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Dr. Brown: 
This is CE on ReachMD, and I'm Dr. Robert Brown from Weill Cornell in New York.

Why is it important to recognize minimal hepatic encephalopathy early? Well, I start with a few things. One, it's important to recognize something early, when early intervention will improve outcomes. And minimal HE meets that definition. But we have to recognize that recognizing minimal HE is challenging, but not impossible, and there is a central role for both primary care providers as well as gastroenterologists in recognizing early HE and minimal HE, but they have to know that there are no good diagnostic tools.

Well, we have to recognize minimal HE because it impacts our patients’ daily lives. It's been shown to impair driving performance, and this leads to increased vehicle accidents as well as traffic violations. This has been shown in both driving simulators as well as in real-world data. It also diminishes quality of life, it leads to increased rates of unemployment, and an increased risk of falls and other adverse events. More importantly, it also predicts the transition to overt HE, or overt hepatic encephalopathy, which we know leads to bad outcomes and is a marker for decompensated cirrhosis. So if we can identify patients with minimal HE, we can intervene earlier. We can also institute more proactive therapy to prevent overt HE.

So how do we do it in the absence of diagnostic tools? Well, what is minimal HE? It is HE that is not recognizable on simple clinical exam. So often it involves using neuropsychiatric testing or apps that will predict impaired concentration. But sometimes you can get the clues to this by just looking at the patient and asking pretty simple questions.

So the first question I ask is, are you sleepy during the day and awake at night? We call this day-night reversal, and it is a subtle sign of minimal HE. Patients may also tell you that things that used to be easy for them are more difficult—whether this is the New York Times crossword puzzle, remembering complex things, balancing their checkbook, et cetera—could give you a clue that a patient has minimal HE. So the first thing you have to do is ask.

So if you ask questions, then you may find. And if you're so motivated, you can then follow that up with tests. Now, most of these pencil-and-paper tests are challenging, but a simple one is the Animal Naming Test. Ask them how many animals they can name in a minute, and if they're having trouble naming a large number, you may have a sign that they have minimal HE.

And there is increasing data that treatment early will improve outcome.

So now you know. Thanks for listening.

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