Minimal Hepatic Encephalopathy: Hiding in Plain Sight?

Transcript

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Dr. Jesudian:
This is CE on ReachMD, and I'm Dr. Arun Jesudian. Here with me today is Dr. Nancy Reau.

Nancy, what are the signs that clinicians need to look for to suspect minimal hepatic encephalopathy?

Dr. Reau:
Yeah, minimal hepatic encephalopathy by definition is a little sneaky, and it's going to be a spectrum, right? So sometimes you really have very few clues, and you need to do formal psychiatric testing in order to demonstrate if someone has minimal hepatic encephalopathy.

On the other hand, there are people who are truly affected; it's just a little more subtle, and that's where we're going to concentrate. That means that things that usually are no big deal are a little bit harder. So you can't remember how to get into your phone. You're a little confused about coming up with your address, and this is kind of where those mind games or Sudoku or some of the things where you have to challenge yourself a little bit more and if you're struggling, that's important.

In the hospital or in the office, we'll often ask pretty easy questions, and that's not going to be good enough for minimal encephalopathy. You really need to get a little bit harder, challenging the brain, making it stay on task and concentrating. And when there's a breakdown then you know you might have HE.

Dr. Jesudian:
Yeah, I agree. It can be so difficult to pick up at the bedside. And this minimal hepatic encephalopathy falls within what we call covert hepatic encephalopathy, which is different from overt hepatic encephalopathy. If you look at the scoring systems like the West Haven criteria, you'll see that patients with overt hepatic encephalopathy have grades 2, 3, and 4. That's really obvious for us to pick up. We'll see asterixis or disorientation or even coma in the severe form. And this minimal or covert is so challenging for the reasons you laid out.

I try and ask my patients about brain fogginess and about if they're functioning at their job the way they normally do. Although it's not perfect, have you ever used the animal naming test?

Dr. Reau:
All the time. And we tell them to vary. Don't just name animals, think about things you can find in your kitchen or favorite restaurants. People learn things. It's the same thing with the Stroop Test. Once you figure it out, if you do it over and over and over again, there's going to be a little bit of pattern recognition. So taking it up a notch to make that brain work is really going to be important.

Dr. Jesudian:
Yeah, so how many of one category of items they can name can give us a tip-off of if they're impaired. But yes, maybe not asking the same one every time so they're not practiced at it.

Do you find that caregivers are helpful at identifying minimal or covert hepatic encephalopathy in patients?

Dr. Reau:
I do, I think, especially when you tell them that subtle behavioral changes can be a sign. We also try to release them so that they don't feel like they're tattling on their loved one. When I talk to my patient in front of me, I'm like, listen, it's really important to get feedback from your family. They're not trying to be mean. They're really trying to find something at a time when we can intervene so that you have better quality of life, so you have better functioning. They're not just saying, “Oh, look, I'm frustrated. You're not your normal self.” That means that you need to call your doctor, talk about what we might be able to change so that you have a better functioning status.

Dr. Jesudian:
Well, and I think it's helpful to talk to them about quality of life and how this even covert hepatic encephalopathy can impact their quality of life. So us identifying it and thinking about treatment can really help how they're feeling and maybe how they even really relate to their family and loved ones.

Dr. Reau:
Absolutely. There's a lot of overlap between depression, being overwhelmed, side effects of medication. So even if a conversation about minimal encephalopathy turns out not to be encephalopathy, it doesn't mean that it's—you know, it’s like a practice, right? So it wasn't ME this time, but maybe next time it will be minimal encephalopathy, and you now have the freedom to talk to your caregivers and your providers about how you're feeling and what's going on and what changes might be able to be made.

Dr. Jesudian:
That's an important point. So if you take one thing away, raise your index of suspicion for hepatic encephalopathy and don't ignore the subtle clues.

Well, I think we nailed it. Thanks so much, and we'll see you next time.

