Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Multicenter Study

Simon Johannes Gairing, Chiara Mangini, Lisa Zarantonello, Stefania Gioia, Elise Jonasson Nielsen, Sven Danneberg, Maria Gabriel, Alena F Ehrenbauer, Patricia P Bloom, Cristina Ripoll, Philippe Sultanik, Peter Robert Galle, Joachim Labenz, Dominique Thabut, Alexander Zipprich, Anna S Lok, Karin Weissenborn, Jens Uwe Marquardt, Mette Munk Lauridsen, Silvia NardelliSara Montagnese, Christian Labenz*

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review


INTRODUCTION: The prevalence of minimal hepatic encephalopathy (MHE), in particular in different subgroups, remains unknown. This study aimed to analyze the prevalence of MHE in different subgroups to identify patients at high risk and to pave the way for personalized screening approaches.

METHODS: In this study, data of patients recruited at 10 centers across Europe and the United States were analyzed. Only patients without clinical signs of hepatic encephalopathy were included. MHE was detected using the Psychometric Hepatic Encephalopathy Score (PHES, cut-off < or ≤-4 depending on local norms). Clinical and demographic characteristics of the patients were assessed and analyzed.

RESULTS: In total, 1,868 patients with cirrhosis with a median model for end-stage liver disease (MELD) of 11 were analyzed (Child-Pugh [CP] stages: A 46%, B 42%, and C 12%). In the total cohort, MHE was detected by PHES in 650 patients (35%). After excluding patients with a history of overt hepatic encephalopathy, the prevalence of MHE was 29%. In subgroup analyses, the prevalence of MHE in patients with CP A was low (25%), whereas it was high in CP B or C (42% and 52%). In patients with a MELD score <10, the prevalence of MHE was only 25%, but it was 48% in patients with a MELD score ≥20. Standardized ammonia levels (ammonia level/upper limit of normal of each center) correlated significantly, albeit weakly with PHES (Spearman ρ = -0.16, P < 0.001).

DISCUSSION: The prevalence of MHE in patients with cirrhosis was high but varied substantially between diseases stages. These data may pave the way for more individualized MHE screening approaches.

Original languageEnglish
JournalThe American Journal of Gastroenterology
Issue number12
Pages (from-to)2191-2200
Publication statusPublished - Dec 2023

Bibliographical note

Copyright © 2023 by The American College of Gastroenterology.


  • Ammonia
  • End Stage Liver Disease
  • Hepatic Encephalopathy/epidemiology
  • Humans
  • Liver Cirrhosis/complications
  • Prevalence
  • Psychometrics
  • Severity of Illness Index
  • PHES
  • MHE
  • frequency
  • Psychometric Hepatic Encephalopathy Score
  • PSE syndrome test
  • point prevalence


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