG and VEP.
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