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Overview
This series of brief episodes focuses on the early recognition and clinical management of hepatic encephalopathy (HE). Drs. Arun Jesudian and Nancy Reau examine subtle signs that may indicate minimal or covert HE and offer strategies for timely diagnosis. The discussion covers practical tools for detection, the role of nutrition and pharmacologic therapy, and evidence-based approaches to prevent progression and hospitalization. Emerging therapies and ongoing clinical trials are also discussed to highlight future directions in HE treatment.
Commercial Support
This activity is supported by an independent educational grant from Bausch Health US, LLC. 
Disclosure of Relevant Financial Relationships
In accordance with the ACCME Standards for Integrity and Independence, it is the policy of Global Learning Collaborative (GLC) that faculty and other individuals who are in the position to control the content of this activity disclose any real or apparent financial relationships relating to the topics of this educational activity. Global Learning Collaborative (GLC) has full policies in place that have identified and mitigated financial relationships and conflicts of interest to ensure independence, objectivity, balance, and scientific accuracy prior to this educational activity.
The following faculty/staff members have reported financial relationships with ineligible companies within the last 24 months.
Faculty:
Arun B. Jesudian, MD
Professor of Clinical Medicine
Weill Cornell Medicine
New York, NY
Research: Salix Pharmaceuticals
Consulting Fees: Madrigal Pharmaceuticals, Mallinckrodt Pharmaceuticals, Salix Pharmaceutical

Nancy Reau, MD
Chief of Internal Medicine
Rush University Medical Center
Chicago, IL
Research: AbbVie Inc., Gilead Sciences, Inc., Salix Pharmaceuticals
Consulting Fees: Arbutus, Gilead Sciences, Inc., Ipsen, Mallinckrodt Pharmaceuticals
Reviewers/Content Planners/Authors: 
- Cindy Davidson has no relevant relationships to disclose. 
- Rosanne Strauss has no relevant relationships to disclose. 
- Brian P. McDonough, MD, FAAFP, has no relevant relationships to disclose. 
Learning Objectives
Upon completion of this activity, learners should be better able to:
- Explain the clinicalimportance of the onset of MHE
- Differentiate the clinical characteristics of covert HE from overt HE
- Determinean appropriate treatment regimen for a patient with HE
- Summarize data from clinical trials of emerging therapeutic approaches to the treatment of HE
Target Audience
This activity has been designed to meet the educational needs of Gastroenterologists and Hepatologists as well as all other physicians, physician assistants, nurse practitioners, nurses, pharmacists, and healthcare providers involved in managing patients with Hepatic Encephalopathy. 
Accreditation and Credit Designation Statements
In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. 

Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Global Learning Collaborative (GLC) designates this activity for 1.0 nursing contact hour(s). Nurses should claim only the credit commensurate with the extent of their participation in the activity.

Global Learning Collaborative (GLC) designates this activity for 1.0 contact hour(s)/0.1 CEUs of pharmacy contact hour(s).

The Universal Activity Number for this program is JA0006235-0000-25-139-H01-P. This learning activity is knowledge-based. Your CE credits will be electronically submitted to the NABP upon successful completion of the activity. Pharmacists with questions can contact NABP customer service (custserv@nabp.net). 

Global Learning Collaborative (GLC) has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit(s) for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credit(s). Approval is valid until December 12, 2026. PAs should claim only the credit commensurate with the extent of their participation in the activity.
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Disclaimer
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of GLC. This presentation is not intended to define an exclusive course of patient management; the participant should use his/her clinical judgment, knowledge, experience, and diagnostic skills in applying or adopting for professional use any of the information provided herein. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Links to other sites may be provided as additional sources of information.
Reproduction Prohibited Reproduction of this material is not permitted without written permission from the copyright owner. 
System Requirements
- Supported Browsers (2 most recent versions):
- - Google Chrome for Windows, Mac OS, iOS, and Android
  - Apple Safari for Mac OS and iOS
  - Mozilla Firefox for Windows, Mac OS, iOS, and Android
  - Microsoft Edge for Windows
- Recommended Internet Speed: 5Mbps+
Publication Dates
Release Date: 12/11/2025
Expiration Date: 12/11/2026