**5.1 Health-related quality of life (HRQoL)**

Quality of life is a multidimensional index that reports all aspects of human well-being, including physical and cognitive capabilities, functional behavior, emotional status, and psychosocial adjustment [50]. The American Association for the Study of Liver Diseases survey conducted in 2007 demonstrated that, most clinicians believe MHE to be a significant problem. However, only 50% of clinicians had examined whether their patients might have MHE, and 38% had never studied their patients with liver cirrhosis [51]. Several evidences show that, HRQoL may seem to be influenced by the coexistence of MHE [48, 52–56]. MHE increases the incidence of disability, and has a negative effect on daily activities. The impact of the perception of the disease, in the form of a "Sickness Impact Profile," has been studied in cirrhotic patients to assess the indicators of QoL. Each profile was significantly reduced in patients with MHE compared to individuals without MHE [48]. In addition, in the presence of MHE, QoL indicators, such as the capacity to drive a car, and the incidence of sleep disorders were also negatively affected [57, 58].

#### **5.2 MHE and falls**

Minimal hepatic encephalopathy is significantly associated with high risk of falls explaining the increased healthcare and hospitalization rate in patients with MHE compared to cirrhotic patients without MHE [49, 59, 60]. The presence of cognitive impairment was the only independent factor predictive of a fall. The chance of a fall in 1 year was found to be significantly higher in patients with MHE compared to those without MHE. Urios et al. demonstrated that, MHE patients show impaired balance, mainly on an unstable surface with eyes open, with longer reaction and confinement times and lower success in stability test limits compared to patients without MHE [61].

#### **5.3 Effect of MHE on driving**

Traffic accidents are more common in patients with MHE compared to normal individuals, as the driving process in patients with MHE is affected by defects in many factors such as, defects in attention and information processing, slow reactions, improper estimation of traffic conditions, and lack of coordination [48, 62]. As many as 33% of MHE patients reported a traffic accident or violation within the past year [63]. Interestingly, treatment with lactulose could substantially reduce societal costs by preventing motor vehicle accidents [64].

#### **5.4 Risk of overt HE**

MHE has been found to predict the development of overt HE in cirrhotic patients [2]. A recent study demonstrated that, CHE and elevated blood NH3 levels contributed to OHE development in cirrhotic patients [65]. The results of Wang et al. showed that, solely serum albumin level < 30 g/L is the predictor for developing OHE in CHE patients [66]. In a study of Thomsen et al., that enrolled 106 clinically stable cirrhotic patients with no previous history of OHE and followed them for 230 ± 95 d, it was found that, 13.3% of CHE patients developed OHE [67]. In a multicenter study by Patidar et al., a total of 170 cirrhotic patients were followed for

**9**

**Table 2.**

*Minimal Hepatic Encephalopathy: Silent Tragedy DOI: http://dx.doi.org/10.5772/intechopen.88231*

ization, and death/transplant [36].

**6. Diagnosis of MHE and CHE**

**6.2 Indications for testing**

Patients at risk of accidents

• Poor memory: "I forget a lot".

• Unprovoked falls

• Risks at work, e.g., machine worker • Driving accident within the past year

Patients who complain of cognitive symptoms

Patients with previous history of episodic HE

• Decreased attention: "I am frequent feelig of confused."

reporting decline in work performance [75, 76].

**6.3 Neuropsychological (paper-and-pencil) tests**

a mean of 13 months. They found that 30% of cirrhotic patients developed at least one OHE episode, and that CHE increased their risk of developing OHE, hospital-

There is no single optimal measure for diagnosis of MHE because none of the diagnostic strategies covers all aspects of deficits that are present in MHE [68, 69]. Testing approaches can be divided into two major types: psychometric and neurophysiological [70, 71]. As MHE affects many elements of cognitive functioning, which may not be impaired to identical degrees, the International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) recommends the use of at least two tests, based on the local population norms and availability, and if possible, with

