Diagnosis of covert hepatic encephalopathy: a multi-center study testing the utility of single versus combined testing

Andres Duarte-Rojo, Sanath Allampati, Leroy R. Thacker, Christopher R. Flud, Kavish R. Patidar, Melanie B. White, Jagpal S. Klair, Douglas M. Heuman, James B. Wade, Edith A. Gavis, Jasmohan S. Bajaj*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


Covert hepatic encephalopathy (CHE) affects cognition in a multidimensional fashion. Current guidelines recommend performing Psychometric Hepatic Encephalopathy Score (PHES) and a second test to diagnose CHE for multi-center trials. We aimed to determine if a two-test combination strategy improved CHE diagnosis agreement, and accuracy to predict overt hepatic encephalopathy (OHE), compared to single testing. Cirrhotic outpatients without baseline OHE performed PHES, Inhibitory Control Test (ICT), and Stroop EncephAlapp (StE) at three centers. Patients were followed for OHE development. Areas under the receiver operation characteristic curve (AUROC) were calculated. We included 437 patients (399 with follow-up data). CHE prevalence varied with testing strategy: PHES+ICT 18%, ICT + StE 25%, PHES+StE 29%, ICT 35%, PHES 37%, and StE 54%. Combination with best test agreement was PHES+StE (k = 0.34). Sixty patients (15%) developed OHE. Although CHE by StE showed the highest sensitivity to predict OHE, PHES and PHES+StE were more accurate at the expense of a lower sensitivity (55%, AUROC: 0.587; 36%, AUROC: 0.629; and 29%, AUROC: 0.623; respectively). PHES+ICT was the most specific (85%) but all strategies including ICT showed sensitivities in the 33–45% range. CHE diagnosis by PHES (HR = 1.79, p = 0.04), StE (HR = 1.69, p = 0.04), and PHES+StE (HR = 1.72, p = 0.04), were significant OHE predictors even when adjusted for prior OHE and MELD. Our results demonstrate that combined testing decreases CHE prevalence without improving the accuracy of OHE prediction. Testing with PHES or StE alone, or a PHES+StE combination, is equivalent to diagnose CHE and predict OHE development in a multi-center setting.

Original languageEnglish (US)
Pages (from-to)289-295
Number of pages7
JournalMetabolic Brain Disease
Issue number1
StatePublished - Feb 1 2019


  • Inhibitory control test
  • Neurophysiological test
  • Neuropsychological test
  • Overt hepatic encephalopathy
  • PHES
  • Stroop encephalapp

ASJC Scopus subject areas

  • Clinical Neurology
  • Cellular and Molecular Neuroscience
  • Biochemistry


Dive into the research topics of 'Diagnosis of covert hepatic encephalopathy: a multi-center study testing the utility of single versus combined testing'. Together they form a unique fingerprint.

Cite this