Chinese guidelines on management of hepatic encephalopathy in cirrhosis

Table 1 Evidence level and recommendation strength

Level	Detailed description
Evidence Level
A	High quality: Further research cannot change the reliability of these treatment assessment results.
B	Moderate quality: Further research may influence the reliability of these treatment assessment results, and may change the treatment assessment results.
C	Low or very low quality: Further research will very likely influence the reliability of these treatment assessment results, and will very likely change the treatment assessment results.
Recommendation strength
1	Strong recommendation: It is clearly shown that either the benefits of intervention clearly outweigh the disadvantages, or that the disadvantages outweigh the benefits.
2	Weak recommendation: The benefits and disadvantages are unclear, or, regardless of the quality of the evidence, the benefits and disadvantages are comparable.

Table 2 Classification of hepatic encephalopathy recommended by the 11th World Congress of Gastroenterology in 1998

Type of hepatic encephalopathy	Definition	Subcategory	Subdivision
Type A	Hepatic encephalopathy associated with acute liver failure	None	None
Type B	Hepatic encephalopathy associated with portosystemic shunt and no liver cell injury-associated liver disease	None	None
Type C	Hepatic encephalopathy associated with cirrhosis with portal hypertension or portosystemic shunt	Episodic hepatic encephalopathy	Accompanying predisposition

Table 3 Revised hepatic encephalopathy grading standards

Traditional West-Haven criteria	Grade 0		HE grade 1	HE grade 2	HE grade 3	HE grade 4
Proposed revision of the HE grading criteria	No HE	MHE	HE grade 1	HE grade 2	HE grade 3	HE grade 4

HE: Hepatic encephalopathy; MHE: Minimal hepatic encephalopathy.

Table 4 Hepatic encephalopathy classification, symptoms, and signs

Revised HE grading criteria	Neuropsychiatric symptoms (that is, cognitive function)	Nervous system signs
No HE	Normal	Normal nervous system signs, normal neuropsychological test results
MHE	Potential HE, no noticeable personality or behavioral changes	Normal nervous system signs, but abnormal neuropsychological test results
HE grade 1	Trivial and mild clinical signs, such as mild cognitive impairment, decreased attention, sleep disorders (insomnia and sleep inversion), euphoria, or depression	Asterixis can be elicited and neuropsychological tests are abnormal
HE Grade 2	Marked personality or behavioral changes, lethargy or apathy, slight orientation abnormality (time and orientation), decreased mathematical ability, dyskinesia, or unclear speech	Asterixis is easily elicited, and neurophysiological testing is unnecessary
HE Grade 3	Marked dysfunction (time and spatial orientation), abnormal behavior, semi-coma to coma, but responsive	Asterixis usually cannot be elicited. There is ankle clonus, increased muscle tone, and hyperreflexia. Neurophysiological testing is unnecessary
HE Grade 4	Coma (no response to speech and external stimuli)	Increased muscle tone or positive signs of the central nervous system. Neurophysiological testing is unnecessary

HE: Hepatic encephalopathy; MHE: Minimal hepatic encephalopathy.

Table 5 Notes on neuropsychological/physiological testing methods in clinical use

Testing methods	Testing purposes	Time	Remarks
Psychological tests
Psychometric hepatic encephalopathy score (PHES)	PHES is an important method for determining cognitive dysfunction and diagnosing MHE in cirrhosis patients	Includes five subtests, namely the number connection test A and B, digit symbol test, line tracing test, and serial dotting test	Pen and paper
			Positives on at least two tests are required for clinical diagnosis
Number connection test A	Ability to concentrate, mental activity speed, can be used for rapid outpatient screening for MHE	30 to 120 s	Correction for age and education level improves accuracy
Number connection test B	Ability to concentrate, mental activity speed, distributed attention ability, can be used for rapid outpatient screening for MHE	1 to 3 min	Psychologist is required
			More complicated than number connection test A
Digit symbol test	Ability to concentrate, mental activity speed, can be used for rapid outpatient screening for MHE	2 min	Psychologist is required
Stroop Smartphone app (Encephal App)	Attention, can be used for rapid outpatient screening for MHE	3 to 5 min	Reliable and easy to use
Repeatable battery for the assessment of neuropsychological status	Compliance and working memory, visual spatial ability, language, cognitive processing speed	25 min	Pen and paper
			Psychologist is required
			ISHEN recommends HE psychometric scores as substitute indicators
Inhibition control test	Attention, reaction inhibition, working memory	15 min	Computer processing
			Patient cooperation is required, and patients must learn before testing
Neurophysiological testing
Flicker fusion frequency	Visual identification, can be used on outpatient basis for HE scores of 2 or lower, value of supplemental diagnosis is low	10 min	Patients must learn before testing
EEG	Generalized brain activity. Suitable for children	Variation	Psychologist and specialized tools are required
Evoked potential	Tests the time difference between electrical stimulation and response	Variation	P300 hearing has been used for the diagnosis of MHE

HE: Hepatic encephalopathy; MHE: Minimal hepatic encephalopathy; ISHEN: International Society for Hepatic Encephalopathy and Nitrogen Metabolism; EEG: Electroencephalography.