Diagnosis of Covert Hepatic Encephalopathy Without Specialized Tests

Clin Gastroenterol Hepatol. 2013 Dec 19. pii: S1542-3565(13)01966-6. doi: 10.1016/j.cgh.2013.12.020. [Epub ahead of print]

Nabi E¹, Thacker LR², Wade JB³, Sterling RK¹, Stravitz RT¹, Fuchs M¹, Heuman DM¹, Bouneva I¹, Sanyal AJ¹, Siddiqui MS¹, Luketic V¹, White MB¹,Monteith P¹, Noble NA¹, Unser A¹, Bajaj JS⁴.

Abstract

BACKGROUND & AIMS: Covert hepatic encephalopathy (CHE) impairs quality of life (QOL) and can be difficult to diagnose. Patient-administered methods that do not require specialized tests or equipment might increase rates of detection. We performed a longitudinal study to determine whether demographic data and responses to a validated QOL questionnaire, the Sickness Impact Profile (SIP), can identify patients with CHE.

METHODS: Patients with cirrhosis without prior overt HE were recruited from outpatient liver clinics at Virginia Commonwealth University Medical Center, from August 2008 through February 2012. We performed cognitive tests on 170 patients (mean age, 55 y; mean model for end-stage liver disease score, 9; 50% with hepatitis C-associated and 11% with alcohol-associated cirrhosis). Patients were also given the SIP questionnaire (136 questions on 12 QOL topics, requiring a yes or no answer) at enrollment, 6 months, and 12 months. The proportion of patients that responded "yes" to each question was compared between those with and without CHE. Patient variables (non-cognitive), demographics (age, education, sex, alcoholic etiology), and SIP questions that produced different responses between groups were analyzed by logistic regression and receiver operating characteristic analyses.

RESULTS: Based on cognitive test results, 93 patients (55%) had CHE when the study began. They had a higher proportion of "yes" responses to 54 questions on the SIP questionnaire, across all categories. We developed a formula to identify patients with CHE based on age, sex, and responses to 4 SIP questions (a SIP CHE score). Baseline SIP CHE scores >0 identified patients with CHE with 80% sensitivity and 79% specificity. Of the 98 patients that returned for the 6-month evaluation, 50% had CHE (the SIP CHE identified these with 88% sensitivity). Of the 50 patients that returned for the 12-month evaluation, 32% had CHE (the SIP CHE score identified these with 81% sensitivity).

CONCLUSIONS: We developed a system to identify patients with CHE based on age, sex, and responses to 4 SIP questions; this formula identified patients with CHE with >80% sensitivity over a 12-month period after the initial enrollment. Patient-administered CHE screening strategies that do not include specialized tests could increase detection of CHE and improve therapy.

Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.

KEYWORDS: A, AB, BCM, BDT, C, CHE, DST, E, EB, HCV, HM, HRQOL, M, NASH, NCT-A/B, ROC, RP, SI, SIP, SIP subcategories (SR, SSRI, W, alertness behavior, ambulation, block design test, body care and movement, cirrhosis, cognition, communication, covert hepatic encephalopathy, digit symbol test, eating), emotional behavior, health-related quality of life, hepatitis C virus, household management, minimal hepatic encephalopathy, mobility, non-alcoholic steatohepatitis, number connection test-A/B, psychometric tests, receiver operating characteristic, recreation and pastimes, selective serotonin reuptake inhibitors, sickness impact profile, sleep and rest, social interaction, work

PMID: 24362049 [PubMed - as supplied by publisher]

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