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Validation of the Psychometric Hepatic Encephalopathy Score (PHES) for Identifying Patients with Minimal Hepatic Encephalopathy

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Abstract

Background

The psychometric hepatic encephalopathy score (PHES) is a battery of neuropsychological tests used in the diagnosis of minimal hepatic encephalopathy (MHE).

Aim

The aim of this study was to construct and validate a dataset of normal values for the PHES.

Methods

Volunteers and patients with cirrhosis with and without low-grade overt hepatic encephalopathy (OHE) were enrolled. All subjects completed the PHES battery, and possible modifying factors were assessed. Formulas to predict expected scores in cirrhotics were constructed, and MHE was diagnosed whenever a deviation of <−4 SDs occurred across the five tests.

Results

Among the 743 volunteers, age and years of education influenced the scores of all tests. Eighty-four patients with cirrhosis lacked evidence of OHE, whereas 20 had OHE: median PHES were −1 [0 to −3] and −9 [−6.5 to −11.8] (P < 0.001), respectively. Thirteen of the 84 patients (15%) with cirrhosis but without OHE had MHE. Patients with MHE were older and less educated than those without MHE (61 ± 8 and 52 ± 10 years old, P = 0.003; 7 ± 4 and 12 ± 5 years education, P = 0.002), whereas liver function was not different (MELD, 8 ± 5 and 8 ± 5). A very strong correlation between these norms and those derived from Spain was observed (r = 0.964, P < 0.001).

Conclusions

PHES performance was mostly influenced by age and education, and expected results in cirrhotics need to be adjusted for these factors. Our validation of Mexican norms for PHES (PHES-Mex) establishes a practical method for assessing MHE and contributes to international attempts to standardize diagnostic protocols for MHE.

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References

  1. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy—definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th world congresses of gastroenterology, Vienna, 1998. Hepatology. 2002;35:716–721.

    Article  PubMed  Google Scholar 

  2. Córdoba J, Mínguez B. Hepatic encephalopathy. Semin Liver Dis. 2008;28:70–80.

    Article  PubMed  Google Scholar 

  3. Torre-Delgadillo A, Cisneros-Garza L, Méndez-Sánchez N, Jacobo-Karam J, Duarte-Rojo A, Solís-Galindo F. Gastroenterology diagnosis and treatment guidelines of hepatic encephalopathy. General approach. Rev Gastroenterol Mex. 2009;74:161–163.

    PubMed  Google Scholar 

  4. Bajaj JS, Wade JB, Sanyal AJ. Spectrum of neurocognitive impairment in cirrhosis: implications for the assessment of hepatic encephalopathy. Hepatology. 2009;50:2014–2021.

    Article  PubMed  Google Scholar 

  5. Bajaj JS, Saeian K, Verber MD, et al. Inhibitory control test is a simple method to diagnose minimal hepatic encephalopathy and predict development of overt hepatic encephalopathy. Am J Gastroenterol. 2007;102:754–760.

    Article  PubMed  Google Scholar 

  6. Baskin-Bey ES, Stewart CA, Mitchell MM, Bida JP, Rosenthal TJ, Nyberg SL. Preliminary report of the hepatic encephalopathy assessment driving simulator (HEADS) score. Ethn Dis. 2008;18:357–364.

    PubMed  Google Scholar 

  7. Prasad S, Dhiman RK, Duseja A, Chawla YK, Sharma A, Agarwal R. Lactulose improves cognitive functions and health-related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy. Hepatology. 2007;45:549–559.

    Article  PubMed  Google Scholar 

  8. Liu Q, Duan ZP, Ha DK, Bengmark S, Kurtovic J, Riordan SM. Synbiotic modulation of gut flora: effect on minimal hepatic encephalopathy in patients with cirrhosis. Hepatology. 2004;39:1441–1449.

    Article  PubMed  Google Scholar 

  9. Malaguarnera M, Gargante MP, Cristaldi E, et al. Acetyl-L-carnitine treatment in minimal hepatic encephalopathy. Dig Dis Sci. 2008;53:3018–3025.

    Article  PubMed  CAS  Google Scholar 

  10. Randolph C, Hilsabeck R, Kato A, et al. Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int. 2009;29:629–635.

    Article  PubMed  Google Scholar 

  11. Weissenborn K. PHES: one label, different goods?! J Hepatol. 2008;49:308–312.

    Article  PubMed  Google Scholar 

  12. Weissenborn K, Ennen JC, Schomerus H, Rückert N, Hecker H. Neuropsychological characterization of hepatic encephalopathy. J Hepatol. 2001;34:768–773.

