Should We Treat Minimal/Covert Hepatic Encephalopathy, and with What?

Hepatic encephalopathy exists along a continuum from abnormal neuropsychiatric testing in the absence of clinical findings to varying degrees of detectable clinical findings. The International Society for Hepatic Encephalopathy and Nitrogen Metabolism has endorsed the term "covert" to encompass minimal hepatic encephalopathy and grade I overt hepatic encephalopathy. Covert hepatic encephalopathy has been associated with poor quality of life, decreased employment, increased falls, and increased traffic accidents that significantly impact quality of life and health care expenditures. Probiotics, nonabsorbable dissacharides, rifaximin, and l-ornithine-l-aspartate have been evaluated with varying levels of success. Because of the lack of universally accepted diagnostic tools, optimal timing of testing and treatment remains controversial.