Copyright ©The Author(s) 2019.
World J Gastroenterol. Sep 28, 2019; 25(36): 5403-5422
Published online Sep 28, 2019. doi: 10.3748/wjg.v25.i36.5403
Table 1 Evidence level and recommendation strength
LevelDetailed description
Evidence Level
AHigh quality: Further research cannot change the reliability of these treatment assessment results.
BModerate quality: Further research may influence the reliability of these treatment assessment results, and may change the treatment assessment results.
CLow 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
1Strong recommendation: It is clearly shown that either the benefits of intervention clearly outweigh the disadvantages, or that the disadvantages outweigh the benefits.
2Weak 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 encephalopathyDefinitionSubcategorySubdivision
Type AHepatic encephalopathy associated with acute liver failureNoneNone
Type BHepatic encephalopathy associated with portosystemic shunt and no liver cell injury-associated liver diseaseNoneNone
Type CHepatic encephalopathy associated with cirrhosis with portal hypertension or portosystemic shuntEpisodic hepatic encephalopathyAccompanying predisposition
Table 3 Revised hepatic encephalopathy grading standards
Traditional West-Haven criteriaGrade 0HE grade 1HE grade 2HE grade 3HE grade 4
Proposed revision of the HE grading criteriaNo HEMHEHE grade 1HE grade 2HE grade 3HE grade 4
Table 4 Hepatic encephalopathy classification, symptoms, and signs
Revised HE grading criteriaNeuropsychiatric symptoms (that is, cognitive function)Nervous system signs
No HENormalNormal nervous system signs, normal neuropsychological test results
MHEPotential HE, no noticeable personality or behavioral changesNormal nervous system signs, but abnormal neuropsychological test results
HE grade 1Trivial and mild clinical signs, such as mild cognitive impairment, decreased attention, sleep disorders (insomnia and sleep inversion), euphoria, or depressionAsterixis can be elicited and neuropsychological tests are abnormal
HE Grade 2Marked personality or behavioral changes, lethargy or apathy, slight orientation abnormality (time and orientation), decreased mathematical ability, dyskinesia, or unclear speechAsterixis is easily elicited, and neurophysiological testing is unnecessary
HE Grade 3Marked dysfunction (time and spatial orientation), abnormal behavior, semi-coma to coma, but responsiveAsterixis usually cannot be elicited. There is ankle clonus, increased muscle tone, and hyperreflexia. Neurophysiological testing is unnecessary
HE Grade 4Coma (no response to speech and external stimuli)Increased muscle tone or positive signs of the central nervous system. Neurophysiological testing is unnecessary
Table 5 Notes on neuropsychological/physiological testing methods in clinical use
Testing methodsTesting purposesTimeRemarks
Psychological tests
Psychometric hepatic encephalopathy score (PHES)PHES is an important method for determining cognitive dysfunction and diagnosing MHE in cirrhosis patientsIncludes five subtests, namely the number connection test A and B, digit symbol test, line tracing test, and serial dotting testPen and paper
Positives on at least two tests are required for clinical diagnosis
Number connection test AAbility to concentrate, mental activity speed, can be used for rapid outpatient screening for MHE30 to 120 sCorrection for age and education level improves accuracy
Number connection test BAbility to concentrate, mental activity speed, distributed attention ability, can be used for rapid outpatient screening for MHE1 to 3 minPsychologist is required
More complicated than number connection test A
Digit symbol testAbility to concentrate, mental activity speed, can be used for rapid outpatient screening for MHE2 minPsychologist is required
Stroop Smartphone app (Encephal App)Attention, can be used for rapid outpatient screening for MHE3 to 5 minReliable and easy to use
Repeatable battery for the assessment of neuropsychological statusCompliance and working memory, visual spatial ability, language, cognitive processing speed25 minPen and paper
Psychologist is required
ISHEN recommends HE psychometric scores as substitute indicators
Inhibition control testAttention, reaction inhibition, working memory15 minComputer processing
Patient cooperation is required, and patients must learn before testing
Neurophysiological testing
Flicker fusion frequencyVisual identification, can be used on outpatient basis for HE scores of 2 or lower, value of supplemental diagnosis is low10 minPatients must learn before testing
EEGGeneralized brain activity. Suitable for childrenVariationPsychologist and specialized tools are required
Evoked potentialTests the time difference between electrical stimulation and responseVariationP300 hearing has been used for the diagnosis of MHE