    Article  PubMed  CAS  Google Scholar 

  13. Romero Gómez M, Córdoba J, Jover R, et al. Normality tables in the Spanish population for psychometric tests used in the diagnosis of minimal hepatic encephalopathy. Med Clin (Barc). 2006;127:246–249.

    Article  Google Scholar 

  14. Amodio P, Campagna F, Olianas S, et al. Detection of minimal hepatic encephalopathy: normalization and optimization of the psychometric hepatic encephalopathy score. A neuropsychological and quantified EEG study. J Hepatol. 2008;49:346–353.

    Article  PubMed  Google Scholar 

  15. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33:464–470.

    Article  PubMed  CAS  Google Scholar 

  16. Virtanen A, Kairisto V, Uusipaikka E. Regression-based reference limits: determination of sufficient sample size. Clin Chem. 1998;44:2353–2358.

    PubMed  CAS  Google Scholar 

  17. Bravo G, Hébert R. Age- and education-specific reference values for the mini-mental and modified mini-mental state examinations derived from a non-demented elderly population. Int J Geriatr Psychiatry. 1997;12:1008–1018.

    Article  PubMed  CAS  Google Scholar 

  18. Romero-Gómez M, Córdoba J, Jover R, et al. Value of the critical flicker frequency in patients with minimal hepatic encephalopathy. Hepatology. 2007;45:879–885.

    Article  PubMed  Google Scholar 

  19. Lockwood AH, Weissenborn K, Bokemeyer M, Tietge U, Burchert W. Correlations between cerebral glucose metabolism and neuropsychological test performance in nonalcoholic cirrhotics. Metab Brain Dis. 2002;17:29–40.

    Article  PubMed  Google Scholar 

  20. Weissenborn K, Ahl B, Fischer-Wasels D, et al. Correlations between magnetic resonance spectroscopy alterations and cerebral ammonia and glucose metabolism in cirrhotic patients with and without hepatic encephalopathy. Gut. 2007;56:1736–1742.

    Article  PubMed  Google Scholar 

  21. Amodio P, Ridola L, Schiff A, et al. Improving the inhibitory control task to detect minimal hepatic encephalpathy. Gastroenterology. 2010;139:510–518.

    Article  PubMed  Google Scholar 

  22. Bajaj JS, Schubert CM, Heuman DM, et al. Persistence of cognitive impairment after resolution of overt hepatic encephalopathy. Gastroenterology. 2010;138:2332–2340.

    Article  PubMed  Google Scholar 

  23. Jover R, Compañy L, Gutiérrez A, et al. Minimal hepatic encephalopathy and extrapyramidal signs in patients with cirrhosis. Am J Gastroenterol. 2003;98:1599–1604.

    Article  PubMed  Google Scholar 

  24. Ortiz M, Córdoba J, Doval E, et al. Development of a clinical hepatic encephalopathy staging scale. Aliment Pharmacol Ther. 2007;26:859–867.

    Article  PubMed  CAS  Google Scholar 

  25. Ortiz M, Córdoba J, Jacas C, Flavià M, Esteban R, Guardia J. Neuropsychological abnormalities in cirrhosis include learning impairment. J Hepatol. 2006;44:104–110.

    Article  PubMed  Google Scholar 

  26. Riggio O, Ridola L, Pasquale C, et al. Evidence of persistent cognitive impairment after resolution of overt hepatic encephalopathy. Clin Gastroenterol Hepatol. 2011;9:181–183.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Hugo Villamil-Ramírez, Daniel Bernal-Serrano, Ricardo Macías-Rodríguez, and Marina Green-Gómez for their technical assistance, and Fundación Mexicana para la Salud Hepática (Fundhepa - FUNSALUD, México) for their invaluable support.

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Authors and Affiliations

  1. Liver Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, México City, 14000, México

    Andrés Duarte-Rojo, José Estradas, Roberto Hernández-Ramos & Aldo Torre

  2. Clinical Epidemiology Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México

    Sergio Ponce-de-León

  3. Servicio de Medicina Interna-Hepatología, Hospital Vall d′Hebron, Barcelona, Spain

    Juan Córdoba

Authors
  1. Andrés Duarte-Rojo
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  2. José Estradas
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  3. Roberto Hernández-Ramos
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  4. Sergio Ponce-de-León
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  5. Juan Córdoba
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  6. Aldo Torre
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Corresponding author

Correspondence to Aldo Torre.

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Duarte-Rojo, A., Estradas, J., Hernández-Ramos, R. et al. Validation of the Psychometric Hepatic Encephalopathy Score (PHES) for Identifying Patients with Minimal Hepatic Encephalopathy. Dig Dis Sci 56, 3014–3023 (2011). https://doi.org/10.1007/s10620-011-1684-0

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  • DOI: https://doi.org/10.1007/s10620-011-1684-0

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