Article type: Literature Review
Article title: Minimal Hepatic Encephalopathy: A Narrative Review
Journal: Cureus
Year: 2026
Authors: Jamir Pitton Rissardo, Fatemeh Rashidi, Hania Moharam, Ibrahim Khalil, Meryem Bahar, Masoumeh Rashidi, Basem Ahmed, Saleh Salem, Ana Leticia Fornari Caprara, Abhishek A. Chouthai, Ahmed M. Kedwany, Hagar H. Sayed, Omesh Prathiraja, Maleesha Jayasinghe
E-mail: jamirrissardo@gmail.com
ABSTRACT
Minimal hepatic encephalopathy (MHE) is primarily a cognitive disorder linked to chronic liver disease that often remains underdiagnosed due to the subtlety of its clinical manifestations. These symptoms are frequently overlooked or dismissed as inconsequential in clinical practice, leading to many undiagnosed cases. The standard neurological examination is usually normal in individuals with MHE. Regular and systematic screening for MHE is essential for early detection, which can improve cognitive outcomes and prevent progression to a more serious and debilitating condition known as overt hepatic encephalopathy. The pathophysiology of MHE is very complex and multifactorial, involving several interacting mechanisms. Mainly, hyperammonemia, systemic inflammation, gut-derived neurotoxins, oxidative stress, and mitochondrial dysfunction are at its root. Any of these factors may interfere with the normal functioning of neurotransmitters, giving rise to the typical subtle cognitive impairments that are hallmarks of MHE. The Animal Naming Test and EncephalApp-Stroop test are practical, rapid, and easily administered tools for screening for minimal hepatic encephalopathy in outpatient and bedside settings. Emerging diagnostic technologies, including advanced neuroimaging techniques and novel biomarkers, have also been investigated and show promise for improving the early detection and diagnosis of MHE.
Keywords: chronic liver diseases, driving impairment, electroencephalography, hepatic encephalopathy, minimal hepatic encephalopathy, neurocognitive testing, neuropsychological testing, psychometric tests, quality of life
Full text available at:
DOI
Citation
Rissardo JP, Rashidi F, Moharam H, Khalil I, Bahar M, Rashidi M, Ahmed B, Salem S, Fornari Caprara AL, Chouthai AA, Kedwany AM, Sayed HH, Prathiraja O, Jayasinghe M. Minimal Hepatic Encephalopathy: A Narrative Review. Cureus 18(8): e113978. doi:10.7759/cureus.113978.
Figure 1. Grades of hepatic encephalopathy.
Figure 2. Role of ammonia in the pathophysiology of hepatic encephalopathy.
Figure 3. The algorithm for arriving at the diagnostically appropriate diagnosis of minimal hepatic encephalopathy.
Figure 4. Proposed clinical algorithm for the diagnosis of minimal hepatic encephalopathy.
Table 1. Diagnostic methods for the detection of MHE. ANT: Animal Naming Test, CFF: critical flicker frequency testing, CHE: covert hepatic encephalopathy, CRT: Continuous Response Time test, EEG: electroencephalography, HRQOL: health-related quality of life, ICT: Inhibitory Control Test, MHE: minimal hepatic encephalopathy, PHES: Psychometric Hepatic Encephalopathy Score, RBANS: Repeatable Battery for the Assessment of Neuropsychological Status, SIP: Sickness Impact Profile, 3-NT: 3-nitrotyrosine.
Table 2. Precipitating factors diagnosis and management. BRTO: Balloon-Occluded Transvenous Retrograde TIPS: transjugular intrahepatic portosystemic shunt, SPSS: spontaneous portosystemic shunt, BRTO: balloon-occluded retrograde transvenous obliteration, CARTO: coil-assisted retrograde transvenous obliteration, PARTO: plug-assisted retrograde transvenous obliteration, HE: hepatic encephalopathy, IV: intravenous, BMI: body mass index, DEXA: dual-energy X-ray absorptiometry, GI: gastrointestinal, PPI: proton pump inhibitor.Obliteration, CARTO: Coil-Assisted Retrograde Transvenous Obliteration, PARTO: Plug-assisted BRTO.
Table 3. Published studies on the management of minimal hepatic encephalopathy. BCAA: branched-chain amino acids, BDT: block design test, CFF: critical flicker frequency, CEP: cognitive evoked potentials, DST: digit symbol test, EEG: electroencephalogram, FOS: fructooligosaccharide, HRQOL: health-related quality of life, ICT: inhibitory control test, LTT: line tracing test, MHE: minimal hepatic encephalopathy, NCT-A: number connection test-A, NCT-B: number connection test-B, NfL: Neurofilament light, OHE: overt hepatic encephalopathy, PHES: psychometric hepatic encephalopathy score, SDT: serial dotting test, SIBO: small intestinal bacterial overgrowth.
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