Title: Diagnosing and Treating Early Hepatic Encephalopathy

Minimal hepatic encephalopathy (MHE) represents a part of the spectrum of hepatic
encephalopathy(HE). MHE is a condition in which patients has normal mental and neurological
status on standard clinical examination exhibit a number of neuropsychiatric and neurophysiological
defects While patients with HE have impaired intellectual functioning, personality changes, altered
levels of consciousness, and neuromuscular dysfunction, patients with MHE have no recognizable
clinical symptoms. Its prevalence varies up to 80% in cirrhotics and 40% in extrahepatic portal vein
obstruction. Increasing evidence indicates that MHE is an important disorder that may seriously
impair a patients daily functioning and quality of life. Psychomotor slowing, visuoconstructive
disabilities, attention deficits are among the few key features while fine motor performance is also
impaired. Driving ability can be impaired in MHE and this may be a significant factor behind motor
vehicle accidents. A crucial aspect of the clinical care of MHE patients is their driving history, which is
often ignored during routine care and can add a vital dimension to the overall disease assessment.
Driving history should be an integral part of the care of patients with MHE. MHE may predict the
development of overt hepatic encephalopathy. Various tools have been evaluated for the correct
diagnosis of MHE, however, in the absence of a “gold standard”, combination of test methods is
recommended to most reliably diagnosed MHE. Studies into inhibitory control, cognitive drug
research and critical flicker frequency tests are encouraging. These tests do not require a
psychologist for administration and interpretation. Pharmacologic therapy is recommended for
patients diagnosed with MHE. The pathogenesis of MHE is considered similar to that of overt HE and ammonia plays a key role. Thus ammonia lowering agents such as lactulose, L-ornithine and L-
aspartate, probiotics and rifaximin have shown good results in many trials.