The diagnosis requires the indication of tests in subjects who appear normal, but may suffer from cirrhosis, as the physician usually does not observe MHE [73]. Further group of patients who are not cirrhotic and may develop MHE are those with porto-systemic shunts of inborn origin or secondary to portal thrombosis. The available data of the neuropsychological characteristics of these patients indicate

There is no consensus on patients to test for MHE. Some physicians recommend screening of all cirrhotic patients. However, testing should be completed in patients at risk (**Table 2**) for MHE such as, cirrhosis or porto-systemic shunts [5]. Special attention should be given to active drivers, patients handling heavy machines or

The American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver recommended neurophysiological

*Patients with cirrhosis, portal vein thrombosis, or porto-systemic shunts who should undergo tests for MHE.*

one of the tests being more widely accepted to serve as a comparator [72].

**6.1 Diseases associated with minimal hepatic encephalopathy**

that cognitive abnormalities are indistinguishable from MHE [74].

• Psychomotor performance: "I have difficulty in carrying out fine motor tasks."

Patients with decline in work performance observed by relatives or colleagues

*Liver Disease and Surgery*

with individuals without MHE [48]. Moreover, those patients suffer from falls [49]

Quality of life is a multidimensional index that reports all aspects of human well-being, including physical and cognitive capabilities, functional behavior, emotional status, and psychosocial adjustment [50]. The American Association for the Study of Liver Diseases survey conducted in 2007 demonstrated that, most clinicians believe MHE to be a significant problem. However, only 50% of clinicians had examined whether their patients might have MHE, and 38% had never studied their patients with liver cirrhosis [51]. Several evidences show that, HRQoL may seem to be influenced by the coexistence of MHE [48, 52–56]. MHE increases the incidence of disability, and has a negative effect on daily activities. The impact of the perception of the disease, in the form of a "Sickness Impact Profile," has been studied in cirrhotic patients to assess the indicators of QoL. Each profile was significantly reduced in patients with MHE compared to individuals without MHE [48]. In addition, in the presence of MHE, QoL indicators, such as the capacity to drive a car, and the incidence of sleep disorders were

Minimal hepatic encephalopathy is significantly associated with high risk of falls explaining the increased healthcare and hospitalization rate in patients with MHE compared to cirrhotic patients without MHE [49, 59, 60]. The presence of cognitive impairment was the only independent factor predictive of a fall. The chance of a fall in 1 year was found to be significantly higher in patients with MHE compared to those without MHE. Urios et al. demonstrated that, MHE patients show impaired balance, mainly on an unstable surface with eyes open, with longer reaction and confinement times and lower success in stability test limits compared to patients

Traffic accidents are more common in patients with MHE compared to normal individuals, as the driving process in patients with MHE is affected by defects in many factors such as, defects in attention and information processing, slow reactions, improper estimation of traffic conditions, and lack of coordination [48, 62]. As many as 33% of MHE patients reported a traffic accident or violation within the past year [63]. Interestingly, treatment with lactulose could substantially reduce

MHE has been found to predict the development of overt HE in cirrhotic patients [2]. A recent study demonstrated that, CHE and elevated blood NH3 levels contributed to OHE development in cirrhotic patients [65]. The results of Wang et al. showed that, solely serum albumin level < 30 g/L is the predictor for developing OHE in CHE patients [66]. In a study of Thomsen et al., that enrolled 106 clinically stable cirrhotic patients with no previous history of OHE and followed them for 230 ± 95 d, it was found that, 13.3% of CHE patients developed OHE [67]. In a multicenter study by Patidar et al., a total of 170 cirrhotic patients were followed for

societal costs by preventing motor vehicle accidents [64].

and have a high risk of development of episodic HE [2].

**5.1 Health-related quality of life (HRQoL)**

also negatively affected [57, 58].

**5.2 MHE and falls**

without MHE [61].

**5.4 Risk of overt HE**

**5.3 Effect of MHE on driving**

**8**

a mean of 13 months. They found that 30% of cirrhotic patients developed at least one OHE episode, and that CHE increased their risk of developing OHE, hospitalization, and death/transplant [36].
