Burden of Minimal Hepatic Encephalopathy in Literate Cirrhotics Aged 15-50 Years: Time to Switch to Digital...

Minimal hepatic encephalopathy (MHE) is a frequent but underdiagnosed entity associated with impaired quality of life and progression to overt hepatic encephalopathy. The Psychometric Hepatic Encephalopathy Score (PHES) remains the conventional diagnostic modality, but digital tools such as Stroop test (EncephalApp) and Critical Flicker Frequency (CFF) offer promising alternatives.

In this cross-sectional study (July 2022-June 2025), 316 cirrhotics with formal education ≥10 years in the age group of 15-50 years underwent PHES, Stroop, and CFF testing. MHE was diagnosed using a PHES score of ≤-5.

Ninety-five patients (30.06%) were diagnosed with MHE. On multivariate logistic regression analysis, Model for End Stage Liver Disease-Sodium (MELD-Na) and presence of Low Hand-grip Strength (probable sarcopenia) were found to be significant predictors of presence of MHE. The internally validated cutoff 212 s of OffTime+OnTime had the best discriminative ability (AUC 0.95) among the measures of Stroop test. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of Stroop and CFF as diagnostic tools were 92.63%, 91.85%, 83.02%, 96.67% and 78.95%, 88.69%, 75.00%, 90.74% respectively. The correlation(ρ) of PHES with Stroop test timings, PHES with CFF Hz, and Stroop test timings with CFF Hz was -0.93, 0.92, and -0.86, respectively, with substantial agreement between the 3 diagnostic tools [Fleiss' Kappa(κ) 0.69]. The time to complete the session in minutes for patients was the shortest with the Stroop test [Median(IQR): 9.90 (8.50-10.33)] and patient acceptance rated on a 10-point scale was highest for CFF tool [Median(IQR): 8.47 (8.21-8.63)].

Stroop and CFF diagnostic modalities are reasonably accurate and better accepted alternatives to PHES in younger literate cirrhotics. Their integration into clinical practice may enable wider screening and timely management of MHE.