Reduced white matter microstructural integrity correlates with cognitive deficits in minimal hepatic encephalopathy

We read with interest the article by Goldbecker et al 1 comparing the accuracy for the diagnosis of hepatic encephalopathy (HE) of the three most commonly used batteries of psychometric test and critical flicker frequency. They conclude that the Psychometric Hepatic Encephalopathy Score (PHES) battery2 is the most robust method for diagnosis of HE. As mentioned by Goldbecker et al ,1 there is a wide agreement that HE needs to be diagnosed and treated and an increasing body of evidence shows that patients benefit from early treatment of overt and minimal HE (MHE). However, the diagnosis of MHE and lower stages of overt HE strongly depends on the experience of the examiner1 and, as indicated by Ferenci3 in his commentary to the paper of Goldbecker et al ,1 psychometric tests are not used routinely in clinical practice for diagnosis of MHE. As a consequence, most patients with MHE (around two million people in USA4 and a similar number in the European Union) remain undiagnosed and untreated. This is an …