The advantage of calling things by the same name.

Abstract

See Article on Page 587 Potential conflict of interest: Nothing to report. In this issue, Reuter et al.1 report on the accuracy in the diagnosis and grading of the severity of hepatic encephalopathy, particularly distinguishing between an unimpaired neurological status, hepatic encephalopathy West Haven Criteria (WHC) < grade 2 and WHC ≥ grade 2. This study included as participants gastroenterology/hepatology fellows and gastroenterology faculty who were shown videos of patients, both in the in‐hospital and outpatient setting, and were asked to state whether the patient had hepatic encephalopathy and if so to grade it. The videos were of patients with unimpaired neurological status and patients with hepatic encephalopathy WHC grades 1‐4. Furthermore, participants were surveyed regarding the clinical history they would perform, the diagnostic tests they would order, and the treatment they would initiate. A greater proportion of observers correctly identified patients who had obvious symptoms of hepatic encephalopathy, ie, patients with WHC ≥ grade 2, than patients who had WHC < grade 2. This result is not unexpected and is the reason why the categories of overt (WHC ≥ 2) and covert (minimal hepatic encephalopathy [MHE] and WHC grade 1) hepatic encephalopathy were proposed.2 This division was initially suggested for the design of clinical trials, in which it is essential that the diagnostic tools used to identify patients are reliable. However, distinguishing between overt and covert hepatic encephalopathy is also relevant for clinical management because treatment for patients with covert hepatic encephalopathy is currently not recommended.3 Detractors of distinguishing covert and overt hepatic encephalopathy base their arguments on clinical and even pathophysiological differences between patients who have hepatic encephalopathy grade 1 and those with MHE.4 Indeed, in the joint American Association for the Study of Liver Diseases (AASLD)/European Association for the Study of the Liver (EASL) guidelines, the informativeness and clinical value of the use of the term covert hepatic encephalopathy was identified as an area of uncertainty.3 The results of the current study, however, endorse the use of this categorization. Identification of patients with overt hepatic encephalopathy seems to be relatively straightforward. Nevertheless, identification of patients with WHC grade 1 is more cumbersome, even more so when one considers MHE. This problem can be partially overcome with the common name of covert hepatic encephalopathy. In the present study, no videos of patients with MHE were included. Although MHE is subclinical by definition and therefore theoretically distinguishable from hepatic encephalopathy grade 1 and not distinguishable from patients who have an unimpaired neurological status, this is not always clear‐cut. Undoubtedly, separating between unimpaired neurological status and hepatic encephalopathy WHC grade 1 in clinical practice can be influenced by a variety of factors that are patient and/or caregiver‐related.6 In addition, detection of these subtle findings by their physicians requires time and expertise. These constraints in distinguishing between MHE and WHC grade 1 in clinical practice support the use of a common name for both entities. The current study was performed in hepatology centers with a longstanding interest in liver disease, and most trainees were hepatology fellows. Even though the study was performed in academic centers, a considerable proportion of participants, mainly nontrainees, proposed management strategies that are not endorsed by the guidelines such as measurement of ammonia or ordering a low‐protein diet. The design of the study does not offer insight as to why these decisions were taken, whether it is simply due to lack of knowledge of the guidelines or other reasons. Although nowadays there is little discussion regarding the negative aspects of using a low‐protein diet, the measurement of ammonia can still be considered to rule out hepatic encephalopathy in patients who have more than 1 possible cause of altered neurological status.5 This underlines the need to increase the efforts to promote diffusion of the AASLD/EASL guidelines to physicians from other specialties who manage these patients. In conclusion, this study by Reuter et al. adds further insight to the complexity of the management of patients with hepatic encephalopathy in clinical practice, indeed the evaluation of its severity is subject to interobserver variability especially with lower grades, even in academic hepatology centers. These results support the use of a common term for low‐grade hepatic encephalopathy such as covert hepatic encephalopathy. Further efforts to reduce this variability are warranted.